PAUL A DWIYANU

Lab/SMF Paru & Kedokteran Respirasi RSUD ULIN

FKU UNLAM
 We, the Forum of International Respiratory Societies
(FIRS), convening at the 40th Union World Conference
on Lung Health in Cancn, Mexico on 6 December
2009, recognize that hundreds of millions of people
around the world suffer each year from treatable and
preventable chronic respiratory disease; acknowledge
that lung health has long been neglected in public
discourse; understand the need to unify different health
advocates behind one purpose; express the urgency for
increased awareness and action on lung health. . . and
therefore declare2010: The Year of the Lung.
Dallas Ft Worth Star-Telegram,
February 17, 2005
Client Alert, July 14, 2005

Judge calls 2005 Multidistrict Litigation

diagnoses methods
frightening Order Criticizes Thousands
++++++++++++++++++++ of Silicosis Claims
Mobile Register, March 13, 2005 ===========================

Doctor's testimony Wall Street Journal, August 12, 2005

ignites legal storm
______________________________________
Fortune, June 13, 2005
Diagnosing for Dollars
**********************************
Silicosis Scandal
******************************
New York Times, October 9, 2005
The Tort Wars, at a Turning
Point
-------------------------------------------
120% 120%
Homicides
100% Skin diseases or 100%
disorders
80% Non-fatal 80%
injuries Overexertion
or repetitive
60% motion injuries 60%
Injury
deaths
40% Pneumo- 40%
coniosis Elevated
deaths blood lead
20% Assaults levels 20%

0% 0%

-20% -20%
Note: Percent of Target Achieved = Most recent value Baseline value
Target value Baseline value
 Pneumoconiosis is a generic name
covering the group of lung disorders which
result from the inhalation of inorganic
dust
 Pneumoconiosis is usually divided into
three groups:

Major pneumoconiosis
Minor pneumoconiosis
Benign pneumoconiosis
 Inhalation of some dusts results in major
fibrosis of the lungs, which results in
interference of lung architecture or lung function
tests.
As:
Silica silicosis
Asbestos asbestosis
Talc talcosis
Coal coal workers pneumoconiosis
(anthracosis)
 Inhalation of some dusts results in minor
fibrosis of the lungs
There is minimal fibrosis of the lungs without
interference of lung architecture or lung function
tests.
These dusts include:
Clay
Kaolin
Mica
Feldspar (non-fibrous silicates)
 Major pneumoconiosis
and
Minor pneumoconiosis
are called

Fibrotic Pneumoconiosis
 There isn't any reaction in the lungs, but
dust deposition casts a shadow in x-ray of
the lung. There is no fibrosis and no
disturbance of lung functions.
No. Dust Pneumoconiosis

1. Asbes Asbestosis
2. Silika Silikosis
3. Coal Coal worker Pneumoconiosis
4. Besi Siderosis
5. Berilium Beriliosis
6. Timah Stanosis
7. Talk Talkosis (talc pneumoconiosis)
8. Aluminium Aluminosis
9. Grafit Pneumokoniosis grafit
10. Debu antimony Antimony pneumoconiosis
11. Debu mineral barite (barium sulfat) Baritosis
12. Debu karbon Pneumokoniosis karbon
13. Debu polyvinyl Chloride (PVC) Pneumokoniosis PVC
14. Debu polyvinylpyrrolidine (PVP) Thesaurosis
15. Debu bakelite Pneumokoniosis bakelite
16. Titanium oksida Pneumokoniosis titanium
17. Zirkonium Pneumokoniosis zirkonium
18. Silicon carbide Carborundum pneumoconiosis
19. Hard metal Tungsten carbide pneumoconiosis (hard
metal diss)
20. Nylon flock Flock Workers Lung
21. Debu campuran
- Campuran silika & besi Silikosiderosis (Hematite pneumc)
- Silikat (campuran silikondioksida, magnesium, aluminium Silikatosis
oksida, calsium)
- Slate (campuran mica, feldspar, crystalline quarts) Slate-workers pneumoconiosis
- Kaolin (partikel multilayer mgd aluminium hidroksida & silikon Pneumokoniosis kaolin
oksida)
- Mica (aluminium & potasium silikat) Mica pneumoconiosis
Full description by
Bernardino Ramazzini
(1633-1714) in early 18th
century. ...when the
bodies of such workers are
dissected, they have been
found to be stuffed with
small stones. Diseases of
Workers (De Morbis
Artificum Diatriba, 1713).
 First U.S. description in 19th century.
Term silicosis ,1870, from Latin silex, or flint.
1930-1931, Hawks Nest Tunnel in Gauley Bridge,
West Virginia the worst industrial accident in
U.S. history. At least 764 tunnel workers died
from silicosis. Hawks Nest disaster
Congressional hearings in 1936, and new laws
protecting workers in many states.
Greatly in recent decades effective
industrial hygiene measures.
 Ingggris (SWORD) Indonesia : belum ada
1990-1998 : 10% data nasional,
Kanada 1992-1993 : prevalence 1%-9,8%
10% Darmanto dkk, 1989,
Afrika Selatan 1996- prevalens CWP 1,15%
1999: 61% OSH Center, 1990,
China 1949-2008 : 10 tambang batu, 3,1%
963 kasus Kasmara, 1998, pekerja
Australia 1979-2002: semen, 1,7%
56% asbestosis, 38% OSH center, 2000,
silikosis, 6% CWP silikosis, 1,5%
Percent
40 Years worked 40
Number of deaths 25+
1999: 1,003 20-24
2000: 950 15-19
30 10-14 30
<10

