Tobacco Worker's Lung Workup
- Author: Roger B Olade, MD, MPH; Chief Editor: Ryland P Byrd, Jr, MD more...
No specific tests exist for tobacco worker's lung (TWL); the diagnosis is established with a history of exposure and possibly with the support of the following tests:
- Elevated serum levels of angiotensin-converting enzyme (ACE), N- acetyl-beta-glucosaminidase (NAG), and beta-glucuronidase (beta-GLU) may be present. Elevation of these enzymes does not have a high sensitivity or specificity.
- Bronchoalveolar lavage (BAL) may show lymphocytosis, neutrophilia or eosinophilia, and reversal of CD4/CD8 ratio.
- Immunoglobulin G, immunoglobulin M, and immunoglobulin A serum antibodies to causative antigens may be present.
- Nonsmoking tobacco harvesters may have cotinine and nicotine levels as high as active smokers in the general populations.
- ImmunoCAP technology can detect IgG antibodies against Aspergillus fumigatus.
Nonspecific markers of inflammation, such as the following, are elevated:
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein
- Positive rheumatoid factor
- Elevated serum lactate dehydrogenase (LDH)
No distinctive changes are noted on chest radiography, but it might show progressive fibrotic changes associated with upper lobe volume loss or diffuse reticulonodular infiltrates in chronic exposure. In acute exposure, the infiltrates are usually more prevalent in the lower lobes.
High-resolution computed tomography (HRCT) scan
This may show a ground-glass appearance, prominent medium-sized bronchial walls, parenchymal micronodules, and absence of hilar adenopathy. Note the images below.
Pulmonary function testing shows mostly restrictive patterns with occasionally mixed restrictive and obstructive patterns, impaired diffusion capacity, and lung volume loss. Peak expiratory flow rates also are reduced.
Arterial hypoxemia with hypocapnia reflecting an increased A-a oxygen gradient commonly occurs at rest, with further worsening on exercise.
Lung biopsies are rarely required to confirm diagnosis because diagnosis is primarily derived from a thorough occupational history, clinical features, and radiography. Both transbronchial and video-assisted thoracoscopic lung biopsy are used to provide adequate specimens for histopathological examination.
Samples from lung biopsies show chronic interstitial inflammation with infiltration of plasma cells, mast cells, macrophages, and lymphocytes, usually with poorly formed nonnecrotizing granulomas. The granulomas are loosely formed and tend to occur in proximity to the bronchioles. Cholesterol clefts and giant cells, as shown in the image below, also are observed within and outside the granulomas.
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