Document mBQg2j56EZ9j15kmoRdYZXXEk

6i6.24--003.656.6 ON THE OCCURRENCE OF CLUMPS OF ASBESTOSIS BODIES IN THE SPUTUM OF ASBESTOS WORKERS. M. J. Stewakt, X. Tatteksall and A. C. Haddow. Leeds. / (Plate LXXXV.) When' asbestosis bodies are found in the sputum of asbestos workers or other persons who have inhaled asbestos dust in appreciable amount, they occur singly or in groups of two or three. The number present is usually small and the use of a concentration method may be necessary for their convenient demonstration (Stewart and Haddow 1929, Stewart 1929, Wood and Gloyne 1930, Lynch and Smith 1930, Siinson and Strachan 1931, Gloyne 1931). Their significance is clear; they indicate merely that asbestos dust has been inhaled into the lung and has remained there for a certain length of time; they do not show that a diseased condition of the lungs necessarily exists. The lime required for the formation of the bodies is short. They were present in the lungs of a patient who had been exposed to dust for two months only (Siinson 1929) and of a guinea-pig which had been for three months in an asbestos factory (Stewart 1930). In one of Simson and Strachan's cases the sputum was positive after only five months exposure and in Gardner and Cummings' guinea-pig experiments (1931) the first imperfectly formed bodies were noted in the lungs after 60 days. In 90 days they had assumed their typical form. We have encountered " bodies " in the sputum of persons whose occupation has only entailed their occasional presence in the asbestos factory aud in one instance we found them in the lungs, post mortem, in a man who lived close to a factory for many years hut who had never been inside it. It may be that quantitative observations will yet show that numbers of bodies above a certain minimum figure are diagnostic (or suggestive) of a condition of pulmonary asbestosis, but certainly no such significance can be attached to their mere presence. One of us (M. J. S.) has now examined the sputum of 24 workers in asbestos and has found bodies in all hut 4. Several of these were persons in excellent health, with nothing to suggest that they were suffering from pulmonary fibrosis. In two instances, however, in addition to single bodies there was found a large clump of some 20 or 30 bodies more or less radially Jouax. OF PATH.--VOI-. XXXV. 7S7 2B 738 M. J. STEWART, N. TATTERSALL AND A. C. HADDOIV~~--- arranged with their bulbous extremities outwards. The uppeatt#^ is similar to what is seen in histological sections of the lung in ej** of pulmonary asbestosis. Here clumps of bodies occur in situations, (1) within the lung alveoli, and (2) embedded in iifc?^ tissue. The alveoli which contain clumps are nearly always tlw**- wliich abut on areas of advanced fibrosis and there is little doubt U|V the clumps within the latter were originally formed inside the alveoli. ' The two patients in whom a clump of bodies was found 4* SL sputum were suffering from advanced and moderately adfttptl? pulmonary asbestosis respectively and one of them has since diagnosis being confirmed at autopsy. Following is a resume ot more important findings. : Case I. mIpE-t.Jj, A* A female aged 31 died on 10th March 1931. The sputum had been eamawi,-: tor tubercle bacilli on several occasions with negative results. Two nmfim taken within the last few weeks of life and examined by the antiformin stdfcw (Stewart 1929) were found to contain abundant asbestosis bodies. FromoMtf the samples the clump shown in fig. 1 was obtained; otherwise all the bw&* occurred singly or in groups of two or three. The patient had worked in an asbestos factory from 1915 until 192S, *sl a break of two years for child-birth in 1923-1925 (her only child). ShcwA 1:i work at the end of August 1928, two and a half years before her death. first complained of cough, dyspnoea and anorexia in October 1925 and again as* under treatment in February 1927, when she showed poor air entry all owU* chest and some coarse crepitations at the right apex. Eadiographic ex&miaabm showed signs of slight infiltration at the bases. She was regarded at this &3* a mild case of pulmonary asbestosis. On 0th July 1929 it was noted that ih* were more signs of fibrosis at both bases, with plenral friction in the tr.3* particularly the left. The apices were emphysematous especially the left*** there were post-tussal crepitations at the right apex and elsewhere. Thet**** no sputum. The radiograph (15.7.29) showed diffuse fine striation tbroori*** the lower third of both lungs. The interlobar fissure was well seen on d* ntS* side, where also the outline of the diaphragm was much blurred. Tier* *** evidence of pleural thickening on the lateral aspect of