Document rBxk5pZNekq5nV8n82wVnm04E

FILE NAME: Z//E DATE:D DOC#: /E DOCUMENT DESCRIPTION::ZWZZ ZZ .I INDIAN JOURNAL OF OCCUPATIONAL HEALTH, 1983(March); XXVI(3): 285-289. ~ PERSONAL EXPERIENCES IN DIAGNOSIS OF ASBESTOS IS by Dr. S. R. KAMAT ** During my medical training it was considered common knowledge that people working in stone quarries get tuberculosis. However the concept of mechanisms in silicosis became clearer to me only during the period of training under British teachers. Over 25 years, I have seen only few cases of active tuberculosis with silicosis. The common silicosisi that is seen in Bombay city is among workers working in foundry, dye casting, sand blasting, s.tonegrinding and quarries. It shows a picture of punctate multiple deposits. In our unit we hav~ seen progressive massive fibrosis in persons exposed to cement, sand and grain storage. The acute progressive silicosis 1 as seen in slate-pencil workers which shows chronic large consolidation ocupying both lung fields is uncommon in this city. It is common in Madhya Pradesh. These are young patients with breathlessness, cough, haemoptysist and black sputum. There is widespread prevalence of silicosis in Andhra Pradesh, Madhya Pradesh and Gujarat. This is vividly ~hown by a recent case of 24 years old female. She had worked for only 5 years in an open quartz mine. However she virtually lived in such mines alongwith her parents and later her husband for 19 years. There is reported ly so much dust in the vicinity of such open mines anywhere in India that the whole community inhales silica dust. The type of silicosis these people get is very disconcerting. This female patient died of respiratory and cardiac failure despite intensive manage~ent . in our ward. Despite absence of infe~t1~ her major complaint was cough wiith scanty expectoration, occasional bloodstreaking and slight edema of feet. We covered her heart failure adequately but could not combat lung failure. She was malnourished, continued to have marked tachycardia d~e: to p?1mon~ hypertension, anox1a and died with exhaustion. The other common pneumocomos1s seen in Bombay is byssinosis, in cotton mill workers, particularly in presence of co.ugh. In latter years these patients do not have wortc relationship but still improve after staying away from work for several weeks. They do show greater decline\ in lung function over a work day. and have increased IgG and IgE levels in comparison to cases with chronic bronchitis 2 They also show an increased r~e of annual decline in lung function as compared to control subjects. 3 We have also fond few cases of oyssi.nosis in workers working inj not so dusty areas, cotton testing,, ginning workers and those who have worked a few. years. In contrast, other pneuomocoruoslS areJ less frequent in India. We have seen cases with coal and gold pneumoconiosis, Berylliosis" and Arc welders lung 5 In the latter case there was signficant increase in fibrosis with round cell infiltration in lung. It was then pointed out that at his Naval Guest lecture ~t Annual Conventionof l.A.O.H. Bombay branch in March 1983. **Dept. of Ch~st Medicine, K.E.M. Hospital & Seth G. S. Medical College, Bombay-400 012. l:AN.111'1/lrl ASBt'S'""" . - u.; INF011MATIO:l C!JITRS ll30 SHERBROOKE S1: , MDNTREAl, {QUEDECJ CA,17, "1 S7. 410 rlAD!I H3A 2!.~a : 286 INDIAN JOURNAL OF OCCUPATIONAL HEALTH workspot he may have been incidentully exposed to asbestos material. Howcv~r we did not find any physiologic or hi,topathol~gi~ c_hanges consi~tent :' ~h asbestosis in this case. Even m Bntam where asbestosis is diagnosed alongwith mesothelioma often, several ca...