Reported occupational respiratory diseases in Catalonia.

OBJECTIVES: A voluntary surveillance system was implemented in Catalonia (Spain) to ascertain the feasibility, incidence, and characteristics of occupational respiratory diseases and compare them with those of the compulsory official system. METHODS: In 2002, in collaboration with the Occupational and Thoracic Societies of Catalonia, occupational and chest physicians and other specialists were invited to report, on a bimonthly basis, newly diagnosed cases of occupational respiratory diseases. Information requested on each case included diagnosis, age, sex, place of residence, occupation, suspected agent, and physician's opinion on the likelihood that the condition was work related. Compulsory official system data derived from statistics on work related diseases for possible disability benefits declared by insurance companies, which are responsible for declaring these diseases to the Autonomous Government of Catalonia. RESULTS: Of 142 physicians seeing patients with occupational respiratory diseases approached, 102 (74%) participated. Three hundred and fifty nine cases were reported, of which asthma (48.5%), asbestos related diseases (14.5%), and acute inhalations (12.8%) were the most common. Physicians rated 63% of suspected cases as highly likely, 28% as likely, and 8% as low likelihood. The most frequent suspected agents reported for asthma were isocyanates (15.5%), persulphates (12.1%), and cleaning products (8.6%). Mesothelioma (5.9%) was the most frequent diagnosis among asbestos related diseases. The number of acute inhalations reported was high, with metal industries (26%), cleaning services (22%), and chemical industries (13%) being the most frequently involved. The frequency of occupational respiratory diseases recorded by this voluntary surveillance system was four times higher than that reported by the compulsory official system. CONCLUSIONS: The compulsory scheme for reporting occupational lung diseases is seriously underreporting in Catalonia. A surveillance programme based on voluntary reporting by physicians may provide better understanding of the incidence and characteristics of these diseases. Persulphates and cleaning products, besides isocyanates, were the most reported causes of occupational asthma. Metal industries and cleaning services were the occupations most frequently involved in acute inhalations with a remarkably high incidence in our register.

[Reactive airways dysfunction syndrome]. / Síndrome de disfunción reactiva de las vías aéreas.

Reactive airways dysfunction syndrome, better known as RADS, was described as a clinical entity consisting in the appearance of bronchial asthma due to massive toxic inhalation. The term was coined and recognised for the first time in 1985. Since then different publications have verified new cases as well as different causal agents. It usually arises from an accident at the work place and in closed or poorly ventilated spaces, where high concentrations of irritant products are inhaled in the form of gas, smoke or vapour. In the following minutes or hours symptoms of bronchial obstruction appear in an acute form, with bronchial hyperresponsiveness persisting for months or years. The affected patients do not show a recurrence of symptoms following exposure to non-toxic doses of the same agent that started the symptoms. This is why diagnosis is based on clinical manifestations as it is not reproducible through a provocation test.

Usefulness of skin test in Farmer's lung.

The skin test with hay extract or with Micropolyspora faeni (MF), is not commonly used in the diagnosis of Farmer's lung (FL), as it is not considered specific. In our study, we have applied the intracutaneous test with these antigens in 26 patients affected with FL; 18 of them were still in contact with the antigen and the remaining eight had not been in contact with the hay during the previous year. Twenty-five asymptomatic farmers (AF) served as a control group. In the first group and with hay extract, the immediate reading (I) was positive in 15 of 18 (83.3 percent), the late reaction (L) in 18 of 18 (100 percent), and the delayed one (D) in eight of 18 (44.4 percent). In the 25 AF, the results were as follows: I, seven of 85 (28 percent); L, 17 of 25 (68 percent); and D, one of 25 (4 percent). Consequently, the differences between both groups were significant: I, p less than 0.01; L, p less than 0.05; and D, p less than 0.01. Using MF as an antigen, the test is somewhat less effective: p less than 0.02, p less than 0.02, and p less than 0.2, respectively. These results suggest that the intradermal injection with hay extract is an easy, effective test in the diagnosis of FL, and at the same time, a better means of distinguishing FL patients from AF than the precipitation test.

Diagnostic value of bronchoalveolar lavage in suspected pulmonary tuberculosis.

