Financial Disclosure Statement Something Old, Something New, - PDF document

Occupational and Environmental Lung Disease: Financial Disclosure Statement Something Old, Something New, Something Unbreakable, and Something Blue Robert Cohen, MD, FCCP Division of Pulmonary n I have no relevant financial relationships and Critical Care Medicine Northwestern University Feinberg School of Medicine Goals of today’s talk Case – Something Old n Something Old: n 55-year-old underground coal miner n Describe recent outbreak of progressive from Kentucky massive fibrosis n Underground miner for 23 years n Something New: n Worked mainly as a roof bolter and n Discuss occupational and environmental longwall shear operator anthracofibrosis n Something Unbreakable: n Describe hard metal lung disease n Something Blue: n Describe Indium Tin Oxide Lung Disease 1

Longwall Shear Operator 1992 1999 2

2003 3

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Resurgence of a Debilitating and Entirely Preventable Respiratory Disease among Working Coal Miners Blackley DJ, Laney AS, Halldin CN – AJRCCM 2014;190(6):708-709 5

n 1/1/15–8/17/16, a total of 60 patients with PMF 49 had their radiograph taken during 2016. n n Surveillance data have indicated a resurgence of PMF in recent years, but the cases described in this report represent a large cluster not discovered through routine surveillance. 6

416 Case of PMF from 3 Clincs Blackley et. al. JAMA 319:5 p. 500-501 PMF cases found in retired miners who never participated in NIOSH CWHSP. Why don’t miners participate? n Holes in the social safety net: n 1985 – 2005, employment in the Appalachia coal mining industry n declined by 56% due to Cost of coal relative to oil and natural gas n Increased mechanization n Shift to contract labor n Fear of job loss n n Fear of disease and associated disability Mistrust of government n 7

Myth that Black Lung Was Black Lung Rediscovered Eliminated n 1998 Review of Coal Workers’ Health n Several miners had been diagnosed with Scheme concluded that pneumoconiosis was other diseases than black lung – i.e. not a problem Sarcoidosis n Changed surveillance program into fitness for n Reviewed images which were consistent with work program CWP n Anyone could take CXRs and no standards n Review of chest imaging of random sample of for whom or how the images were classified 300 miners found 18 new cases n Images sent to the Government – but not n The dust hit the fan reviewed n No central data capture or processing 8

Australian Federal Government Discovery of Cases Lead to Parliamentary Investigation n Miners with Black Lung n Union Industry n Government Regulators n Thoracic Society n n Radiology Society n College of Occupational Medicine Australian Federal Government Queensland Parliament Investigation Report Issued May 2017 Investigation – February 2016 n Congressional Hearings – 3 days of testimony n Witnesses from Labor, Industry, Government, and miners with black lung “Black lung in whatever form is totally preventable.” n Dr Brian Plush, Particulate Matter Scientist, University of Wollongong n “ The number 1 thing is to mitigate and control the dust before the disease even starts.” n Professor Robert Cohen, Consultant, Queensland Department of Natural Resources and Mines n “ I said to my wife that if I had found out then that I was going to be like this I would have got out of the mine straight away. It has buggered my life.” n Mr Percy Verrall, former coal miner, diagnosed with Coal Workers‘ eumoconiosis in 2015 9

Something New: Anthracofibrosis Anthracofibrosis – Occ and Environmental Disease n Described 1998 by Chung et. al. n Bronchial anthracofibrosis – Pilaniya et. al. n Obstructive impairments n 1320 cases summarized by 2011. Gupta et. al. n Decreased 6-minute walk distance n Associated with biomass fuel exposure n Desaturation. n Women n Most patients were women n Elderly n Associated with RML syndrome and segmental atelectasis. n Associated with RML syndrome and segmental atelectasis. n Associated with TB – Kunal et. al. n Pneumonia and cancer implicated as well. Anthracofibrosis – Occupation Anthracofibrosis – with ILD n Bakers n Farmers n Miners n Dust exposed workers n Tile factory n Asbestos, coal, slate 10

Case – Something Unbreakable Case n 55 y/o male with PMH of increasing SOB for n 38 year old man presented with abdominal 10 years to the point where he cannot climb pain more than one flight of stairs n CT abdomen incidentally revealed lower zone n Chronic cough for 10 years with clear, yellow, abnormalities in the lungs. or green sputum production n He had never smoked and had no history of n 2011 à progressive hypoxemia and bilateral previous lung disease or drug abuse . infiltrates at OSH. n Examination revealed early clubbing, and n Underwent VATS with anthracosis with mild bilateral late inspiratory crackles in the lower adhesions zones. 11