~s -have been found in dock workers ~ind casual labqurers ' . First asbestQsis case I saw in 1ndia was in: Madras. A 35 year old nonsmoking male complained of breathlessness on short exertion and cough wi.th expectoration. He had worked as sprayer of railway coaches for 10 years and stopped due to chest sympton:is. The radiograph suggested areas with collapse and fibrosis i.n both lower zones and an associated hyperlu.:cnce in upper zones. Pulmonary function test showed slight obstruction and anoxi.a on exercise. The patient earlic:had been submitted to bronchograph.,. which confirmed loss of lung volume and crowding of bronchi w~:hout dibtation. Our Physicians are sti0ll looking for asbestos bodies in sputum for confirmation of di.agnosis of asbestosis This patient or several of our later ~a tients never showed any, on routine sputi'.llTl examination. Their presence only indicates an exposure to asbestt1s in a community. There is poor correlation between asbestos bodies in srutum and lung tissue 7 In 1970 in Bomhay we saw a male patient aged 37 years who had worked as asbestos sprayer for 12 years. Later. the factory employed him as clerk as he was breath less for 6 years. However for past :2 years he was unable to do even that joh. He smoked 15 cigarettes. a day and had stopped smoki.ng due to chest symptoms. He never had any haemoptysis or larize quantity of sputum but was treated as tuberculosis for 2 months. He had lo<1t atleast 4 kgs. in weil!ht over one ycur and had gr. IV dyspnoea (on !'ili!!ht cxcrti.c.m). He also develoi:ed swelling of feet and signs . ?f cardiac f.:ilurc over 6 months. Chmcal exa- mination revealed accentuated pulmo- nary second sound, rales at bo~h bases and rio0 ht mid zone, dullness m lower zones and trachea was deviated to right sdc. An ECG reve~led RBBB and RYH. The radiographss done over 2 years showed increased heart sliuzme ~ linear and fibrosis, basal loss of lung congestion. voAfter treatment of heart failure the signs of failure reduced. S:veral admissions re- vealed a variable! degree of anoxi:i. Pul- monarv function studies revealed redu.;:- tion or'vital capacity (24% of predicted) FEY 1 :FVC%-86% FEY t -0.92 Lit. FYC-1..07 lit. MBC-47.6 Lit. mild reduction i.n expiratory flow rates (PEF 21 O Lit). The oxvgen uptake at rest was normal (228 ml). There was mild drop in oxygen saturation on exercise (from 89.1 to 87.0%) along- wi.th reduction in i:CO 2 (29 mm). His capacity to do exercise was very limi- ted <280 kizmimin). Patient di.~d dur- in!! fourth admis<iion with exhaustion. cardi.ac and respiratory failure. In 1974. we saw an industrialist aged 45 years. who had signs of bilateral basal fj.brosis and had undergon~ several investigations here and abroacl including open lung biopsy. He also gave a histcry of tobacco smoki.n!! (60!day) and pethidine addiction; from both he w~s salvaged. During his voumz apprenti::e days he was exposed to asbestos ore as it was brought to his gcdown by railway wagons in -Bomba\.'. He used to sup:!rvi~c breakiniz of asbestos ore and i.ts storage by his workforce for 4 vears but never handled it himself. He wac; also exposed to tak clay and iron ores for few years. He started feeling tired at the end of this pe-r.<Jd and was !!ettin!! cou!!h with cJif!ht breathlessness on heavy -exertion. EXPERIENCES IN DIAGNOSIS OF ASBESTOSIS 287 He was, married at the age of 28 years but found difficult to enjoy marital life; therefore he took to addktion but was salvaged. Over previous 10 years he continued to do his executive job with some dfo;ability. When we saw him at the; age of 45 he had a few rales. The radiograph had remained unchanged over 12 years. lt showed small areas of fibrosis at both bases. Lung hiops~ has revealed nonspecific lung and some pleural fibrosis with silica dust~ anu several lung functions had shown re duction in diffusion capacity a drop in p02 on exercise (Table l ). Our lung functions showed a reduction in VC (60%) with some obstructioo which improved after aerosol. His diagnosis was almost certainly asbes- tosis gr~ I. A typical mild case can be described as follows. A male aged 45 years (Engineer) has been working in asbestos yam making for 22 years and also smoked 30 cigarettes per day for 35 years. He had a history of smoker's cough for several years which was worse for 3 months with small quantity of sputum. He was complaining of tiredness and fatigue on exertion particu- larly on climbing for several months (gr. II dyspnoea). After giving some bronchodilators he had no lung signs. A chest radi.o~aoh revealed increased vasculature, calcified scars in right paracardiac region and grade I linear fibrosis suggestive of