Chronic pleuritic pain in four patients with asbestos induced pleural fibrosis

Our plain-English summary of Chronic pleuritic pain in four patients with asbestos induced pleural fibrosis, by A. Miller (British Journal of Industrial Medicine, 1990).

The study

• Author: A. Miller
• Journal: British Journal of Industrial Medicine
• Published: 1990;47(3):147-53
• Type of article: Case report
• Cited by: 18 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text
• In J-M's library: Johns-Manville's company medical library held a copy (J-M no. 000029).

Abstract

Four patients occupationally exposed to asbestos, each suffering at least eight years of disabling, persistent, and often bilateral pleuritic pain are described. Radiographic evidence of pleural disease ranged from plaques seen only on computed tomography to typical bilateral plaques or diffuse thickening to extensive diffuse and circumscribed pleural fibrosis and calcification. There was no history or evidence of acute pleuritis or pleural effusion in three patients. Intermittent pleural friction rubs have been present in all four; one patient showed pleural uptake of gallium-67. Extensive workups including repeated pulmonary ventilation-perfusion scans and cardiac catheterisation have not yielded other diagnoses to explain the pain. It is proposed that persistent pleuritic pain be added to the manifestations of benign asbestos induced pleural disease.

In plain English

This article reported four cases seen by the author at Mount Sinai in New York. All four men had worked with asbestos insulation or asbestos cements, in jobs that included shipyard, plant maintenance, plumbing and insulation work. Each had persistent pleuritic chest pain, made worse by breathing in, coughing or moving. Their pleural disease ranged from plaques not seen on plain X-rays to extensive diffuse and circumscribed pleural disease. Pleural friction rubs were heard in all four. One man's gallium scan showed uptake in the pleura. Prednisone at first cleared one man's pain and rub, but later episodes responded less well, and repeated drug treatments gave no lasting relief. One man had nerve surgery, and his pain later returned. Other causes had been repeatedly ruled out in the three men without a history of acute pleuritis or effusion, and mesothelioma had been ruled out. The author could offer no explanation for why the pain persisted. The author concluded that a rare syndrome of persistent pleuritic pain should be added to the known effects of benign asbestos induced pleural disease.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case reports (case series of four patients)
• Who was studied: Four men with documented benign asbestos induced pleural disease and persistent pleuritic pain, seen by the author at Mount Sinai in New York between 1979 and 1988 (first seen October 1979, June 1982, September 1987 and October 1988)
• Exposure: Occupational asbestos exposure. Patient 1 was an iron worker and boilermaker in shipyards from 1938, removing asbestos insulation and mixing asbestos cements. Patient 2 was a bystander from 1951 to 1954 and then a maintenance mechanic in nylon and mylar plants from 1954 to 1981, removing insulation, cutting asbestos blocks and mixing asbestos cements. Patient 3 was a plumber and a shipyard and power plant pipefitter foreman. Patient 4 was an asbestos insulator from 1963. Fiber types were not specified.
• Main results:
  • All four patients had persistent, often bilateral, pleuritic pain together with evidence of asbestos related disease
  • Pleural disease differed between patients. Patient 1 had no specific evidence on plain films despite marked abnormalities on tissue examination. Patient 2 had typical pleural plaques. Patient 4 had typical diffuse thickening and small irregular opacities. Patient 3 had extensive diffuse and circumscribed pleural disease.
  • Intermittent pleural friction rubs were present in all four patients
  • In patient 1, two gallium scans showed persistent uptake read as pleural localisation
  • In patient 1, prednisone at first cleared the pain and rub, but recurrent episodes responded less well. Later repeated attempts with non-steroidal anti-inflammatory drugs and steroids were unsuccessful.
  • In patient 4, injections, nerve blocks and surgical interruption of the right intercostal nerves were tried. The stabbing component went away for a time, but by October 1986 the pain had increased again.
  • In the three patients without a history of acute pleuritis or effusion, other causes of chest pain were repeatedly ruled out. Mesothelioma was ruled out by long observation, computed tomography and biopsies.
  • All four patients had slight to moderate restrictive impairment of lung function. Patients 1 and 4 showed gas exchange abnormalities of interstitial fibrosis.
  • For patient 2, psychiatric and psychological evaluation found psychological factors contributing to chronic pain. Hypochondriacal neuroses, conversion disorder and malingering were not thought to be present.
• The authors' conclusion: The author concluded that a rare syndrome of persistent pleuritic pain, which may be associated with other markers of active inflammation such as friction rubs and gallium-67 uptake, should be added to the list of effects of benign asbestos induced pleural disease.
• Limitations the authors state:
  • The author could offer no explanation for why the pleuritic pain persisted in these four patients
  • There was no evidence that patients 1 and 2 had pleural effusions, but the author noted that effusions may have occurred without coming to medical attention

Topics

The National Library of Medicine indexes this study under subjects our site covers: Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Pleuritic Chest Pain, Fibrosis, Bilateral, Pleural Effusion.

Related studies

• "Not your grandfather's pleural disease": rapid progression, ventilatory impairment, and chronic pleuritic pain from Libby vermiculite/amphibole — A. Miller (2014)
• Pleurectomy for persistent pain in benign asbestos-related pleural disease — D.I. Fielding, J.L. McKeon, et al. (1995)
• Asbestos-induced pleural fibrosis and impaired lung function — D.A. Schwartz, L.J. Fuortes, et al. (1990)
• Chronic disease prevention, asbestos exposure in diamond miners — P. Noone (2012)
• Diffusing capacity and forced vital capacity in 5,003 asbestos-exposed workers: relationships to interstitial fibrosis (ILO profusion score) and pleural thickening — A. Miller, R. Warshaw, et al. (2013)
• Splicing factor SRSF6 mediates pleural fibrosis — L.M. Liang, L. Xiong, et al. (2021)

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