[A rare case: Erasmus syndrome and tuberculosis]. / Un caso poco frecuente: síndrome de Erasmus y tuberculosis.

We present the case of a 35-year-old male patient, sandblaster for eight years, recently diagnosed with pulmonary tuberculosis and systemic sclerosis, who was admitted with dyspnea and poor general condition. Chest X-ray showed a grade I pneumothorax, and on the chest tomography he presented confluent hyperdense masses associated with a pattern of non- specific interstitial pneumonia (NSIP), findings compatible with complicated silicosis. Due to the advanced clinical stage, neither invasive diagnostic test nor pulmonary function test could be performed. Initial treatment included placement of a pleural drainage tube, antituberculosis treatment and chronic home oxygen. The patient was referred to the interstitial disease and rheumatology departments for multidisciplinary management, although the infectious condition contraindicated the possibility of immunosuppressive treatment. The patient eventually died under palliative care. Silica inhalation is the cause of silicosis, but it is also implicated in the development of systemic sclerosis (Erasmus syndrome) and although they share a common risk factor, it is rare to find both diseases coexisting. We present the case of a young patient in whom both diseases presented aggressively, with the aim of highlighting the importance of actively searching for expositional diseases and associated conditions.

Presentamos el caso de un hombre de 35 años, arenador durante ocho años, con diagnóstico reciente de tuberculosis pulmonar y esclerosis sistémica, que ingresó por cuadro de disnea y mal estado general. Se realizó radiografía de tórax donde se evidenció neumotórax grado I, en la tomografía de tórax, también presentó masas hiperdensas confluyentes, asociadas a un patrón de neumonía intersticial no especifica (NSIP), hallazgos compatibles con silicosis pulmonar complicada. Debido al avanzado estadio clínico, no pudieron realizarse estudios diagnósticos invasivos ni estudios de función pulmonar. Como tratamiento inicial se colocó un tubo de avenamiento pleural, se realizó tratamiento antifímico y se indicó oxigenoterapia crónica domiciliaria. Se remitió al paciente a consultorios de enfermedades intersticiales y reumatología para un manejo multidisciplinario, aunque el cuadro infeccioso contraindicó la posibilidad de un tratamiento inmunosupresor. Finalmente, el paciente falleció bajo cuidados paliativos. La inhalación de sílice es la causa de la silicosis, pero también está implicada en el desarrollo de la esclerosis sistémica (síndrome de Erasmus) y aunque comparten un factor de riesgo común, es raro encontrar ambas enfermedades coexistiendo. Presentamos el caso de un paciente joven donde ambas condiciones se presentaron de manera agresiva, con el objetivo de remarcar la importancia de la búsqueda activa de las enfermedades por exposición y sus condiciones asociadas.

Volume-based tomography for the diagnosis of incipient silicosis in former gold miners.

OBJECTIVE: To evaluate silicosis diagnosed through CT, with integration of clinical-occupational data, in silica-exposed workers presenting chest X-rays within International Labor Organization (ILO) category 0. METHODS: Cross-sectional study with 339 former gold miners, with comparable exposures and X-rays classified as ILO subcategory 0/0 (n=285) and 0/1 (n=54) were submitted to volume-based CT. The findings were classified according to the International Classification of HRCT CT for Occupational and Environmental Respiratory Diseases. RESULTS: A profusion degree of round opacities (RO)>1 was found in 22.4% (76/339) of the CT exams. After integrating the CT findings with clinical and occupational data, silicosis was diagnosed as follows: 43/285 (15.1%) and 14/54 (25.9%) in workers whose X-rays had been classified as 0/0 and 0/1, respectively. There was an upward trend towards longer exposures, reaching 38.9% when working more than 10 years underground and classified as 0/1 (p=0019). Those with presence of RO whose final diagnosis was not silicosis were mainly cases of tuberculosis or 'indeterminate nodules'. Emphysema was found in 65/339 (19.1%), only 5 being detected in the X-ray. CONCLUSION: Volume-based CT proved to be useful in the investigation of silicosis among individuals with a relevant exposure to silica, capturing diagnoses that had not been identified on X-rays. A response gradient of silicosis was showed by CT even in this population with ILO category 0 radiographs. It can be indicated based on quantitative and/or qualitative criteria of occupational exposure, especially considering the possibilities of low CT dosage.