Case – Continued n Only job was working 16 years in a company manufactured machine components made of stainless steel, nickel, chrome, aluminium, bronze and tungsten carbide. n CT chest showed cystic air spaces and fibrosis. n PFTs: mild restriction and obstruction. (TLC 80%, FVC 88% , FEV1 72 % FEV1/FVC 67%, DLCO 37%. Surgical Path Path Results n Multinucleated giant cells were found in airspaces, with a ‘cannibalistic’ appearance typical for giant cell interstitial pneumonitis (GIP ). n SEM/EDS findings, showed high numbers of individual metal particles in situ 57/100 consecutive particles contained tungsten. 12

Hard Metal Lung Disease (HMLD) History or Cobalt Lung n Hard metals first manufactured in Germany in n Occupational lung disease with 3 possible early 1900s. physiologic reactions: n Tugsten reacts with carbon and then is “sintered” n Occupational asthma with cobalt to make hard metal cutting tools. n Hypersensitivity pneumonitis-like syndrome n Sintering compacts powdered Tungsten Carbide n Giant cell interstitial pneumonia (GIP) into a Cobalt Matrix using very high pressure or n Exposed to dust in production of tungsten heat but without melting. carbide n Several decades later, case reports of a n Thought to be related to cobalt use as a pneumoconiosis began to appear with CXR binder with 5-25% when tungsten and abnormalities. carbide are heated n HMDLD as GIP described by Liebow -1975 Pathophysiology PFTs n Typically show restrictive lung defect with n Cobalt is key to the disease process as reduction in DLCO animal studies from n This may be reversible in early stages 1950s with instillation of tungsten and cobalt n In end-stage disease, an obstructive defect produced disease, but may also develop when cystic changes tungsten alone did not. predominate. n Workers using diamond-studded tools can use cobalt as well and get the same disease with no exposure to tungsten 13

CT Findings: Diffuse centriolobular micronodular opacities in middle and lower lobes (corresponds to centrilobular fibrosis with giant cell accumulation in the airways), Subpleural curvilinear densities, GGOs. May also get extensive reticular opacities, traction bronchiectasis, irregular linear opacities, and/or consolidation. BAL Giant Cell Interstitial Pneumonia n Increased total cell counts n Increased lymphocytes and eosinophils n Decreased CD4/CD8 ratio n May see bizarre multinucleated giant cells (diagnostic) n Elemental analysis can be done of these cells to look for tungsten Low Power: Centrilobular inflammation High Power: Irregular multinucleated and fibrosing lesions giant cells in alveolar spaces 14

Elemental Analysis EPMA Data – Moriayam et. al. n Key in the disease is detection of the offending element which can be done either liquid (digesting pathologic specimen) or solid (preferred). n Solid analysis is done with an electron probe microanalyzer that use spectrometers to detect the various elements n Normally looking for tungsten Diagnostic Criteria for HMLD Treatment n History of hard metal exposure n First, remove the exposure n May improve spontaneously n HRCT chest with centrilobular micronodular opacities n May add corticosteroid therapy n Giant cells on BAL and/or GIP on biopsy n Prednisone 40-60 mg/day n Elemental analysis n Methylprednisolone 1 g/day x 3 days n May require second agent such as cyclophosphamide, azathioprine, or cyclosporine. n Lung transplantation 15

And…. Something Blue Indium-Tin Oxide (ITO) n Main application: liquid crystal displays n Indium tin oxide – lung (LCDs); other use: touch screens disease n Interstitial fibrosis n Pulmonary alveolar proteinosis (PAP) n Emphysema Indium-Tin Oxide (ITO) Toxicology n Indium oxide is a semiconductor doped with tin oxide n Pulmonary to form ITO. The process is also sintering (9 parts n PAP – in animal studies and humans indium; 1 part tin) n Emphysema n Sintering - the process of compacting and forming n Interstitial fibrosis a solid material by heat and/or pressure without melting to the point of liquefaction. n Carcinogenicity – no data to suggest a n Applied as thin film by “sputtering” human carcinogen. n Sputtering - particles are ejected from a solid n No data on reproductive effects target material due to bombardment by energetic particles. Sputter deposition is a physical vapor deposition of thin film deposition by sputtering. Bomhard. Environ Tox and Pharm 58 (2018) 250-258 16