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Environmental Medicine: Integrating a Missing Element into Medical Education
progresses, the dyspnea worsens. A dry cough typically occurs, but a productive cough, even in a nonsmoker, is not uncommon. Patients often describe a “tight” feeling in the chest. The interstitial disease is radiographically demonstrated as a reticular fibrosis located predominantly in the lower lung fields. Radiologic evidence is often not present until at least 5 years after exposure.
Fibrosis found symmetrically in the lower aspects of both lungs is typically caused by asbestos. Fibrotic lung disease due to asbestos inhalation is often associated with pleural plaque formation, which eliminates other etiologic possibilities such as drugs, radiation, sarcoidosis, collagen vascular disorders, Goodpasture’s syndrome, hemosiderosis, idiopathic pulmonary fibrosis secondary to lung infections, and inhaled silica, coal dust, or organic dusts.
Lung Cancer
❑ Asbestos-associated lung cancers produce the same symptoms as cancers due to other etiologies.
Lung cancer caused by asbestos exposure cannot be differentiated from cancer caused by other environmental factors. The differential diagnosis of lung cancer in an asbestos-exposed patient should include other possible etiologies such as exposure to cigarette smoke, arsenic, chloromethyl ethers, chromium, nickel, and ionizing radiation. Clubbing of the distal phalanges or cyanosis of the nail beds may be present.
Mesothelioma
❑ The latency period for mesothelioma is 20 years or more, but the onset of symptoms is sudden.
Both pleural and peritoneal mesotheliomas may be seen in asbestos-exposed patients. These tumors are rapidly invasive. Although onset of mesothelioma is not sudden, symptoms of the disease may be. Peritoneal mesotheliomas are more difficult to diagnose by noninvasive means than pleural occurrences. They are frequently detectable as an expanding “doughy” feeling on abdominal palpation. Mesothelioma is seldom associated with etiologies other than asbestos exposure.
Laboratory Tests and Special Procedures
❑ Chest X ray and pulmonary function tests are important procedures in diagnosing asbestos-associated disease.
Established tests and procedures helpful in diagnosing asbestos-associated disease include radiographic techniques, pulmonary function tests, and possibly computerized tomography scanning. Neither sputum studies nor blood chemistry studies are useful in diagnosing asbestos-associated disease in the clinical setting.
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