Of 222 patients suspected of having pulmonary tuberculosis (PT), studied during a one-year period, we performed fiberoptic bronchoscopy together with bronchoalveolar lavage (BAL), bronchial washing and postbronchoscopy sputum smears and Löwenstein cultures in 20 patients. Bronchoalveolar lavage proved to be the most effective method leading to diagnosis in 17 of 20 cases. Diagnosis was obtained in 11 of 20 cases using bronchial washing and postbronchoscopy sputum. The results of this study suggest that bronchoscopy may be required in selected cases for the diagnosis of PT. However, it should be accompanied by BAL, bronchial washings and postbronchoscopy sputum smears. Indications for bronchoscopy as a diagnostic tool for PT may include: (a) patients suspected of having PT with negative smears and in whom treatment must be started due to clinical status; (b) suspicion of associated neoplasia; (c) selected patients with negative Löwenstein cultures; (d) lack of material being obtained by simpler methods.

Evolution of idiopathic pleural effusion: a prospective, long-term follow-up study.

UNLABELLED: The management of idiopathic pleural effusion remains controversial. Because the long-term evolution of this entity is not well known, two different approaches, aggressive and conservative, have been proposed. We conducted a 10-year study of the evolution of idiopathic pleural effusion. METHODS: Between 1984 and 1994, we prospectively studied 40 consecutive patients (30 men and 10 women; mean [+/- SD] age, 53.8 +/- 19.4 years) with exudative pleural effusion undiagnosed after exhaustive evaluation. The pleural fluid adenosine deaminase level was below 43 IU/L in all; periodic chest radiographs and clinical evaluation were carried out in all patients for a mean of 62 months (range, 36 to 108 months). Further diagnostic procedures were performed whenever the effusion recurred or when indicated by the clinical picture. RESULTS: Effusions resolved in a mean time of 5.6 months (range, 7 days to 48 months). Five patients (12.5%) had one or more relapses of their pleural effusion, and in a further 5 (12.5%), the effusion persisted unchanged for more than 1 month. In 32 cases (80%), no potential cause of the effusion was detected. The diagnoses in the remaining eight cases were asbestos pleural effusion in three, pulmonary adenocarcinoma in one, mesothelioma in one, congestive heart failure in one, liver cirrhosis in one, and rheumatoid arthritis in one. Tuberculosis was not detected in any of the cases, although 19 patients initially had positive tuberculin tests. CONCLUSIONS: Most idiopathic pleural effusions follow a benign course. Our results support conservative treatment of patients with idiopathic pleural effusion. Antituberculous treatment does not appear to he warranted, regardless of tuberculin test results, if the pleural fluid adenosine deaminase level is not elevated.

Time of exposure as a prognostic factor in avian hypersensitivity pneumonitis.

Spirometric values were subsequently evaluated in 22 patients suffering from hypersensitivity pneumonitis caused by avian problems. First spirometric values were abnormal in 18/22 (82%) of patients. A restrictive pattern was observed in 16/22 (72%) of patients and an obstructive pattern in 6/22 (27%). The TLCO was reduced in all cases (12/12). Improvement or normalization of the respiratory function occurred 3.4 +/- 2.4 months after the avian contact had ceased. At the end of the follow-up, parameters were normal in 13/22 (59%) of patients. The restrictive pattern remained unchanged in 7/22 (32%), and the obstructive pattern persisted in 4/22 (18%) of the patients. The TLCO was normal in 6/12 (50%) of patients. Neither age nor treatment with corticosteroids (13 patients) had a significant influence upon the evolution of the lung function. However, total recovery or significant improvement was observed in 12/12 (100%) of patients who had been in contact with birds less than 2 years, in contrast to 6/10 (60%) of patients with more than 2 years of contact (P = 0.002).

Inhaled antibiotic therapy in non-cystic fibrosis patients with bronchiectasis and chronic bronchial infection by Pseudomonas aeruginosa.