the left lower lobe. T)*** was more striation tban normal in the upper two-thirds of the lungs, tba here being coarser than in the lower third. The cardiac outline was bluni V* the strands of fibrous tissue crossing it. The appearances, in short, were typ****^ the diffuse basal fibrosis encountered in cases of asbestosis and there was ooisn to suggest a tuberculous infection. In January 1931 the patient became sc**# ill, with symptoms and signs of bronchopneumonia, first at the right ba* then on the left side also. The temperature was only slightly raised the pulse was very rapid and there were cyanosis, dyspnoea and painful a*** Marked dullness and abundant moist sounds at both bases, with pleural trie*** in places, continued until her death two months later. It was during tw* *** (13.1.31) that the clump of asbestosis bodies was found in the sputum. : Vost-mortem examination. There was notable diffuse fibrosis of UmS>**** (basal) portion of both lower lobes. On the left side, only the extreme *P* _ the lower lobe was crepitant, on the right approximately the upper third. I** these lobes were very greatly reduced in size. The fibrosed areas showed, a moderate grade of patchy anthracotic mottling, the intervening tiu* Ml . in : M-i t;. lie . , Ml : Iva: li.-'i. ; X,U.. - i Mi' ; Ml "I tii. iiit *>\ < i ' ! 11 i '. ' li.it ' !t' l A 1. It h'l- . ; i Ml _*!. - ` I ])'1 I--' ' hrlV - = '1 i. - ie .-lu:./ lurr* a t ? ty | '* ; not!;:* - ; ***. I.--Ome I. Clump of asbcstosis bodies recovered from the sputum of a patient with 4 pttinwmary asbestOMS. Note the radial arrangement of the bodies with their bulbous I txirealities at the periphery. Unstained, x 080. | Im. C-e-e II. A similar clump from another ease. Unstained, x 650. ;im* * :il * d tii.:. ilii- : .m- ' ,i. ' r- : u , li " u- ' : i II. A clump of bodies m stOt in a lung alveolus. the alveolar wall is welt v'TM ami the radial arrangement of the bodies. Prussian blue reaction, x 1100. JSBESTOSIS BODIES 739 pink in colour. A few tiny abscess cavities were seen scattered Uie fibrosed areas. The upper lobes were mainly spongy and Uct there were a number of scattered small areas of dense fibrosis beneath the pleura. The non-fibrosed tissue was somewhat emphy- Tjscera) and parietal pleura on both sides of the chest were ,tned and fibrosed. On the right side the sac was almost obliterated dense adhesions; on the left, adhesions were equally dense but less The non-obliterated portion of the sacs presented a cake-icing with some recent sero-fibrinous pleurisy. 'jfrti'r--"1 examination. I. The solid, non-crepitant portions of lung, | the greater part of both lower lobes as above described, and smaller ` -giinly subpleural, in the upper lobes, show changes of two kinds: --i slight fibrous thickening of alveolar walls, with various combina'"'y. ti tedema, catarrh, fibrinous pneumonia and patchy purulent broncho'.-jpawu; and (4) patches of advanced fibrosis, often clearly related to dilated jSfiiit (o*-SiVti bronchioles. It is in and around these densely fibrosed areas that bodies arc found in greatest profusion. Here they often occur in large 'fljyMf ermuged clumps, both in surviving alveoli abutting on the fibrous (tit 31 and embedded within the fibrous tissue itself. The acutely ikbtly fibrosed portions of solid lung show only scattered asbestosis in small numbers, mainly in the thickness of the alveolar walls, liy in the oedematous or inflammatory exudate filling the alveoli. The areas of crepitant lung tissue constituting the major portion of the -jSfiP* l>*** and the smaller, apical portions of the lower lobes show slight : tbrogL-, again mainly peribronchiolar, with emphysema of the intervening A*t*t(sis bodies are present in moderate numbers, mainly in and liw fibrous patches. Much carbon pigment is present in these patches, :*<*# Wk arras of more grossly fibrosed lung. Itl The visceral pleura is everywhere greatly thickened and densely `n one block showing obliterated pleura between lung and intercostal , there is mi active tuberculous lesion with numerous well formed follicles OarffHs: cells. There is no evidence of tuberculosis of the luwjs in any of the V' :> ; Case II. a f. Ittlnalt. age 44 in 1932, commenced work in an asbestos factory 2/ Jews was continuously employed there except for a 5 cars **kre. She had been mainly employed on mattress maki ^ ^ fiv .. excessively dusty process, but ^ad ",s ^ne^ood untilthree ffMcud warping" for 5 or 6 years. Her tork for three ninths. She -t-|WTW-**liC*Otwwohesnimshielahr aadtta"cpknseusmincoen,iatheanladstwmas koeffaiwuoarrky h smheucb0aids .*JM6**Mty* each winter since the first attack, with sik, . gradually increasing dys,^mcea Shah* in four 1*4 cW w*a*ll*an*d agecnheersatl ecxopnadnistiioonn iosf foanire, iwncithh. 