Tobacco Worker's Lung Workup

Author: Roger B Olade, MD, MPH; Chief Editor: Zab Mosenifar, MD more...

Updated: Jan 18, 2012

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Laboratory Studies
Imaging Studies
Other Tests
Procedures
Histologic Findings
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Laboratory Studies

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.^[7]
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.^[8]

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)

Chest radiograph

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.

High-resolution CT scan of lungs shows ground-glass opacification seen in an acute phase of tobacco worker's lung.

High-resolution CT (HRCT) scan shows a ground-glass appearance and reticulonodular opacities in subacute phase of hypersensitivity pneumonitis (HP) secondary to moldy hay.

Other Tests

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.^[9]

Arterial hypoxemia with hypocapnia reflecting an increased A-a oxygen gradient commonly occurs at rest, with further worsening on exercise.

Procedures

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.

Histologic Findings

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.

Giant cells are a characteristic feature of acute tobacco worker's lung, which is a form of hypersensitivity pneumonitis.

Proceed to Treatment & Management

Contributor Information and Disclosures

Author

Roger B Olade, MD, MPH Medical Director, Providence Health Group

Roger B Olade, MD, MPH is a member of the following medical societies: American College of Occupational and Environmental Medicine and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Jazeela Fayyaz, DO Pulmonologist, Department of Pulmonology, Unity Hospital

Jazeela Fayyaz, DO is a member of the following medical societies: American College of Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gregg T Anders, DO Medical Director, Great Plains Regional Medical Command , Brooke Army Medical Center; Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary Disease, University of Texas Health Science Center at San Antonio

Gregg T Anders, DO is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Timothy D Rice, MD Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

References

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