P2 Case B Answers

A patient is referred to your Pulmonology clinic. He is a 67 yo man with a 20 pack year smoking history, hypertension, hyperlipidemia, and rheumatoid arthritis. He was referred to you by his Primary Care Physician for a better assessment of his complaints of dyspnea. He recently retired from his work as an electrician for military naval yard. Despite his retirement, he has continued to work on his passion to do the re-do wiring in homes in his community, usually built in the 60's and 70's, though, he has been unable to do so this past month due to increased difficulty in breathing. He denies fevers, chills, hemoptysis, and recent weight loss.

1. Amongst the following pulmonary pathology images, select the most likely to be found in your patient. In addition, describe each image's lung pathology and name the diagnosis.

H/O of working in old homes and naval yard suggest a chronic exposure to asbestos. 

A. Coal Worker's Pneumoconiosis
i. Sources
-Coal mines, large urban centers, tobacco smoke
ii. Pulmonary Anthracosis
-Alveolar macrophages with anthracotic pigment are called "dust cells"

"Coal worker's pneumoconiosis. Note the heavy anthracotic pigment deposition in the fibrotic tissue. Subjacent alveoli are dilated. " -Goljan

B. Silicosis
i. Sources
-Sandblasting, mines, foundries. Quartz is most often implicated
ii. Pathogen
-Quartz is highly fibrogenic and deposits in the upper lungs. It activates and causes alveolar macrophages to lyse, which then releases cytokines that stimulate fibrogenesis.

"Silicosis. Note the nodular fibrotic mass in the lung" -Goljan

C. Asbestosis
i. Sources
-insulation pipes in ship yards, roofing material/ceiling tiles/floor tiles >20 yr ago, and demolition of old buildings
ii. Asbestos Bodies
-Fibers coated by iron/protein called Ferruginous bodies

"Asbestos body. The straight, golden-brown, beaded asbestos body represents an asbestos fiber coated by iron and protein." -Goljan

2. His concomitant diagnosis of Rheumatoid Arthritis suggests this disease.

Caplan Syndrome

3. You always remember a litigation associated with the pulmonary disease you've diagnosed him with at your clinic. Use the following images to name these well-known possible complications.

Malignant Mesothelioma

Pleural Plaques

While these two complications are possible from asbestosis, primary bronchogenic carcinoma is also a possibility and should be a concern when following this patient.