asbestosis. The hmg functions were normal YC-3.08 Ut (98%) of predicted. FEY, -VC%- 86%, FEY 1 -2.66 lit. PEF-300 to 330 lit. after bronchodilator aerosol.. Minute ventilat~on and oxygen uptake were normal at rest and on exerci.se. How i;:r his capacity to do exercise was limited to 4C'i::>-500 Kgm;min. Arterial pO? at rest wac; 85 mm and declined to 75 mm after exercise, pCO z at rest was 34 and rose to 36 mm on exercise. He developed respiratory acidosi'i: pH was 7.44 at rest and chanaed to 7:3'4 on exercise, p02 after oxygen was 500 mm i.ndicating a mild diffusion blc:k. We have seen several patients who are exposed regularly to asbestoslike insulation material, work in engi- neering or electrical industries getting symptoms similar to; this patient. A factory dealing with asbestos cement sheets requested us to read their workers' radi.ographs. In this factory it was learnt that several older workers were complaining of respiratory prob- lems and had taken retirement. The regular workers (789) presently in employment were studied for symptoms and radiographs were read by two trai.ned readers independently and in consultation. We found 28% as having gr. I l l asbestos related fibrosis. Another 8.4% radiographs were sug- gestive ot gr. 112 asbestosis. There were changes suggestive of nonspecific scars in 16.3 % and tuberculous scars in 2.4%. We do think quite a few of these scars may be also related to work exposure. There were cal- cified ple~.iral scars i,n 2.8 % subjects. We also later studied a similar number of radiographs from another factory in Ind;,a and found a large prevalence of abnormalities attributable to asbestos exoosure. Due to administrative con.: siderations. these findings were explained awav. With inteUigent cooperation of workers and some doctors we were privileged to see 28 workers working in asbestos industrv over last 2 years 9 : 20<71 <;f) of these were smokers. Thev had a mean work exposure of 12.9 years. One of these developed symptoms before 5 years of exposure and 7 after an exposure of 6-10 years. Most had exertional dyspnoea as the prominent symptom. Che.st pain (usually dull) came with feeling of tightness. In 57% there was wei~ht loss: weakne!'s was complained hv 79% and CC:Ul:!h was present in 46%. Fi.nger 288 INDIAN JOURNAL OF OCCUPATIONAL HEALTH clubbing was seen in 25 % On clinical examination only a few had evidence of rhonchi or bronchospasm: 8 had diminished breath sounds and rales were present in 46%. Of 28 cases 24 subjects .were con:;idered as having asbestosis. Thus 7'Y< showed linear and nodular fibrosis in lower and mid zones. Pleural sc:.irs were see~ in 15 subjects. One worker with circular masses in both lung:; was suspected to have malignancy but on direct aspirat.Wn this proved to be u collection of pus. We also have seen a case with bilateral pleural transudates in a station master who was working at a station where asbestosloaded wagons were unloaded. One of OUii patients with gr. II asbestosis devc- loped cancer and died soon after dis charge. We had another patient who had advanced c::.rdiac fahlure with asbestosis. Routine spirometry was normal in 48% and showed restriction in 53%; low FEV 1 was !:een in 17%. In 82 % workers there was no cvi.dence of obstruction. Of 23 patient~ who had blood gas studies done at restl and exercise, 11 had above 90 mm pO 2 at rest, 8 subjects had resting p0 2 levels below 90 mm. After cxerci.se testing there was no adequate rise in p02 in 13 patients; in 9 patents there was signi.ficant drop in p0 2 on exercise. We have seen patients with pleurill plaques m nearly asymptomatic - wor- kers but large shadows seem uncommon. Intermittently we see exposed workers who complain of symptoms which may be related to work in asbestos i,ndustries. Several times we have heard that the manaaement or medical consultants or union officials do not encourage obtaining a conf],rmation of diagnosis. We have notir;~d that radiographs done are regularlv read as bronchiectas.i.s or nonspecifi: fibrosis. As in our first case from Madras, several workers as they complai.ned of cough or haemoptysis are treated as tuberculosis and several workers are persuaded to retire with questionable benefits. Mild attempts at getting some of our patients compensated have met with covert :<esi.