1 ; eivrendiranti0otne , **.tk*W half of both lungs. The breath sounds are The IllwWpxi. Scattered dry creaking sounds are Jsbestosis bodies are . i* consistently negative for tubercle bacilli b < ***** fairi>' larc numbers. On one occasion (4A3-^a^ arge r.: nrmimcd of the 'aswf, U i0 or so " bodies" was seen (fig-2). M ray exan h w* tiinu.se fine striafcion and light mottling o "arc u0 appear- sonic irregularity of outline of the diaphragm. ' fibrosis **erpv>tive of pulmonary tuberculosis ; the picture is that of diffuse > ' land is typical of moderately advanced asbestosis. 740 M. J. STEWART, N. TATTERSALL AND A. C. HADDO >,v Commentary. - We suggest that- the finding of a large clump or clumps of asl^jj^j bodies in the sputum as here described is a clear indication of integration of lung tissue, whether by a process of simple suppum^ bronchopneumonia, as in our first case, or as a result of secnirf^ tuberculous infection. In either case it is reasonable to concha)* ji^ there is also a definite underlying asbestosis. Tn the concentration method which we employ the sample tf sputum is rather roughly treated, and it may be that by a more % manipulation of the specimens clumps of bodies would he found mu frequently. On the other hand we have never seen portions of bn4* - up clumps such as might he expected to result from rough handing ' The radial arrangement of the bodies with their bulbous extremity* at the periphery, identical as it is with many of the clumps fouoia lung sections (fig. 3), clearly shows that we are dealing not with artefact but with a formation built up in situ within the lung ;dnl**, from which it could only escape as a result of some seeowkrr disintegrative process. -" Asbestosis bodies are encountered with great frequency in sputum of asbestos workers, especially those who have been long a the industry. Simson and Strachan (1931), who examined speeiuw** from 50 workers in a South African asbestos mill, found 48 of ;h positive. In our own series of 24 cases 20 gave a positive rero.t, including all who had been at work for 5 years or longer. By cmnm. clumps would seem to be encountered very infrequently. Simson atn Strachan make no mention of their occurrence, and we have i.uiin u, find any other reference in the literature. Lynch and Smith (ILCriv however, figure a typical clump of "asbestosis bodies in spnua concentrate." These authors examined the sputum of four kw pulmonary asbestosis, of which three were positive. The clump sw** was presumably obtained from their first case, where bodies ** numerous, whereas eases II and III showed only "sparse Iwdies" .-4 the spit. It is worthy of note that case I wa3 the subject of .icnr* tuberculosis with positive sputum. Elliuan (1932) also figure* * typical clump of bodies from the sputum (fig. 76). I11 a penot** communication he states that this was obtained from a very advance case of the disease. It would appear, therefore, that while individual asbestosis hr*nr in large or small numbers are present in the sputum of the vs** majority of asbestos workers, clumps of bodies are only encounter**1 on rare occasions. Their presence points to disintegration <>i i=ac tissue and is therefore of far greater significance than the timiim.' `4 single bodies however numerous. It may be compared with "t* presence of elastic tissue in the sputum in phthisis. 15%. ( ' n.-\* -* iBtr8**'1 cSfe "'" "^- jtfij- a- . _ a- : - ASBESTOSIS BODIES m REFERENCES. ' '&?:3As p ............................. Cliest diseases in general practice, London, 1032, ** ' ' p. 116. L. TJn and Com- Journ. Indust. Ilyj., 1931, xiii. G5 and 97. a e. g......................... Journ. Indust. Ilya., 1931, xiii. S5. ^:jSLIlr~*c, j|_ and Smith, .Tow n. Amcr. Med. Assoc., 1930, xcv. 6u9. VUL r.vr. . . - Ann. Hep. S. African Inst, for Med. Research, ' ' 1929, p. 64. ' S. F- W., and this Journal, 1031, xxxiv. 1. ., _ . _ c*as. A- 5* ^cjiwrirT JI.J....................... Jtrit. Med. Jovrn., 1929,ii. 581. ai!^ ....................this Journal. 1030, xxxiii. 848. ' H. J., ami Had- this Journal, 1929, xxxii. 172. JLC. R, and Glovne, Lancet, 1930, i. 445. t. Kfi: . fnsn ... m`*\r: :<*-. r,-. ** "% W - -, i* #' - : vt .,,. ? \%f\ i e T*V>; * ^4V-T,I -?.i^`Ss^JVr*.' 'it; tf'V:' - . Jprv;-.. -1 -'on jjiv. B2 B**ok aBubo - Dmias The Journal of n? athology and Bacteriology The Official Journal of the Pathological Society of Great Britain and Ireland EDITED BY A. E, BOYCOTT M. J. STEWART W. W. C. TOPLEY C. C. OKELL FOUNDED IN 1892 BY GERMAN SIMS WOODHEAD VOLUME THIRTY-FIVE--PART I Pages 1 -473 Edinburgh : Oliver and Boyd London : 33 Paternoster Row 1932