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A woman with nodules in her lungs
CASE REPORT
Case report
A woman with nodules in her lungs
H Järveläinen, H Vainionpää, T Kuopio, A Lehtonen A 67-year-old woman came to the outpatient clinic in September, 1996, because she had a high serum glucose and raised blood pressure. Before retirement she had worked as a telephone operator. She had never smoked tobacco. 2 years earlier she had had a subarachnoid haemorrhage which left her with difficulties in walking and swallowing. At the time of her outpatient visit, she had almost completely recovered; only some difficulties in swallowing remained. Nothing remarkable was detected on examination, except for an increased blood pressure. Routine laboratory tests, excluding serum glucose, were normal. A chest radiograph showed two nodular infiltrates in the middle and basal areas of her right lung, which were not present in the chest radiograph taken at the time of subarachnoidal haemorrhage 2 years earlier (figure). Computed tomography (CT) of her chest suggested that the infiltrates were metastases. To locate the primary tumour, ultrasound examination of the upper abdomen and thyroid gland, gastroscopy, mammography, barium enema, CT of the abdomen, and gynaecological examination were done; nothing abnormal could be found. A chest radiograph 4 weeks later showed nodular infiltrates in her left lung as well. A bronchoscopy was done, but no abnormalities were found. Thoracoscopy was also normal. Tests of respiratory function were normal. Eventually, she had an open lung biopsy. There were numerous small nodules, 0·5–1·0 cm diameter, on the surface of the lung. Histological examination showed that the nodules consisted of fibrotic tissue, and polarised microscopy revealed birefrigent silica particles. No signs of cancer were seen. She was questioned about exposures to silica and said that soon after the subarachnoidal haemorrhage she had started to use a silica-containing powder (C-Piimaa, Leo Health Co, Kuopio, Finland; containing 40% glucose, 32·4% silica crystals, 19·5% cherry extract, and 5·5% fructose with blackcurrant extract) given by a nature healer to aid recovery. She had taken spoonfuls of powder several times a day for more than 2 years. She often coughed heavily due to inhalation of the powder when taking it dry or mixed with milk. There was no other exposure to silica. She stopped taking the powder, and when last seen in October, 1997, she felt fine and had no dyspnoea.
Chest radiographs at time of subarachnoid haemorrhage (top) and 2! s years later (bottom)
Silicosis is typically an occupational disease affecting people working in mining, stone cutting, ceramics production, or the construction industry.1 However, silicosis due to domestic cleaning powders,2,3 fly ash,4 and photocopier toner dust5 have been described. This report suggests a new risk factor for silicosis: silica-containing natural health products. This is important to keep in mind because the use of various natural health products has become more popular in western countries. Furthermore, our report reminds physicians of the need to take an adequate history of possible exposure to silica when there are nodules in the lung. References 1 2
Lancet 1998; 351: 494 Department of Medicine, Turku University Central Hospital, FIN-20520 Turku, Finland (H Järveläinen MD, H Vainionpää MD); Department of Pathology, University of Turku (T Kuopio MD); Department of Geriatrics, Turku City Hospital (A Lehtonen MD) Correspondence to: Dr H Järveläinen
494
3 4 5
Wagner GR. Asbestosis and silicosis. Lancet 1997; 349: 1311–15. Dumontet C, Biron F, Vitrey D, et al. Acute silicosis due to inhalation of a domestic product. Am Rev Respir Dis 1991; 143: 880–82. Dumontet C, Vincent M, Laennec E, Girodet B, et al. Silicosis due to inhalation of domestic cleaning powder. Lancet 1991; 338: 1085. Cho K, Cho YJ, Shrivastava DK, Kapre SS. Acute lung disease after exposure to fly ash. Chest 1994; 106: 309–11. Gallardo M, Romero P, Sanchez-Quevedo MC, Lopez-Caballero JJ. Siderosilicosis due to photocopier toner dust. Lancet 1994; 344: 412–13.