20 20

10 10

0 1973-1978 1978-1981 1982-1986 1987-1991 1992-1995 1996-2002 0

Note: Includes only miners who are examined.
Source: Coal Workers X-Ray Surveillance Program, NIOSH.
Coal Workers' Pneumoconiosis-related Years of Potential Life Lost before Age 65
Years United States, 19682006
JM Mazurek, MD; AS Laney, PhD; JM Wood, MS
Figure 2-173. Distribution of pneumoconiosis deaths in U.S. residents aged 15 or older
by sex, 1990-1999.
Men accounted for more than 98% of the 31,452 decedents with any type of
pneumoconiosis during 1990-1999. However, an unusually large proportion of byssinosis
decedents (33%) were female.
(Source: NIOSH [2002f].)
Professions associated with exposure:
Mining - ore of Au, Fe, Pb, Zn, Cu, rock
Production - rock & concrete works,
abrasives, pottery, isolation material
Construction - tunnels, roads and train
tracks, boiler makers, restoration of old
buildings.
 Prevalence:
22/1000 miners (1917-20) to <8/1000
miners currently
Risk: 24 years vs 36 years
exposure to:
low dust levels: 5% 10%
high dust levels: 15% 40%
Macroscopic :
hard gray-black nodules upper lobes and
perihilar
Massive fibrosis - large firm masses, shrunken
upper lobes, emphysematous lower lobes and
subpleural blebs
PMF (progressive massive fibrosis): upper mid
and lower lobes (accelerated silicosis)
Cavitation (ischaemic necrosis) secondary
Tb silicotuberculosis
Microscopic: silicotic nodule
Central zone: hialine connective tissue in
concentric layers - acellular, no capillaries,
varying silica content, occasional ischaemia
Middle zone: cellular connective tissue
Peripheral zone: halo of macrophages projecting
into parenchyma, high silica content
Located around respiratory bronchioli, blood
vessels, pleural surfaces, interlobular septae
Pneumoconiosi
s: comparison
of imaging and
pathologic
findings.
Chong S, Lee
KS, Chung MJ,
Han J, Kwon OJ,
Kim TS.
Figure 1. Multiple factors released by pulmonary alveolar macrophage upon
exposure to mine dust.
 Classic / Uncomplicated silicosis
Chronic silicosis
Accelerated silicosis
Acute silicosis
Silicoproteinosis
Silico-tuberculosis
PMF
Complicated silicosis
 History of exposure
Radiology
Eliminate potentially treatable diseases
( Tb, sarcoidosis, Idiopathic pulmonary fibrosis)
Lung biopsy
ChestX-Ray- small nodules, 1-10 mm upper lung
zones, calcification
Reticular veiling
Hilar and mediastinal lymphadenopathy (egg shell
calcification)
Cavitation
Pneumothorax
Alveolar veiling
Caplan syndrome
Gambaran radiologi Deskripsi

Perselubungan halus
bercak kecil bulat
p Diameter sampai 1,5 mm
q Diameter 1,5 3 mm
r Diameter 3 10 mm
bercak kecil irreguler
s Diameter sampai 1,5 mm
t Diameter 1,5 3 mm
u Diameter 3 10 mm
Kerapatan Kerapatan berdasarkan konsentrasi perselubungan pd zona yang terkena
0/- 0/0 0/1 Kategori 0 tidak terlihat perselubungan lingkar kecil atau kerapatan kurang dr
kategori 1
1/0 1/1 1/2 Kategori 1 terlihat perselubungan lingkar kecil dengan jumlah relatif sedikit
Kategori 2 terlihat beberapa perselubungan ireguler kecil. Corakan paru tidak
2/1 2/2 2/3 terlalu jelas
Kategori 3 banyak terlihat perselubungan lingkar kecil. Corakan paru sebagian
3/2 3/3 3/4 atau keseluruhan tidak jelas

Perselubungan kasar
A Satu perselubungan dgn 1 5 cm atau bbrp perselubungan dgn masing2 >
1 cm tetapi bila tiap peselubungan dijumlahkan maka tidak melebihi 5 cm