Labeling mesenchymal cells with DMSA-coated gold and iron oxide nanoparticles: assessment of biocompatibility and potential applications.

BACKGROUND: Nanoparticles' unique features have been highly explored in cellular therapies. However, nanoparticles can be cytotoxic. The cytotoxicity can be overcome by coating the nanoparticles with an appropriated surface modification. Nanoparticle coating influences biocompatibility between nanoparticles and cells and may affect some cell properties. Here, we evaluated the biocompatibility of gold and maghemite nanoparticles functionalized with 2,3-dimercaptosuccinic acid (DMSA), Au-DMSA and γ-Fe2O3-DMSA respectively, with human mesenchymal stem cells. Also, we tested these nanoparticles as tracers for mesenchymal stem cells in vivo tracking by computed tomography and as agents for mesenchymal stem cells magnetic targeting. RESULTS: Significant cell death was not observed in MTT, Trypan Blue and light microscopy analyses. However, ultra-structural alterations as swollen and degenerated mitochondria, high amounts of myelin figures and structures similar to apoptotic bodies were detected in some mesenchymal stem cells. Au-DMSA and γ-Fe2O3-DMSA labeling did not affect mesenchymal stem cells adipogenesis and osteogenesis differentiation, proliferation rates or lymphocyte suppression capability. The uptake measurements indicated that both inorganic nanoparticles were well uptaken by mesenchymal stem cells. However, Au-DMSA could not be detected in microtomograph after being incorporated by mesenchymal stem cells. γ-Fe2O3-DMSA labeled cells were magnetically responsive in vitro and after infused in vivo in an experimental model of lung silicosis. CONCLUSION: In terms of biocompatibility, the use of γ-Fe2O3-DMSA and Au-DMSA as tracers for mesenchymal stem cells was assured. However, Au-DMSA shown to be not suitable for visualization and tracking of these cells in vivo by standard computed microtomography. Otherwise, γ-Fe2O3-DMSA shows to be a promising agent for mesenchymal stem cells magnetic targeting.

Patrón de lectura radiológica digital para la clasificación de imágenes compatibles con silicosis / Digital reading radiation pattern for classification of image about silicosis (P0140-2013)

La silicosis es una enfermedad sin tratamiento. El programa de vigilancia de trabajadores expuestos a sílice está diseñado para detectarla lo más precozmente posible mediante una radiografía de tórax. A pesar de su rol fundamental, esta adolece de una gran variabilidad técnica y de interpretación. Para disminuir estos fenómenos, la OIT creó un sistema de clasificación ampliamente usado en Chile y el mundo. Este se basó en la radiografía análoga, la que ha sido reemplazada por el mismo set análogo, digitalizado. Si bien la OIT permite el uso de este nuevo tipo de imagen, indica que el patrón de comparación debe seguir siendo el análogo. Muchos estudios han demostrado que es mejor utilizar patrones de comparación digitales. El objetivo de este trabajo fue generar un set de radiografías digitales que representen las profusiones centrales de opacidades redondas del sistema de clasificación OIT. De un universo de 32.826 radiografías de pacientes expuestos a sílice, se obtuvo 252 radiografías, de las cuales 54 fueron informadas por 3 lectores acreditados, seleccionándose 8 casos que contaban con opacidades redondas puras de diferentes profusiones, las que se proponen como patrón digital para Chile.

Silicosis is a disease without treatment. The surveillance program for workers exposed to silica is designed to detect as early as possible by a chest radiograph. Despite its fundamental role, it suffers from a great technique and interpretation variability. To reduce these phenomena, the ILO created a classification system widely used in Chile and the world. This was based on analog radiography, which has been replaced by the same analog set, digitized. While the ILO permits the use of this new type of image it indicates that the pattern comparison must remain analog. Many studies have shown that it is best to use digital comparison patterns. The objective of this work was to generate a set of digital x-rays representing the central profusion of round opacities of ILO classification system. From a universe of 32,826 x-rays of patients exposed to silica, 252 films, of which 54 were reported for 3 accredited readers, selected 8 cases that had pure round opacities of different profusions was obtained, which are proposed as digital pattern for Chile.