THE LANCET • Vol 351 • February 14, 1998
Case report
A woman with nodules in her lungs
H Järveläinen, H Vainionpää, T Kuopio, A Lehtonen A 67-year-old woman came to the outpatient clinic in September, 1996, because she had a high serum glucose and raised blood pressure. Before retirement she had worked as a telephone operator. She had never smoked tobacco. 2 years earlier she had had a subarachnoid haemorrhage which left her with difficulties in walking and swallowing. At the time of her outpatient visit, she had almost completely recovered; only some difficulties in swallowing remained. Nothing remarkable was detected on examination, except for an increased blood pressure. Routine laboratory tests, excluding serum glucose, were normal. A chest radiograph showed two nodular infiltrates in the middle and basal areas of her right lung, which were not present in the chest radiograph taken at the time of subarachnoidal haemorrhage 2 years earlier (figure). Computed tomography (CT) of her chest suggested that the infiltrates were metastases. To locate the primary tumour, ultrasound examination of the upper abdomen and thyroid gland, gastroscopy, mammography, barium enema, CT of the abdomen, and gynaecological examination were done; nothing abnormal could be found. A chest radiograph 4 weeks later showed nodular infiltrates in her left lung as well. A bronchoscopy was done, but no abnormalities were found. Thoracoscopy was also normal. Tests of respiratory function were normal. Eventually, she had an open lung biopsy. There were numerous small nodules, 0·5–1·0 cm diameter, on the surface of the lung. Histological examination showed that the nodules consisted of fibrotic tissue, and polarised microscopy revealed birefrigent silica particles. No signs of cancer were seen. She was questioned about exposures to silica and said that soon after the subarachnoidal haemorrhage she had started to use a silica-containing powder (C-Piimaa, Leo Health Co, Kuopio, Finland; containing 40% glucose, 32·4% silica crystals, 19·5% cherry extract, and 5·5% fructose with blackcurrant extract) given by a nature healer to aid recovery. She had taken spoonfuls of powder several times a day for more than 2 years. She often coughed heavily due to inhalation of the powder when taking it dry or mixed with milk. There was no other exposure to silica. She stopped taking the powder, and when last seen in October, 1997, she felt fine and had no dyspnoea.
Chest radiographs at time of subarachnoid haemorrhage (top) and 2! s years later (bottom)
Silicosis is typically an occupational disease affecting people working in mining, stone cutting, ceramics production, or the construction industry.1 However, silicosis due to domestic cleaning powders,2,3 fly ash,4 and photocopier toner dust5 have been described. This report suggests a new risk factor for silicosis: silica-containing natural health products. This is important to keep in mind because the use of various natural health products has become more popular in western countries. Furthermore, our report reminds physicians of the need to take an adequate history of possible exposure to silica when there are nodules in the lung. References 1 2
Lancet 1998; 351: 494 Department of Medicine, Turku University Central Hospital, FIN-20520 Turku, Finland (H Järveläinen MD, H Vainionpää MD); Department of Pathology, University of Turku (T Kuopio MD); Department of Geriatrics, Turku City Hospital (A Lehtonen MD) Correspondence to: Dr H Järveläinen
494
3 4 5
Wagner GR. Asbestosis and silicosis. Lancet 1997; 349: 1311–15. Dumontet C, Biron F, Vitrey D, et al. Acute silicosis due to inhalation of a domestic product. Am Rev Respir Dis 1991; 143: 880–82. Dumontet C, Vincent M, Laennec E, Girodet B, et al. Silicosis due to inhalation of domestic cleaning powder. Lancet 1991; 338: 1085. Cho K, Cho YJ, Shrivastava DK, Kapre SS. Acute lung disease after exposure to fly ash. Chest 1994; 106: 309–11. Gallardo M, Romero P, Sanchez-Quevedo MC, Lopez-Caballero JJ. Siderosilicosis due to photocopier toner dust. Lancet 1994; 344: 412–13.
THE LANCET • Vol 351 • February 14, 1998