The aim of this study was to investigate the long-term effectiveness and safety of inhaled antibiotic treatment in non-cystic fibrosis patients with bronchiectasis and chronic infection by Pseudomonas aeruginosa, after standard endovenous and oral therapy for long-term control of the infection had failed. After completing a 2-week endovenous antibiotic treatment to stabilize respiratory status, 17 patients were randomly allocated to a 12-month treatment either with inhaled ceftazidime and tobramycin (group A) or a symptomatic treatment (group B). One patient from group A abandoned inhaled treatment because of bronchospasm and another from group B died before the end of the study. The remaining 15 patients, seven from group A and eight from group B, completed the study. Both groups had similar previous characteristics. The number of admissions and days of admission (mean +/- SEM) of group A [0.6 (1.5) and 13.1 (34.8)] were lower than those of group B [2.5 (2.1) and 57.9 (41.8)] (P < 0.05). Forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1), PAO2 and PACO2 were similar in the two groups at the end of follow-up, showing a comparable decline in these parameters. There were no significant differences either in the use of oral antibiotics or in the frequency of emergence of antibiotic-resistant bacteria between groups. Microbiological studies suggested that several patients had different Pseudomonas aeruginosa strains. None of the patients presented impaired renal or auditory function at the end of the study. This study suggests that long-term inhaled antibiotic therapy may be safe and lessen disease severity in non-cystic fibrosis patients with bronchiectasis and chronic bronchial infection by Pseudomonas aeruginosa which do not respond satisfactorily to antibiotics administered via other routes.

Validation of specific inhalation challenge for the diagnosis of occupational asthma due to persulphate salts.

BACKGROUND: The significant value of tests used to certify the diagnosis of occupational asthma due to persulphate salts remains uncertain. AIMS: To validate the specific inhalation challenge (SIC) test for the diagnosis of occupational asthma. METHODS: Eight patients with occupational asthma due to persulphate salts, eight patients with bronchial asthma who were never exposed to persulphate salts, and ten healthy subjects were studied. Clinical history taking, spirometry, bronchial challenge with methacholine, skin prick testing to common inhalant allergens and persulphate salts, total IgE levels, and SIC to potassium persulphate were carried out in all subjects. The SIC used increasing concentrations of potassium persulphate (5, 10, 15, and 30 g) mixed with 150 g of lactose. Patients tipped the mixture from one tray to another at a distance of 30 cm from the face for 10 minutes in a challenge booth. RESULTS: The SIC was positive in all subjects with persulphate induced asthma and in one patient with bronchial asthma who had never been exposed to persulphate salts. Sensitivity was 100% (95% CI 67.6 to 100) and specificity was 87.5% (95% CI 52.9-97.8) when patients with occupational asthma due to persulphate salts were compared with those with bronchial asthma never exposed to persulphate salts. CONCLUSIONS: SIC to persulphate salts performed according to the protocol described appears to be useful for the diagnosis of occupational asthma secondary to inhalation of this substance.

[Langerhans cell histiocytosis. Clinical longitudinal study of 21 patients]. / Histiocitosis de células de Langerhans. Estudio clínico y evolución a largo plazo de 21 pacientes.

BACKGROUND: Clinical data of patients with Langerhans cell histiocytosis are well established, although new diagnostic methods and specially long term evolution of the disease with lung involvement are not well-known. METHODS: In all cases, patients were diagnosed by means of pathologic study of the lung samples, either by transbronchial biopsy in 7 patients, or by surgical lung biopsy in 8 patients. Six patients were diagnosed by bone biopsy. Other patients were diagnosed by bronchoalveolar lavage (BAL). In 4 patients, who underwent BAL, the study of antibodies CD1 (CD1a) was positive (> 5%). Lymphocytopenia was detected in 28% of patients, whereas no decrease in delayed cutaneous hypersensitivity tests was detected in any of them. After a follow-up study of 12.8 years (range: 4-22 years), 7 patients had dead, 6 patients showed severe lung involvement and other 5 patients did not have lung affection. CONCLUSIONS: The diagnosis of Langerhans cell histiocytosis has improved by detection of immunologic and histochemical markers recently introduced. The study of the delayed cutaneous hypersensitivity tests did not show anergy or hipoergy. Long term evolution of patients with lung involvement is poor.

