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Tobacco Worker's Lung Workup

  • Author: Roger B Olade, MD, MPH; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Jun 03, 2014
 

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.[8]
  • 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.[9]
  • 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)
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Imaging Studies

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-glasHigh-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-glasHigh-resolution CT (HRCT) scan shows a ground-glass appearance and reticulonodular opacities in subacute phase of hypersensitivity pneumonitis (HP) secondary to moldy hay.
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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.[10]

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

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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.

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

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

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

Disclosure: Nothing to disclose.

Coauthor(s)

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

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, World Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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

Disclosure: Nothing to disclose.

References
  1. Huuskonen MS, Husman K, Jarvisalo J, et al. Extrinsic allergic alveolitis in the tobacco industry. Br J Ind Med. 1984 Feb. 41(1):77-83. [Medline].

  2. Blanco-Romero LE, Vega LE, Lozano-Chavarría LM, Partanen TJ. CAREX Nicaragua and Panama: Worker exposures to carcinogenic substances and pesticides. Int J Occup Environ Health. 2011 Jul-Sep. 17(3):251-7. [Medline].

  3. Pauly JL, Paszkiewicz G. Cigarette smoke, bacteria, mold, microbial toxins, and chronic lung inflammation. J Oncol. 2011. 2011:819129. [Medline]. [Full Text].

  4. Yanev I, Kostianev S. Respiratory findings in tobacco industry workers. Chest. 2004 Feb. 125(2):802. [Medline].

  5. Camarena A, Juárez A, Mejía M, Estrada A, Carrillo G, Falfán R, et al. Major histocompatibility complex and tumor necrosis factor-alpha polymorphisms in pigeon breeder's disease. Am J Respir Crit Care Med. 2001 Jun. 163(7):1528-33. [Medline].

  6. Rahman M. Health Hazards And Quality Of Life Of The Workers In Tobacco Industries: Study From Three Selected Tobacco Industries At Gangachara Thana In Rangpur District Of Bangladesh. Internet J Epidemiol. 6(2):[Full Text].

  7. Zhang Y, Chen J, Chen Y, Dong J, Wei Q, Lou J. Environmental mycological study and allergic respiratory disease among tobacco processing workers. J Occup Health. 2005 Mar. 47(2):181-7. [Medline].

  8. Huuskonen MS, Jarvisalo J, Koskinen H, Kivisto H. Serum angiotensin-converting enzyme and lysosomal enzymes in tobacco workers. Chest. 1986 Feb. 89(2):224-8. [Medline].

  9. Swami S, Suryakar AN, Katkam RV, Kumbar KM. Absorption of nicotine induces oxidative stress among bidi workers. Indian J Public Health. 2006 Oct-Dec. 50(4):231-5. [Medline].

  10. Ghosh T, Barman S. Respiratory problems of workers in the zarda industry in Kolkata, India. Int J Occup Saf Ergon. 2007. 13(1):91-6. [Medline].

  11. Kokkarinen JI, Tukiainen HO, Terho EO. Effect of corticosteroid treatment on the recovery of pulmonary function in farmer's lung. Am Rev Respir Dis. 1992 Jan. 145(1):3-5. [Medline].

  12. Curwin BD, Hein MJ, Sanderson WT, Nishioka MG, Buhler W. Nicotine exposure and decontamination on tobacco harvesters' hands. Ann Occup Hyg. 2005 Jul. 49(5):407-13. [Medline].

  13. Braun SR, doPico GA, Tsiatis A, Horvath E, Dickie HA, Rankin J. Farmer's lung disease: long-term clinical and physiologic outcome. Am Rev Respir Dis. 1979 Feb. 119(2):185-91. [Medline].

  14. [Guideline] Tarlo SM. Cough: occupational and environmental considerations: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan. 129(1 Suppl):186S-196S. [Medline].

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High-resolution CT scan of lungs shows ground-glass opacification seen in an acute phase of tobacco worker's lung.
Giant cells are a characteristic feature of acute tobacco worker's lung, which is a form of hypersensitivity pneumonitis.
High-resolution CT (HRCT) scan shows a ground-glass appearance and reticulonodular opacities in subacute phase of hypersensitivity pneumonitis (HP) secondary to moldy hay.
 
 
 
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