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Granulomatous pneumonitis and mediastinal lymphadenopathy due to photocopier toner dust
THE LANCET
Control of communicable diseases is often based on common sense rather than perfect science. Let us therefore refrain from fuelling the current bovine hysteria with conjecture and focus our efforts on encouraging communities and individuals to prevent faecal contamination of food.
Fe
Cu Cu
Fe Cu Si
D N Durrheim Cu
Mpumalanga Department of Health, Private Bag X11278, Nelpruit, South Africa
1 2
3 4
Wilson ME. A world guide to infections: diseases, distribution, diagnosis. New York: Oxford University Press, 1991: 479–80. Diaz-Camacho S, Candil-Ruiz A, Uribe-Beltran A, et al. Serology as an indicator of Taenia solium tapeworm infections in a rural community in Mexico. Trans R Soc Trop Med Hyg 1990; 84: 563–66. Baily GG. Intestinal cestodes. In: Cook GC, ed. Manson’s tropical disease, 20th ed. London: Saunders, 1996; 1477–80. Malnick SDH, Geltner D. Tapeworm disease in vegetarians. Lancet 1996; 347: 1766.
Granulomatous pneumonitis and mediastinal lymphadenopathy due to photocopier toner dust SIR—Granulomatous pneumonitis is caused by exposure to several respirable metal particles including copper.1 Lymphadenopathy is described in patients with chronic beryllium disease, which is commonly misdiagnosed as sarcoidosis.2 We describe a patient with granulomatous pneumonitis and mediastinal lymphadenopathy after exposure to photocopier toner dust. A 39-year-old man with no history of smoking presented with dry cough and dyspnoea after moderate effort for 1 year. At the time of consultation he had worked for 18 months in a newspaper agency as a specialist in computer-based data collection. Physical examination was unremarkable, as were laboratory studies including antinuclear antibodies, antibody subsets to nuclear antigens, and angiotensin-convertingenzyme concentrations in the blood. A chest radiography showed a bilateral interstitial micronodular pattern and enlargement of the hilar and mediastinal lymph nodes, which worsened during the subsequent 3 months. Tests of respiratory function revealed predominantly peripheral bronchial obstruction (maximum expiratory flow after 75% of vital capacity exhaled [MEF 25], 65% predicted), reduced diffusing capacity of the lung for carbon monoxide (DLCO, 60% predicted), and reduced DLCO corrected for alveolar volume (85% predicted). The forced expiratory volume at 1 s (FEV1, 85% predicted), and total lung capacity (95% predicted) were normal. Bronchoscopy under generalised anaesthesia, including bronchoalveolar lavage (BAL) and transbronchial lung biopsy, was done. The BAL fluid yielded 30% macrophages, 10% lymphocytes, and 60% neutrophils. The patient also had mediastinoscopy. Histological examination of the lung and lymph-node specimens showed non-necrotising granulomas with epitheloid cells and giant cells of Langerhans, and foreign-body-type and pigmentcontaining macrophages. The specimens of the lung and the lymph nodes and the toner dust were examined by X-ray energy dispersive microanalysis with scanning electron microscopy.3 Copper was detected in the biopsy specimens and the toner dust (figure), leading to the diagnosis of granulomatous pneumonitis and mediastinal lymphadenopathy due to photocopier toner dust. Respiratory symptoms and pulmonary function improved only a little with oral corticosteroids after 9 months. No improvement in radiological findings was seen. Gallardo et al4 described a rare case of siderosilicosis due to photocopier toner dust, which contains different metals such as copper and iron. Lymphadenopathy is usually linked to chronic beryllium disease.
690
Cu Cu
Si
Si
Cu
<0·6
Cu
Cu
5·746 keV
>10·9
Figure: X-ray spectrograms of toner dust (top) and intracellular particles in lung (middle) and mediastinal lymph nodes (bottom) Silicon (Si) and copper (Cu) are identified in toner dust, lung, and lymph nodes. Specific multiple peaks for a single element are highlighted and marked with the corresponding symbol. In addition toner dust and intracellular inclusions in lung biopsy specimen frequently contained iron (Fe) and sometimes aluminium (not shown). In lymph-node specimen few particles were found that contained silicon and copper. X-ray energy dispersive microanalysis is based on interaction of accelerated electrons with inner orbital electrons of an atom. Some of these inner electrons are ejected and the hole is filled by electron from shell of higher energy, resulting in X-ray radiation (peaks) characteristic for shells transversed. Since most elements including iron and copper contain several shells, multiple peaks are generated.