Relationships between the pulmonary densitometry values obtained by CT and the forced oscillation technique parameters in patients with silicosis.

OBJECTIVE: To evaluate the correlations between pulmonary densitometry values and forced oscillation technique (FOT) parameters in patients with silicosis. METHODS: This cross-sectional study comprised 36 non-smoker patients with silicosis and 20 matched control subjects who were submitted to FOT and multidetector CT (MDCT). RESULTS: Compared with the control subjects, the MDCT evaluation demonstrated that patients with silicosis exhibited greater total lung mass. These patients also had larger non-aerated and poorly aerated compartments, which included nodules and scarring. Compared with the control subjects, FOT evaluation demonstrated that patients with silicosis exhibited changes in both reactive and resistive properties of the respiratory system. In these patients, there was a greater heterogeneity of the respiratory system and increased work of breathing. Significant correlations between non-aerated compartment size and FOT parameters that reflect the non-homogeneity of the respiratory system were observed. The dynamic compliance of the respiratory system was negatively correlated with non-aerated compartment size, while the impedance at 4 Hz was positively correlated with non-aerated compartment size. CONCLUSION: Patients with silicosis have heavier lungs. In these patients, a larger non-aerated compartment is associated with a worsening of lung function. A more significant pulmonary involvement is associated with a loss of homogeneity and increased mechanical load of the respiratory system. Advances in knowledge The findings provided by both pulmonary densitometry and FOT may add valuable information to the subjective analysis of silicosis; however, more studies are necessary to evaluate the potential use of these methods for assessing disease progression.

Silicosis in sandblasters of shipyard versus silicosis in stone carvers in Brazil: a comparison of imaging findings, lung function variables and cardiopulmonary exercise testing parameters.

OBJECTIVES: To compare imaging findings, lung function variables and cardiopulmonary exercise testing (CPET) results between Brazilian sandblasters of shipyard and stone carvers with silicosis. METHODS: Of the 41 patients, 25 subjects were sandblasters and 16 were stone carvers, with median ages of 52 and 46.4 years, respectively. All of the patients underwent pulmonary function tests and CPET. Chest radiographs were classified according to the International Labour Organization recommendations. The following parameters were examined through the use of high-resolution computerized tomography (HRCT): nodules, progressive massive fibrosis (PMF), emphysema, and intrathoracic lymph node enlargement. RESULTS: Large opacities on chest radiography were observed in 76% of sandblasters and only 18.7% of stone carvers. Using HRCT, PMF was identified in 92% of sandblasters and only 43.7% of stone carvers. Although carbon monoxide diffusing capacity results were significantly different between the sandblasters and stone carvers, these differences were more pronounced in the CPET results. While 92% of sandblasters failed to reach at least 80% of their predicted peak oxygen uptake (VO(2)), this was observed for only 43.7% of stone carvers. A breathing reserve of less than 25% was observed in 40.5% of sandblasters but not in any of the stone carvers. CONCLUSION: In silicosis, imaging findings, lung function and CPET results are strongly influenced by the type of exposure to silica dust. Additionally, CPET abnormalities are more pronounced compared to measurements taken at rest.

[Occupational exposure and occurrence of pneumoconioses in Campinas, Brazil, 1978-2003]. / Exposição ocupacional e ocorrência de pneumoconioses na região de Campinas (SP) Brasil, 1978-2003.

