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Weekly Chest CasesArchive of Old Cases

Case No : 761 Date 2012-05-29

  • Courtesy of Hyo Rin Kim, Sang Hyun Paik, Jai Soung Park / Soon Chun Hyang University Bucheon Hospital
  • Age/Sex 33 / M
  • Chief ComplaintDyspnea and cough for 3 months. (Occupational History: Handling tungsten in factory)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Figure 1.

Diagnosis With Brief Discussion

Diagnosis
Giant-cell interstitial pneumonia
Radiologic Findings
Initial HRCT demonstrates patchy ground-glass opacities in peripheral portion of both lungs. Follow up HRCT after 3 months shows patchy and centrilobular ground-glass opacities in both lungs.
Pathologic specimen obtained with video-assisted thoracoscopic surgical biopsy in the lower lobe of the right lung shows macrophages with multinucleated giant cells and peribronchiolar fibrosis.
Brief Review
Hard metal is an alloy of tungsten carbide and cobalt, sometimes mixed with other metals. Of these, at least cobalt is toxic to the lung. Exposure to aerosolized particulates containing cobalt inhaled during the manufacture or grinding of hard metal results in interstitial inflammation with fibrosis and lung destruction, which may develop within a few years of exposure. The histologic appearance of hard metal pneumoconiosis has been termed giant cell interstitial pneumonia.
The clinical features of GIP are nonspecific. Patients complain of shortness of breath, cough and dyspnea on exertion. Generally, if exposure is avoided, patients improved in symptoms and physiologic study, although residual lesions tend to persist.
HRCT findings include ground-glass opacity, coarse reticular opacities, consolidation, architectural distortion, traction bronchiectasis and bronchiolectasis, and subpleural bullae. The presence of ground-glass opacity and reticulation are most common, but honeycombing may occur with disease progression. These CT findings correspond histopathologically to areas of interstitial thickening caused by fibrosis and inflammatory cell infiltration and to areas of intra-alveolar accumulation of macrophages and multinucleated giant cells. The distribution may be patchy or with upper or lower lobe predominance.
The histopathologic manifestations of hard-metal disease range from bronchitis to subacute fibrosing alveolitis to interstitial fibrosis. Obliterative bronchiolitis is reported to be the earliest manifestation of hard-metal disease. Subacute fibrosing alveolitis is characterized by the desquamation of epithelial cells and the accumulation of macrophages and multinuclear giant cells in the alveolar spaces within a few years of initial exposure, whereas chronic diffuse mural fibrosis with honeycombing occurs several years or more after initial exposure.
References
1. Webb, WR, Muller, NL, Naidich, DP High resolution computed tomography findings of lung disease, 4th eds. 2009,329 Lippincott William & Wilkins. Philadelphia, PA.
2. Lee SM, Moon CH, Oh YB, et al. Giant-cell interstitial pneumonia in a gas station worker. J Korean Med Sci1998 ;13:545 -547
3. Pakes WR. Cobalt. In: Pakes WR, ed. Occupational lung disease. London, England: Butterworths, 1982; 464
Keywords
lung, inhalation, Occupational lung disease,

No. of Applicants : 88

▶ Correct Answer : 50/88,  56.8%
  • - Hanam sungshim hospital , Korea (South) CHANG IL KIM
  • - Kyung Hee Universitiy Hospital at Gangdong , Korea (South) Seong Jong Yun
  • - University of British Columbia , Canada Amr Ajlan
  • - GM InHospital , Korea (South) Ju Won Lee
  • - Samsung medical center , Korea (South) Hyun Su Kim
  • - Saga University , Japan Ryoko Egashira
  • - Kurashiki Seijin-byo Center , Japan Akihiro Tada
  • - Retd. Prof Thoracic Surgery B.J.MEDIDCAL COLLEGE Punr India;Visitng Prof of Thoracic Surgery KLE University Belgaum , India Bankim Amin
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - kyunghee university medical center , Korea (South) An ji young
  • - Chonnam national univ. hospital , Korea (South) Choi Seul-Gi
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - stanley medical college & GHTM , India madhan k
  • - o2 clinic, pudukottai, india , India siva raja
  • - Kohka Public Hospital , Japan Akitoshi Inoue
  • - China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Radnet Teleradiology Istanbul , Turkey Armagan Sarac
  • - Asan Medical Center , Korea (South) Ji Eun Kim
  • - Asan medical center , Korea (South) Hyun Joo Lee
  • - Asan Medical Center , Korea (South) Hye Jeon Hwang
  • - Asan Medical Center , Korea (South) Eunyoung Kim
  • - Mashhad University of Medical Sciences , Iran Bita Abbasi
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Fortis hospital , India shaleen rana
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Az Osp Santa Maria Terni , Italy angelo carloni
  • - A.P.Chest hospital ,hyderabad , India bhaskar kakarla
  • - Himeji St.Mary Hospital , Japan Yuichiro Kanie
  • - chungbuk national university hospital , Korea (South) soojung lee
  • - Chungbuk national university hospital , Korea (South) Jisun Lee
  • - Hanyang University Hospital , Korea (South) Yo Won Choi
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Gangnam severance , Korea (South) Young Yoon
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Asan medical center , Korea (South) Jong Woo Kim
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Centre Hospitalier Lyon Sud , France matthieu ROUSSET
  • - Ukrainian Children , Ukraine Oleksandr Kondrachuk
  • - Private sector , Greece Vasilios Tzilas
  • - Korea university , Korea (South) Kun Woo Kang
  • - Chonnam national university hospital , Korea (South) Jang-hyeon Song
  • - XiangYa hospital , China Xia Yu
  • - Asan medical center , Korea (South) Sang Young Oh
  • - Chonnam National University Hospital , Korea (South) Jung hyun Kim
▶ Correct Answer as Differential Diagnosis : 8/88,  9.1%
  • - Sunchun university hospital, Bucheon , Korea (South) So Young Bae
  • - KING ABDULAZIZ SPECIALIST HOSPITAL , Saudi Arabia Elbagir Nasser
  • - ghtm,tambaram , India siva suba
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Asan Medical Center , Korea (South) Sang Min Lee
  • - SNUH , Korea (South) Euijin Hwang
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - All India Institute of medical sciences , India Justin Moses
▶ Semi-Correct Answer : 17/88,  19.3%
  • - radiologist, aditya imaging centre , India vivek patel
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - CHU Poitiers , France CHAN paul
  • - Korea Uivercity Medical Center , Korea (South) Euddeum Shim
  • - McGill University Health Center , Canada Alexandre Semionov
  • - CLCC , France nicolas gautier
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
  • - GOLD child and chest clinic tirunelvelli , India saravanan m
  • - CH de la C�te Basque , France Paul ARDILOUZE
  • - Fukuyama city hospital , Japan Ryotaro Kishi
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
  • - Seoul St Mary Hospital , Korea (South) Chae Lim
  • - Okayama university , Japan Mayu Uka
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