With increasing use of photocopiers, more patients with pulmonary disease due to exposure to toner dust are expected. Therefore a detailed environmental and occupational history should be the first step in examination of such patients. We thank Ulrike Liska-Setinek for preparing the biopsy specimens for histological examination.
*Christine Armbruster, G Dekan, Anny Hovorka 2nd Medical Department/Pulmologisches Z entrum Vienna, A-1140 Vienna, Austria; and Clinical Institute of Clinical Pathology, University of Vienna, Vienna
1 2 3
4
Villar TG. Vineyard sprayer’s lung. Am Rev Respir Dis 1974; 110: 545–55. Bost TW, Newman LS. Metal-induced interstitial lung diseases: a clinicopathologic approach. Semin Respir Med 1993; 14: 197–211. Shelbourne JD, Ingram P, Le Furgey A, Herlong R. Preparatory techniques. In: Ingram P, Shelbourne JD, Roggli VL, eds. Microphobe analysis in medicine. New York: Hemisphere, 1989. Gallardo M, Romero P, Sanchez-Quevedo MC, Lopez-Caballero JJ. Siderosilicosis due to photocopier toner dust. Lancet 1994; 344: 412–13.
Dietary salt and essential hypertension SIR—Antonios and MacGregor (July 27, p 250)1 begin their wide-ranging and provocative essay by asserting the importance of salt intake as a determinant of raised blood pressure. They proceed to accuse dissenters of obfuscating the evidence, and further claim that debate on the issue is contrived. It would have been better had they mentioned findings that do not readily accord with their views, in particular reservations about the recently revised data of the INTERSALT study set out by Davey Smith and Phillips.2
Vol 348 • September 7, 1996
Control of communicable diseases is often based on common sense rather than perfect science. Let us therefore refrain from fuelling the current bovine hysteria with conjecture and focus our efforts on encouraging communities and individuals to prevent faecal contamination of food.
Fe
Cu Cu
Fe Cu Si
D N Durrheim Cu
Mpumalanga Department of Health, Private Bag X11278, Nelpruit, South Africa
1 2
3 4
Wilson ME. A world guide to infections: diseases, distribution, diagnosis. New York: Oxford University Press, 1991: 479–80. Diaz-Camacho S, Candil-Ruiz A, Uribe-Beltran A, et al. Serology as an indicator of Taenia solium tapeworm infections in a rural community in Mexico. Trans R Soc Trop Med Hyg 1990; 84: 563–66. Baily GG. Intestinal cestodes. In: Cook GC, ed. Manson’s tropical disease, 20th ed. London: Saunders, 1996; 1477–80. Malnick SDH, Geltner D. Tapeworm disease in vegetarians. Lancet 1996; 347: 1766.
