|Year : 2018 | Volume
| Issue : 5 | Page : 436-438
Pleural effusion in silicosis: A rare case report
Pragyan Rout, Garima Markam
Department of Pulmonary Medicine, S.C.B. Medical College and Hospital, Cuttack, Odisha, India
|Date of Web Publication||5-Sep-2018|
S.C.B. Medical College and Hospital, Room No.82, S.R. Hostel, Cuttack, Odisha
Source of Support: None, Conflict of Interest: None
Silicosis is a diffuse pulmonary interstitial disease characterized by a fibrotic response in lung parenchyma caused by continual inhalation of crystalline silica (SiO2). Pleural effusion is an extremely rare presentation of silicosis. To the best of our knowledge, there have been only few cases of silicosis with pleural effusion reported in medical literature. Herein, we describe a case of a 60-year-old male, who presented with shortness of breath for 5 years. He was a nonsmoker. He had a history of exposure to mineral dusts for 25 years. Chest X-ray showed left-sided pleural effusion and bilateral reticulonodular opacities. High-resolution computed tomography thorax showed the presence of bilateral pleural effusion (left >right) with left-sided pleural thickening, bilateral septal thickening, and bilateral randomly distributed nodules, and also bilateral segmental consolidation with air bronchogram. The patient had undergone extensive workup and was diagnosed with silicosis.
Keywords: Pleural effusion, pneumoconiosis, silicosis
|How to cite this article:|
Rout P, Markam G. Pleural effusion in silicosis: A rare case report. Med J DY Patil Vidyapeeth 2018;11:436-8
| Introduction|| |
Silicosis is a diffuse pulmonary interstitial disease characterized by a fibrotic response in lung parenchyma caused by continual inhalation of crystalline silica (SiO2). It is one of the primary pneumoconiosis diseases caused by inhalation of mineral dust, and its presentation, clinical course, and severity are variable. Several forms of the disease can be identified from the clinical, radiological, and functional data. These are classified as chronic silicosis (simple, complicated, and interstitial pulmonary fibrosis), accelerated silicosis, and acute silicosis.
Various pleural involvements such as pleural thickening and progressive multifocal fibrosis-associated pleural invaginations are well-recognized complications associated with silicosis, particularly advanced pulmonary silicosis. However, pleural effusion is not a well-recognized finding in patients with silicosis and extremely rare presentation. To the best of our knowledge, there have been only few cases of silicosis with pleural effusion reported in medical literature. Herein, we describe a case of a 60-year-old male, who presented with shortness of breath and left-sided pleural effusion. The patient had undergone extensive workup and was diagnosed with pulmonary silicosis.
| Case Report|| |
A 60-year-old male with a history of diabetes mellitus and hypertension presented to the emergency department with worsening shortness of breath. He reported that he has been having some chronic baseline dyspnea on exertion for the last 5 years. The dyspnea aggravated for the last 15 days to such an extent that he was dyspneic with simple tasks such as while getting dressed and showering. He also complained of dry cough for the last 2 years. There was no history of fever or hemoptysis or chest pain. He did not have any history of joint pain or swelling or rash. He was a nonsmoker. He used to work in a stone crusher factory as laborer for around 25 years. There was no history of tuberculosis (TB) exposure. The patient was on insulin therapy, and he had received antitubercular drugs on the basis of clinical suspicion in the primary health center for 6 months, but the symptoms did not subside.
On examination, he was afebrile and tachypneic with respiratory rate of 30 per min. His oxygen saturation was 88% on room air at rest. There was presence of pallor and clubbing. On chest examination, he had signs of left-sided pleural effusion along with coarse crepitations bilaterally.
Routine laboratory studies such as complete blood count, liver function test, renal function test, and serum electrolytes were normal. Fasting blood sugar was 210 mg/dl. Serology for rheumatoid arthritis factor was negative. Sputum for acid-fast bacilli was negative. Chest X-ray posteroanterior view showed the presence of bilateral reticulonodular opacities along with left-sided pleural effusion [Figure 1]. In high-resolution computed tomography (HRCT) thorax, there was the presence of bilateral pleural effusion (left >right) with left-sided pleural thickening, bilateral septal thickening, and bilateral randomly distributed nodules [Figure 2]a. HRCT thorax also showed bilateral segmental consolidation with air bronchogram [Figure 2]b. Fiberoptic bronchoscopy (FOB) showed anthracotic pigmentations and inflammation in all the lobar and segmental bronchi with normal trachea and carina. Electrocardiography and two-dimensional echocardiography were done and were normal.