[Familial incidence of bird-breeder's lung and HLA (author's transl)]. / Incidencia familiar del pulmón del cuidador de aves y HLA.

The cases of two siblings affected with bird-breeder's lung are reported. The analysis of their HLA group demonstrated that both belonged to the haplotype HLA Bw15. The finding of a familial incidence of this type of alveolitis favors the presence of a genetic susceptibility for the disease. The same HLA group has been found in the rare families heretofore reported with bird-breeder's lung. Given that the pathogenesis of extrinsic allergic alveolitis has recently been linked to cellular immunity (T cells), and that the presence of a common HLA haplotype in patients suffering from bird-breeder's lung is related to the capacity for an immune response in general, and to the cellular immune response in particular, the presence of a genetic susceptibility in this disease appears as very likely, although the influence of other factors can not be ruled out.

[Delayed nonspecific cutaneous hypersensitivity in extrinsic allergic alveolitis and idiopathic pulmonary fibrosis]. / Hipersensibilidad cutánea retardada inespecífica en la alveolitis alérgica extrínseca y en la fibrosis pulmonar idiopática.

BACKGROUND: A study of delayed nonspecific cutaneous hypersensitivity in extrinsic allergic alveolitis and in idiopathic pulmonary fibrosis. METHODS: 13 patients with extrinsic allergic alveolitis, 10 with idiopathic pulmonary fibrosis, 34 with sarcoidosis and a control group of 110 subjects without respiratory disease or apparent defects in cell immunity were evaluated. The skin tests of delayed hypersensitivity were carried out with five antigenic extracts (candidin, staphylococcal toxoid, tuberculin-PPD, trichophyllin, streptokinase-streptodornase). The reactions were read after 48 hours. Delayed nonspecific cutaneous hypersensitivity was globally calculated, both quantitatively (sum of the mean diameters) and quantitatively (overall average of positive reactions). RESULTS: No significant differences were found between the group of patients with idiopathic pulmonary fibrosis and the control group, nor between those with extrinsic allergic alveolitis and those with sarcoidosis. However, differences were found between the control group and the patients with extrinsic allergic alveolitis, both in the quantitative and the qualitative analysis. CONCLUSIONS: Delayed nonspecific cutaneous hypersensitivity in extrinsic allergic alveolitis is depressed in a similar way as in sarcoidosis, whereas it appears to be preserved in idiopathic pulmonary fibrosis. Therefore, extrinsic allergic alveolitis should be considered as another cause of reduction of delayed nonspecific cutaneous hypersensitivity as it is the case with sarcoidosis.

[Churg-Strauss syndrome: 8 cases in the last 10 years]. / Síndrome de Churg-Strauss. Ocho casos en los últimos diez años.

The clinical and histopathological findings of 8 patients with a diagnosis of Churg-Strauss syndrome seen in our institution in a 10 year period have been reviewed. All patients had asthma and hypereosinophilia (mean eosinophil count 7.64 x 10(9); range: 0.748 x 10(9)-31.46 x 10(9) eosinophils/l). The organs and systems involved in the late phase of the syndrome (vasculitic phase) were: nervous system (16 cases), respiratory system (5 cases), skin and subcutaneous tissue (5 cases), heart (3 cases), digestive system (3 cases) and kidney (1 case). The diagnosis was made on the basis of the clinical and histopathological findings. In 7 cases necrotizing angiitis was shown, tissue eosinophilia in 4, and extravascular granulomas in 2. In most cases, corticosteroid therapy resulted in a favorable course, but cyclophosphamide was required in two patients. In the discussion, the evolution of the criteria for the diagnosis of this condition is analyzed.

[Benign asbestos pleural effusion. Report of a first series in Spain]. / Derrame pleural benigno por asbesto. Descripción de la primera serie en España.

