A 64-year-old man is brought to the emergency department after a motor vehicle collision in which his chest hit the steering wheel. The patient has no prior medical conditions and takes no medications. Temperature is 36.7 C (98 F), blood pressure is 132/78 mm Hg, pulse is 76/min, and respirations are 14/min. Physical examination shows mild tenderness over the lower right chest. Imaging of the neck and chest reveals no fractures or dislocations. However, the chest CT scan reveals pleural opacities as shown below. These abnormal findings are most likely to occur in a patient with which of the following occupational histories?

Question

A 64-year-old man is brought to the emergency department after a motor vehicle collision in which his chest hit the steering wheel.  The patient has no prior medical conditions and takes no medications.  Temperature is 36.7 C (98 F), blood pressure is 132/78 mm Hg, pulse is 76/min, and respirations are 14/min.  Physical examination shows mild tenderness over the lower right chest.  Imaging of the neck and chest reveals no fractures or dislocations.  However, the chest CT scan reveals pleural opacities as shown below.  These abnormal findings are most likely to occur in a patient with which of the following occupational histories?

Quizplus · Accepted Answer

11ec160b_3a06_aced_9249_c31f68e5d3ec_MD0001_00 This CT scan demonstrates an incidental finding of pleural plaques (focal or band-like pleural thickening, often with calcifications). Pleural plaques are a hallmark of asbestos exposure; inhaled fibers result in chronic inflammation and collagen deposition within the pleura. They occur most commonly along the parietal pleura covering the ribs and diaphragm. Diffuse pleural thickening, benign pleural effusions, and mesothelioma can also occur. Some patients eventually develop asbestosis, which presents with slowly progressive, diffuse pulmonary fibrosis. Interstitial lung injury due to fiber inhalation predominantly affects the lower pulmonary zones and manifests radiographically as interstitial densities that predominate in the lung bases. Asbestos exposure typically occurs during occupational exposure (eg, insulation manufacturing and application, shipbuilding, drywall workers). There is usually a 20-30 year latent period between asbestos exposure and onset of symptoms. (Choice A) Beryllium is used in the aerospace manufacturing and nuclear weapon industries. Pulmonary berylliosis closely resembles sarcoidosis (nodular infiltrates, enlarged lymph nodes, noncaseating granulomas) but is not strongly associated with pleural plaques. (Choice B) Coal worker's pneumoconiosis presents radiologically as multiple small, discrete nodules that are most prominent in the upper lung zones. Pleural plaques are not typical. (Choice D) Hypersensitivity pneumonitis due to inhalation of agricultural dusts or bacteria (eg, farmer's lung) tends to result in diffuse, nodular interstitial infiltrates; pleural plaques are unexpected. (Choice E) Petroleum processing can result in exposure to sulfur oxides and aromatic hydrocarbons; these can cause occupational asthma and (rarely) bronchiolitis obliterans, which result in air trapping and bronchial wall thickening (as opposed to the pleural thickening seen in asbestos exposure). (Choice F) Silicosis is most common in patients with a history of sandblasting or mining. Numerous upper lobe nodular densities and eggshell calcifications of the hilar nodes are seen; pleural plaques are unexpected. Educational objective: Asbestos-related pleural disease is characterized by pleural plaques (focal pleural thickening, typically with calcifications). Common occupational exposures include shipbuilding, insulation manufacturing and application, and drywall application. Most affected patients remain asymptomatic for 20-30 years following initial exposure. __________ References: Asbestos-induced lung diseases: an update. (http://www.ncbi.nlm.nih.gov/pubmed/19304273)

A 64-Year-Old Man Is Brought to the Emergency Department After