>tance 'and interpersonal difficulties. A typical case from factory may present to his doctors after 8-15 years of exposure to asbestos. He notices some dyspnoea or tirednes,:; which later progresses to chest pain, anorexia and loss of weight. Clinical. examination shows few rales but there mav be no . clubbing. Radiographs may show micro-nodular and linear deposits partiCl'Jlarly at right base and sometimes a ground glass appearance elsewhere. Pulmonary function may show mild restriction, lowered 0 2 uptake o~ exerci,sc and a droP! in pO l on exercise. This may be due to izr.I asbestosis with pleural thickening and moderate functional disability. We suspect that several experts in India are trying to minimise the occurrence of asbestos related diseases with following defensive arguments (a) We do not have the same intensity of industrial exposure; (b) Our workers are not very productivei and do not get heavily exposed; (c) Our workers smoke heavily, imbibe alcohol and often izct complicating diseases like infections. bronchiectasis or tuberculosis: (d) Indians are perhaps more resistant to di.seases prevalent in developed countnes. (e) By text book criteria unles:; asbest~s bodies in sputum are found or rlu~ndg~ogbriaopphssy..shsohw~ws aasdbveasntocesdbodcihe~s~eosr smular to s1licos1s, we should not diagnose asbestosis. Some of these arizum~nts according to our group arc not stnctly based scientific evidence. As symptoms with asbestosis ilre not EXPERIENCES IN DIAGNOSIS OF ASBESTOSIS 289 path"l{nomonic the liseases m ")aC'urn. lung should be investigated properly .We have seen cases of mesothelioma or lung cancer diagnosed on autopsy in our institute and mesotheliomas have been reported in farmers of Maharashtra perhaps with exposure to asbestos containing earth. We believe that asbestosis . and related diseases may be common in cities of India and it needs greater vigilance, suspicion and proper investigation to diagnose them more often. With rapid industrial!.sation taking place in our country the medical experts should practice this approach to encourage sustained productivity, labour welfare and to prevent premature loss of young workers. Acknowledgem:!nts : We thank Dr. C. K. Deshpande, Dean for allowing this work to be done. The pulmonary function data was analysed by Smt. Sulabha Athawale. References : l. Suratt P.M., Winn W.C.Jr., Brody A.R., Bolton W.K., Giles R.D. Acute silicosis in Tombstone sandblasters. Am. Rev. Resp. Dis. 1977:115:521-529. 2. Kamat S.R., Taskar S.P.. Iyer E.R., Naik M., Kamat G.R. Discrimination between byssinosis and chronic bronchitis in cotton mill workers by Serum lmmunoglobulin patterns. J. Sex:. Occup. Med. 1979:29:102-106. 3. Kamat S.R.. Kamat G.R., Salpekar V.Y., Loboi E. Dis~i.nguish ing byssinosis from chrom: oh- structive pulmonary disease results of a prospective five year !.tudy of cotton mill workers in India. Am. Rev. Resp. Dis. 1981 : 124:31-40. 4. Patel K.C., Shah D.P., Kamat S.R. Chronic Berylliosis. Ind. J. Occup. Hlth. 1977:20:181. 5. Patel K.C., Sheth S.M. Kamat S.R Arc Welders' Lung. J. Postgrad. Med. 1977:25:35-38. 6. Constantinidis K. Asbestos exposure -- its related disorders. Brit. J. Clin. Pract~ 1977:31:89-101. 7. Roggli V.L.. Greenberg S.D., McLarty J. W. et al Comparison of sputum and lung asbestos body counts in former asbestos workers. Am. Rev. Resp. Dis. 1980:122: 941-45. 8. Kamat S.R., Salpekar V.Y., Godkhindi K.D. Relation between pneumoconiosis and pulmonary tuberculosis. Proceeding. Symposium on recent advances in Tuberculosis. Aug. 1980: p. 87-88. 1982. 9. Sh:ih S.P., Kamat S.R., Mahashur A.A: Pattern of asbestos workers in Bombay. Ind. J. Occ. H!th. 1983 under publication. I '.'. Berry G., Gilson J.C.. Holmes S.. Lewinsoh:i H.C.. Roach S.A. Asbestosis: a study of dose response re!::tionships i.n an asbestos textile factory. Brit. J. lndustr. Med. 1979:36:98-112. 11. Enterline P.E. Estimating health risks in studies of the health effects of asbestos. Am. Rev. Resp. Dis. 1976:113:175-180.