OBJECTIVE: To develop and consolidate a comprehensive database on the occurrence of pneumoconioses in an industrialized region of Brazil, with a special focus on the activities most frequently related to these diseases. METHODS: A retrospective, observational study was conducted in order to gather data on cases of pneumoconioses treated at the outpatient clinic of the State University at Campinas Hospital das Clínicas between 1978 and 2003. Individuals diagnosed with pneumoconiosis, based on their occupational history and on chest X-ray findings of abnormalities consistent with interstitial lung disease involving the parenchyma, in accordance with the 1980 and 2000 recommendations of the International Labour Organization, were included in the study. RESULTS: A total of 1147 cases of pneumoconiosis were identified (1075 in males and 72 in females): 1061 cases of silicosis (92.5%); 51 cases of mixed-dust pneumoconiosis (4.45%); 15 cases of asbestosis (1.31%); 13 cases of phosphate rock-related pneumoconiosis (1.13%); and 7 cases of other types of pneumoconiosis (0.6%), including those related to exposure to coal, graphite and hard metals. The most common chest X-ray findings were 1/0, 1/1 or 1/2 profusion and small regular opacities (p, q or r), although 192 patients (16.74%) presented large opacities. There has been a substantial decline in the occurrence of the disease since the 1990s, and the duration of exposure was typically shorter than that observed in a study conducted in the United States. CONCLUSIONS: Our findings have been compiled into a comprehensive database for the investigation of pneumoconiosis in an industrialized area of Brazil. These data make it possible to conduct follow-up studies and develop health policies related to occupational respiratory disorders.

High-resolution computed tomography in silicosis: correlation with chest radiography and pulmonary function tests.

OBJECTIVE: To correlate tomographic findings with pulmonary function findings, as well as to compare chest X-ray findings with high resolution computed tomography (HRCT) findings, in patients with silicosis. METHODS: A cross-sectional study was conducted in 44 non-smoking patients without a history of tuberculosis. Chest X-ray findings were classified according to the International Labour Organization recommendations. Using a semiquantitative system, the following HRCT findings were measured: the full extent of pulmonary involvement; parenchymal opacities; and emphysema. Spirometry and forced oscillation were performed. Pulmonary volumes were evaluated using the helium dilution method, and diffusing capacity of the lung for carbon monoxide (DLCO) was assessed. RESULTS: Of the 44 patients studied, 41 were male. The mean age was 48.4 years. There were 4 patients who were classified as category 0 based on X-ray findings and as category 1 based on HRCT findings. Using HRCT scans, we identified progressive massive fibrosis in 33 patients, compared with only 23 patients when X-rays were used. Opacity score was found to correlate most closely with airflow, DLCO and compliance. Emphysema score correlated inversely with volume, DLCO and airflow. In this sample of patients presenting a predominance of large opacities (75% of the individuals), the deterioration of pulmonary function was associated with the extent of structural changes. CONCLUSIONS: In the early detection of silicosis and the identification of progressive massive fibrosis, HRCT scans are superior to X-rays.

Silicoproteinosis: high-resolution CT findings in 13 patients.

OBJECTIVE: The purpose of this study was to evaluate the high-resolution CT findings of silicoproteinosis. CONCLUSION: Silicoproteinosis usually manifests as bilateral consolidation in the posterior portions of the lungs and as numerous centrilobular nodules. Calcification within areas of consolidation is a common finding.

Continued exposure to silica after diagnosis of silicosis in Brazilian gold miners.

BACKGROUND: There is a paucity of studies analyzing the effect of continued silica exposure after the onset of silicosis with regard to disease progression. The present study investigates differences in clinical and radiological presentation of silicosis among former workers with a diagnosis of silicosis, and compares workers who continued to be exposed to silica with those who stopped silica exposure after having received their diagnosis. METHODS: A sample of 83 former gold miners with a median of 21 years from the first diagnoses of silicosis, had their clinical and occupational histories taken and underwent both chest radiography (International Labor Organization standards) and spirometry. Their silica exposure was assessed and an exposure index was created. The main outcome was the radiological severity of silicosis and tuberculosis (TB). The statistical analysis was done by multiple logistic regression. RESULTS: Among the 83 miners, 44 had continued exposed to silica after being diagnosed with silicosis. Continuation of silica exposure was associated with advanced radiological images of silicosis (X-ray classification in category 3, OR = 6.42, 95% CI = 1.20-34.27), presence of coalescence and/or large opacities (OR = 3.85, CI = 1.07-13.93), and TB (OR = 4.61, 95% CI = 1.14-18.71). CONCLUSIONS: Differential survival is unlikely to explain observed differences in silicosis progression. Results reinforce the recommendation that silica exposure should be halted at an early stage whenever X-ray is suggestive of the disease.