Granulomatous pneumonitis and mediastinal lymphadenopathy due to photocopier toner dust SIR—Granulomatous pneumonitis is caused by exposure to several respirable metal particles including copper.1 Lymphadenopathy is described in patients with chronic beryllium disease, which is commonly misdiagnosed as sarcoidosis.2 We describe a patient with granulomatous pneumonitis and mediastinal lymphadenopathy after exposure to photocopier toner dust. A 39-year-old man with no history of smoking presented with dry cough and dyspnoea after moderate effort for 1 year. At the time of consultation he had worked for 18 months in a newspaper agency as a specialist in computer-based data collection. Physical examination was unremarkable, as were laboratory studies including antinuclear antibodies, antibody subsets to nuclear antigens, and angiotensin-convertingenzyme concentrations in the blood. A chest radiography showed a bilateral interstitial micronodular pattern and enlargement of the hilar and mediastinal lymph nodes, which worsened during the subsequent 3 months. Tests of respiratory function revealed predominantly peripheral bronchial obstruction (maximum expiratory flow after 75% of vital capacity exhaled [MEF 25], 65% predicted), reduced diffusing capacity of the lung for carbon monoxide (DLCO, 60% predicted), and reduced DLCO corrected for alveolar volume (85% predicted). The forced expiratory volume at 1 s (FEV1, 85% predicted), and total lung capacity (95% predicted) were normal. Bronchoscopy under generalised anaesthesia, including bronchoalveolar lavage (BAL) and transbronchial lung biopsy, was done. The BAL fluid yielded 30% macrophages, 10% lymphocytes, and 60% neutrophils. The patient also had mediastinoscopy. Histological examination of the lung and lymph-node specimens showed non-necrotising granulomas with epitheloid cells and giant cells of Langerhans, and foreign-body-type and pigmentcontaining macrophages. The specimens of the lung and the lymph nodes and the toner dust were examined by X-ray energy dispersive microanalysis with scanning electron microscopy.3 Copper was detected in the biopsy specimens and the toner dust (figure), leading to the diagnosis of granulomatous pneumonitis and mediastinal lymphadenopathy due to photocopier toner dust. Respiratory symptoms and pulmonary function improved only a little with oral corticosteroids after 9 months. No improvement in radiological findings was seen. Gallardo et al4 described a rare case of siderosilicosis due to photocopier toner dust, which contains different metals such as copper and iron. Lymphadenopathy is usually linked to chronic beryllium disease.
690
Cu Cu
Si
Si
Cu
<0·6
Cu
Cu
5·746 keV
>10·9
Figure: X-ray spectrograms of toner dust (top) and intracellular particles in lung (middle) and mediastinal lymph nodes (bottom) Silicon (Si) and copper (Cu) are identified in toner dust, lung, and lymph nodes. Specific multiple peaks for a single element are highlighted and marked with the corresponding symbol. In addition toner dust and intracellular inclusions in lung biopsy specimen frequently contained iron (Fe) and sometimes aluminium (not shown). In lymph-node specimen few particles were found that contained silicon and copper. X-ray energy dispersive microanalysis is based on interaction of accelerated electrons with inner orbital electrons of an atom. Some of these inner electrons are ejected and the hole is filled by electron from shell of higher energy, resulting in X-ray radiation (peaks) characteristic for shells transversed. Since most elements including iron and copper contain several shells, multiple peaks are generated.
With increasing use of photocopiers, more patients with pulmonary disease due to exposure to toner dust are expected. Therefore a detailed environmental and occupational history should be the first step in examination of such patients. We thank Ulrike Liska-Setinek for preparing the biopsy specimens for histological examination.
*Christine Armbruster, G Dekan, Anny Hovorka 2nd Medical Department/Pulmologisches Z entrum Vienna, A-1140 Vienna, Austria; and Clinical Institute of Clinical Pathology, University of Vienna, Vienna
1 2 3
4
Villar TG. Vineyard sprayer’s lung. Am Rev Respir Dis 1974; 110: 545–55. Bost TW, Newman LS. Metal-induced interstitial lung diseases: a clinicopathologic approach. Semin Respir Med 1993; 14: 197–211. Shelbourne JD, Ingram P, Le Furgey A, Herlong R. Preparatory techniques. In: Ingram P, Shelbourne JD, Roggli VL, eds. Microphobe analysis in medicine. New York: Hemisphere, 1989. Gallardo M, Romero P, Sanchez-Quevedo MC, Lopez-Caballero JJ. Siderosilicosis due to photocopier toner dust. Lancet 1994; 344: 412–13.
Dietary salt and essential hypertension SIR—Antonios and MacGregor (July 27, p 250)1 begin their wide-ranging and provocative essay by asserting the importance of salt intake as a determinant of raised blood pressure. They proceed to accuse dissenters of obfuscating the evidence, and further claim that debate on the issue is contrived. It would have been better had they mentioned findings that do not readily accord with their views, in particular reservations about the recently revised data of the INTERSALT study set out by Davey Smith and Phillips.2
Vol 348 • September 7, 1996