|Figure 1: Left-sided pleural effusion and bilateral reticulonodular opacities|
Click here to view
|Figure 2: (a) Bilateral pleural effusion (left > right) with left-sided pleural thickening, bilateral septal thickening, and bilateral randomly distributed nodules. (b) Bilateral segmental consolidation with air bronchogram|
Click here to view
Post-FOB sputum and bronchoalveolar lavage (BAL) fluid cartridge-based nuclear acid amplification test (CBNAAT) for mycobacterium were negative. BAL fluid showed no growth for any organism in culture. Pleural fluid analysis showed exudative features with protein of 4.6 mg/dl, lactate dehydrogenase of 734 IU/L, and adenosine deaminase of 14 IU. Pleural fluid culture showed no growth for any bacteria, TB, or fungi. Medical thoracoscopy was attempted, but the procedure was stopped because lungs were extensively fibrosed and did not collapse.
| Discussion|| |
Silicosis is a well-known occupational lung disease caused by silica inhalation. Phagocytosis of crystalline silica in the lung causes lysosomal damage, activating the NALP3 inflammasome and triggering the inflammatory cascade with subsequent fibrosis. Occupational silicosis has both pulmonary and extrapulmonary manifestations. Involvement of pleura is rare but well described in silico sis. Pleural involvement in silico sis is well recognized, especially in advanced pulmonary silicosis. TB is a well-established complication of silicosis. Silicosis was also found to be associated with some chronic kidney diseases, rheumatoid arthritis, and systemic sclerosis. However, pleural silicosis is still less common and less emphasized in medical literature than asbestosis as an occupational lung disease that is associated with pleural plaque, pleural effusion, and diffuse pleural thickening.
Our patient had a history of occupational exposure to silica dust for 25 years and was symptomatic for 5 years. Chest X-ray showed bilateral reticulonodular opacities with left-sided pleural effusion, and the computed tomography scan features suggested the presence of silicosis. Sputum and BAL fluid CBNAAT were negative. Hence, TB was almost ruled out. Pleural fluid and BAL fluid culture were negative and hence excluded any other infective etiology. The patient had no history of joint pain, and pleural fluid sugar level was not low. Hence, rheumatoid arthritis was almost excluded. Pleural fluid was negative for any malignant cells. Bronchoscopic findings were also in favor of pneumoconiosis. Hence, it is speculated that the pleural effusion is due to silicosis.
It is plausible that silicosis can cause a pleural reaction and pleural effusion similar to that which occurs in asbestosis. Although pleural effusion is unusual in silico sis, it is a possible cause if infectious, malignant, cardiovascular, renal, and connective tissue disease causes have been ruled out.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
I am extremely thankful to Dr Lulup Kumar Sahoo for literature search, editing, and guidance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alvarez RF, Gonzalez CM, Martinez AQ, Perez JJB, Fernandez LC, Fernandez AP. Guidelines for the diagnosis and monitoring of silicosis – Recommendations of SEPAR. Arch Bronconeumol 2015;51:86-93.
Salih M, Aljarod T, Ayan M, Jeffrey M, Shah BH. Pulmonary silicosis presents with pleural effusion. Case Rep Med 2015;2015:543070. doi: 10.1155/2015/543070. Epub 2015 Sep 7.
Leung CC, Yu IT, Chen W. Silicosis. Lancet 2012;379:2008-18.
Zeren EH, Colby TV, Roggli VL. Silica-induced pleural disease: An unusual case mimicking malignant mesothelioma. Chest 1997;112:1436-8.
Craighead JE, Kleinerman J, Abraham JZ. Diseases associated with exposure to silica and nonfibrous silicate minerals. Archives of Pathology and Laboratory Medicine 1988:112;673-720.
National Institute for Occupational Safety and Health. Health Effects of Occupational Exposure to Respirable Crystalline Silica. Cincinnati, Ohio, USA: Department of Health and Human Services; 2002.
Makol A, Reilly MJ, Rosenman KD. Prevalence of connective tissue disease in silico
sis (1985-2006)-a report from the state of Michigan surveillance system for silicosis. Am J Ind Med 2011;54:255-62.
al-Kassimi FA. Pleural effusion in silico
sis of the lung. Br J Ind Med 1992;49:448-50.
[Figure 1], [Figure 2]