B Satu atau bbrp perselubungan yg lebih besar atau lebih banyak dibandingkan
kategori A dengan jumlah luas perselubungan tidak melebihi luas lapangan
paru kanan atas

C Satu atau beberapa perselubungan yang jumlah luasnya melebihi luas lapangan
paru kanan atas atau sepertiga lapangan kanan

 Lung function: -varies from normal to
obstructive or restrictive or combination
Diffusion decreased
Hypoxaemia on exertion
ATLAS OF PATHOLOGY
2nd Edition

Pulmonary silicosis. Continuous accumulation of collagen around inhaled silica

crystals produces pulmonary fibrotic hyalinized (silicotic) nodules. They present
concentric laminated collagen fibers (blue) and tend to become confluent,
compressing adjacent alveoli. Silica crystals appear as empty cleft-like spaces. With
progression, perivascular and peribronchiolar collagen deposits will produce
pulmonary hypertension. (Simionescu trichromic staining, ob. x4)
 Terminate exposure to prevent PMF
Corticosteroids, pulmonary lavage, lung
transplantation
Treat complications: Tb, pneumothorax,
COPD, Cor pulmonale, collagen vascular
diseases.
Compressed air at high pressure is used to blow fine sand or other abrasive
material through a hardened spray nozzle. The abrasive particles quickly eat
away whatever they are directed at, leaving a clean, matte surface.

 Serpentine asbestos: Chrysotile (white
asbestos) RSA, Russia, Canada
Amphibole asbestos:
Crocidolite ( blue asbestos) RSA Limpopo,
Mpumulanga, Northern Cape
Amosite ( brown asbestos) - as above
Anthophyllite Finland, worldwide
Actinolite RSA, Taiwan
 Imports 70,000 tons of asbestos annually
Mainly from Brazil, Canada & Russia
Used for building materials, insulation, brakes
& many other products
Indonesia has banned the use of amphibole
asbestos
 Fibers 10 20 m length are fibro- & oncogenic
Asbestos body rod shaped , 1-6 m wide and
10 30 m long, yellow-brown with pale center,
maybe clubbed at one or both ends, usually
contains amphibole asbestos, is formed
intracellularly in macrophages, Asbestos bodies
are found in lung parechyma, pleura, sputum,
pleural effusion, other organs
 Non-malignant pleural disease: pleural
thickening, pleural plaques, benign exudative
pleuritis, round atelectasis (pseudo tumor)
Pleural disease puts patient at risk for other
asbestos related diseases 10% get interstitial
fibrosis within 10 years and 2x higher risk for
further pleural disease
 Asbestosis = parenchymal disease interstitial
fibrosis
Associated more with crocidolite
Smokers more prone to disease and CXR :
interstitial infiltrates
Smokers 2,6x greater risk to die of asbestosis
 Clinical presentation: exertional dyspnea, late
inspiratory creps, clubbing (60%)

CXR: reticular veiling lower lobes, ground glass

veiling, pleural changes, PMF in mixed exposure,
rarely Caplan syndrome
Lungfx: restrictive, diffusion, art hypoxemia,

Non-specific immunologic findings: ANF, RF,

HLAB27 association ?
 Bronchogenic Ca: 5x higher incidence in
non-smoking asbestos workers, 90x higher
in smoking asbestos workers
Prevalence for adeno ca
Chrysotile highest risk bronchus Ca
Crocidolite highest risk for mesothelioma
 Diffuse malignant mesothelioma: 35-45 y after
exposure, more with crocidolite, pleural plaques
not a precursor
4 histologic patterns: epithelial, mesothelial,
mixed, undifferentiated
Presentation: Chest pain prominent, dyspnea,
clubbing, pleural effusion
CXR: effusion
CT: pleural based lobular mass with chest wall
and rib involvement
 Simple anthracosis asymptomatic or slight
productive cough , x-ray diagnosis after 15 y
Complicated anthracosis chronic bronchitis,
small % get PMF, functional impairment, PHT
& cor pulmonale, may develop PTb, associated
auto-immune reactions & incidence of RA
Exposure is terminated simple type will not
progress; PMF type will progress
 Radiology: nodular veiling upper lung zones,
nodules > 1 cm indicative of PMF
Lungfx:
normal simple type
restrictive complicated type
in smokers - obstructive
Prognosis:
simple type good
complicated type cardio-respiratory failure
 CWP is indistinguishable from Silicosis
Normal chest x-ray
Copyright (C) 1995-2010 JETRO. All rights reserved.
Dust collected to minimize dispersion into the environment
 Silica is a common, naturally occurring crystal.
Found in most rock beds, it forms a fine dust during
mining, quarrying, and tunneling. Silica is a principal
component of sand, so glass workers and sand-
blasters can also receive heavy exposure.
 Beach sand, desert
sand, golf bunker
sand -- not harmful
with ordinary
exposure.
Silicosis requires
intense &/or
prolonged exposure
to very fine airborne
sand particles.