A MATTER OF FLUX: A CASE REPORT ON ARC WELDER'S LUNG

Abstract

SESSION TITLE: Medical Student/Resident Occupational and Environmental Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Occupational diseases are a major cause of individual health deterioration We present a case of occupational exposure to metal fumes resulting in Arc Welder’s Lungs (AWL). CASE PRESENTATION: A 63-year old male presented with shortness of breath and productive cough for 8 days. He was a welder for 27 years. He never smoked and was not taking any medications. He was afebrile, hypoxic at 78% O2 saturation, respiratory rate was 31, pulse of 97 and blood pressure of 172/90 mmHg. He had diffuse rhonchi most prominent in the bibasilar lung fields. Labs revealed a leukocytosis of 14.2 K/uL, normal liver and chemistry panels and a procalcitonin of 0.1 ng/mL. Chest X Ray showed perihilar and basilar multifocal consolidation.(Image A) A chest CT angiography was negative for pulmonary embolism but showed extensive bilateral focal consolidation and diffuse ground glass opacities with an enlarged main pulmonary artery.(Image B) He was started on antibiotics, steroids and required 6L of nasal cannula. Transthoracic echocardiography showed severe left ventricular hypertrophy, an ejection fraction of 70% and an estimated pulmonary artery pressure of 91 mmHg. His symptoms progressively worsened and oxygen requirements escalated. Viral panels, autoimmune serologies, amyloid workup and cultures were all negative. A right heart catheterization showed right atrial pressure of 6 mmHg, right ventricular pressure of 75/5 mmHg, pulmonary capillary wedge pressure of 10 mmHg, a cardiac index of 3.9 L/min/m2 and pulmonary vascular resistance of 5.3 WU suggesting a potential arteriopathy component in the setting of acute pulmonary inflammation. A bronchoscopy with lavage showed numerous hemosiderin laden macrophage with positive iron staining and positive oil red O stain. A transbronchial biopsy was not pursued due to potential bleeding risk in setting of pulmonary hypertension. Serum ferritin level was 2163 ng/mL. Based on occupational history and bronchoscopy findings, the patient was diagnosed with AWL. Given the acute inflammatory parenchymal process, pulse dose steroids were initiated with subsequent clinical improvement. DISCUSSION: AWL can present in different forms of lung disease.[1] Cases are usually “benign” without residual effects, however there are reports of symptomatic presentations with underlying fibrosis.[2] We describe the first welder’s lung case with an acute inhalational pneumonitis responsive to pulse dose steroids. Three months interval CT scan showed significant improvement of ground glass component with residual areas of underlying reticular and fibrotic changes in the bases, possibly suggestive of desquamative interstitial pneumonia.(Image C) CONCLUSIONS: Our case highlights the implications of occupational diseases which can be preventable and the possible variability in presentations. Physicians should be aware of AWL and include it in their differential diagnosis Reference #1: Riccelli MG, Goldoni M, Poli D, Mozzoni P, Cavallo D, Corradi M. Welding Fumes, a Risk Factor for Lung Diseases. Int J Environ Res Public Health. 2020;17(7):2552. Published 2020 Apr 8. doi:10.3390/ijerph17072552 Reference #2: M. P. Cosgrove, Pulmonary fibrosis and exposure to steel welding fume, Occupational Medicine, Volume 65, Issue 9, December 2015, Pages 706–712, https://doi.org/10.1093/occmed/kqv093 DISCLOSURES: No relevant relationships by Youssef Abouleish, source=Web Response No relevant relationships by Mit Patel, source=Web Response No relevant relationships by Anthony Quaranta, source=Web Response