Up to now, only 2 cases of benign asbestos pleural effusion have been described in Spain. We report our experience of 15 patients diagnosed of benign asbestos pleural effusion (BAPE). Between 1980 and January 1995, 15 patients were diagnosed of BAPE according to the following criteria: a) evidence of pleural effusion; b) previous asbestos exposure, and c) exclusion of other etiologies of last during 3 years of follow-up. Retrospective review of diagnostic and evolutive data from the patients' clinical records. Asbestos exposure was intense in 8 patients and slight in 7. There were 11 effusions on the left side and 4 on the right side. All effusions were exudative, with a pleural adenosine deaminase level lower than 43 U/l. Eleven patients had a lymphocytic pleural fluid. All patients had nonspecific pleural histology, and asbestos bodies were detected in one case. Eleven patients achieved a radiographic resolution in less than 3 months, and 3 patients presented relapses. Fourteen patients had a good outcome, and one patient presented a lung adenocarcinoma after 5 years of follow-up. Benign asbestos pleural effusions are predominant on the left side, have a tendency to relapse and the exposition can be occasional. The outcome is good in most of the cases.

[Pulmonary thromboendarterectomy in a patient with primary antiphospholipid syndrome]. / Tromboendarterectomía pulmonar en un paciente con síndrome antifosfolípido primario.

Pulmonary arterial hypertension (PAH) is an infrequent manifestation of the primary antiphospholipid syndrome (PAPS). It may appear due to different mechanisms although the most common cause is recurrent pulmonary embolisms. In some cases the thrombi do not dissolve and organize to form fibrous masses which occlude the pulmonary veins giving place to chronic thromboembolic pulmonary hypertension. When the thrombi are located in the proximal arteries, thromboendarterectomy may be curative. The first case of a patient with PAPS diagnosed with PAH secondary to chronic thrombosis of the proximal pulmonary arteries, in whom a successful pulmonary thromboendarterectomy was performed is herein reported.

[Occupational asthma due to isocyanates: a study of 21 patients]. / Asma ocupacional por isocianatos: estudio de 21 pacientes.

BACKGROUND: A descriptive-evolutive study of a series of patients diagnosed with bronchial occupational asthma due to isocyanate exposure. SUBJECTS AND METHODS: Retrospective study of 21 patients diagnosed with bronchial occupational asthma due to isocyanates. Family story, clinical data, functional respiratory study, allergic and laboratory tests were collected. Clinical and functional performance one year after diagnosis was evaluated in patients who had and who had not stopped causal exposure. RESULTS: 17 men and 4 women aged 22 to 59 years were evaluated. In 5 cases (23.8%) family story of atopy was documented and 12 (57.14%) patients were smokers. Seven out of 21 patients were exposed to paint related products at work being this the most common reason. Average time (SD) from the beginning of exposure to development of symptoms was 16.10 (22.5) months. IgE levels were high in 6 (28.57%) and specific IgE to isocyanates was high in 8 (38%), in all cases bronchial hyperreactivity was detected. In 18 patients (85.7%), the study of maxim expiratory flow (MEF) register demonstrated occupational asthma while in the remaining 3 patients a provocation test was performed with positive result. In the annual follow up visit, the 17 patients who avoided casual exposure showed clinical improvement, 7 of them also with functional improvement while in the remaining 10 patients no significant functional change was observed. On the other hand, 3 of the 4 patients who, although protected, underwent exposure, became clinical and functionally worse (p = 0.003, Fisher test). CONCLUSIONS: The etiology of occupational asthma due to isocyanates is not often assessed and usually lately diagnosed. This aspect is worth considering as the illness prognosis seems related to casual agent avoidance.

[Delayed skin reaction in a group of 400 hospital patients: control study (author's transl)]. / Reactividad cutánea retardada en una población de 400 pacientes hospitalizados. Estudio control.

Delayed hypersensitivity skin tests were carried out with 5 antigens - PPD, staphylococcus, streptokinase/streptodornase, candida and trichophytin-in 400 hospital patients without any known causes for diminished delayed hypersensitivity. The degree of reactivity to each antigen was: PPD. 69.50%; candida 49.75%; streptokinase/streptodornase 44.50%; trichophytin 42.00%; staphylococcus 14.25%. Reactivity to either PPD or candida occurred in 86.50% of all cases. Positive response to streptokinase/streptodornase was present in 7%; which brings the total cases with reactions to one or more of the 3 antigens to 93.50%. Those who responded to trichophytin or staphylococcus were 3% only, bringing the total response of all cases to at least one antigen, to 96.5%.