Conglomerated masses of silicosis in sandblasters: high-resolution CT findings.

The purpose of this study was to describe the high-resolution CT aspects of the silicosis and progressive massive fibrosis in sandblasters. The study was performed with 25 consecutive patients with silicosis and large opacities on chest radiography according to the International Labor Office (ILO) classification of pneumoconiosis. All patients presented with conglomerate masses involving the upper lobes, and in 92% of the cases the lesions were located in the posterior region of the lungs. The masses frequently showed nodular contour (76%), air bronchograms (76%), foci of calcification (72%), paracicatricial emphysema (72%), and adjacent pleural thickening (92%). Calcification of hilar or mediastinal lymph nodes (96%), mainly of the egg-shell type (56%), was also a common finding. In conclusion, in this specific group of patients, the sandblasters, the high-resolution CT demonstrated conglomerated masses with nodular contour, air bronchograms and foci of calcification, which were distributed mainly in the posterior region of the upper lobes. Calcification of hilar or mediastinal lymph nodes was also commonly seen.

Progressive massive fibrosis in silica-exposed workers. High-resolution computed tomography findings.

OBJECTIVE: To evaluate the radiological characteristics of conglomerate masses using high-resolution computed tomography of the chest. METHODS: From among the patients treated between 1986 and 2004 at the Antonio Pedro University Hospital, 75 patients with silicosis and massive fibrosis, most working in the field of sandblasting, were selected for study. These patients were submitted to a clinical evaluation, chest X-ray and high-resolution computed tomography of the chest. RESULTS: In more than half of the patients with accelerated silicosis, the chest X-ray revealed large type B and C opacities, denoting the severity of the disease in those patients. In 1 case, a unilateral mass simulating lung cancer was observed. High-resolution computed tomography scans of the chest were acquired for 44 patients. In most cases (88.6%), the masses were located in the superior and posterior thirds of the lung. Common findings within the masses included air bronchograms (in 70.4%) and calcifications (in 63.6%). A history of tuberculosis was reported by 52% of the patients. CONCLUSION: In the vast majority of cases, the masses were bilateral, predominantly located in the superior and posterior regions of the lung, featuring air bronchograms and interposed calcifications. Concomitant calcification of the mediastinal and hilar lymph nodes was another common finding. Exposure to high concentrations of dust and having a history of tuberculosis were considered significant risk factors for the development of progressive massive fibrosis.

[Imaging in occupational lung diseases]. / Imagem nas doenças ocupacionais pulmonares.

This chapter consists of a review of the literature regarding radiographic and tomographic characteristics of the principal occupational respiratory diseases (silicosis and asbestosis). Special attention is given to the practical relevance of high-resolution computed tomography, which is the most sensitive and specific method of identifying and quantifying the extent of pleural and parenchymal lesions related to such diseases.

High-resolution CT in silicosis: correlation with radiographic findings and functional impairment.

OBJECTIVE: To assess high-resolution computed tomography (HRCT) findings in silicosis and to better define the role of HRCT in early detection of parenchymal abnormalities in silica-exposed workers. METHODS: Forty-one stone carvers were evaluated with chest radiographs (CR), HRCT, and pulmonary function tests (PFT). Inter-reader agreement was calculated using the kappa statistic (k). Correlation between radiographic and HRCT profusion scores and PFT was assessed using the Spearman correlation coefficient. RESULTS: The most common HRCT findings were branching centrilobular structures, seen in 28/41 workers (68.3%). Nodules consistent with silicosis were detected in 53.7% workers on CR and in 56.1% workers on HRCT. Inter-reader agreement for diagnosis of silicosis was better on HRCT (k = 0.84) than on CR (k = 0.54). Small opacity profusion on HRCT correlated inversely with total lung capacity and FVC%. CONCLUSION: Profusion of opacities on HRCT correlates with functional impairment. The presence of branching centrilobular structures may be helpful in early recognition of silicosis.