Grand rounds: asbestos-related pericarditis in a boiler operator

Our plain-English summary of Grand rounds: asbestos-related pericarditis in a boiler operator, by B.A. Abejie, E.H. Chung, R.W. Nesto, et al (Environmental Health Perspectives, 2008).

The study

• Authors: B.A. Abejie, E.H. Chung, R.W. Nesto, S.N. Kales
• Journal: Environmental Health Perspectives
• Published: 2008;116(1):86-9
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Context: Occupational and environmental exposures to asbestos remain a public health problem even in developed countries. Because of the long latency in asbestos-related pathology, past asbestos exposure continues to contribute to incident disease. Asbestos most commonly produces pulmonary pathology, with asbestos-related pleural disease as the most common manifestation. Although the pleurae and pericardium share certain histologic characteristics, asbestos-related pericarditis is rarely reported.

Case Presentation: We present a 59-year-old man who worked around boilers for almost 30 years and was eventually determined to have calcific, constrictive pericarditis. He initially presented with an infectious exacerbation of chronic bronchitis. Chest radiographs demonstrated pleural and pericardial calcifications. Further evaluation with cardiac catheterization showed a hemodynamic picture consistent with constrictive pericarditis. A high-resolution computerized tomography scan of the chest demonstrated dense calcification in the pericardium, right pleural thickening and nodularity, right pleural plaque without calcification, and density in the right middle lobe. Pulmonary function testing showed mild obstruction and borderline low diffusing capacity.

Discussion: Based on the patient's occupational history, the presence of pleural pathology consistent with asbestos, previous evidence that asbestos can affect the pericardium, and absence of other likely explanations, we concluded that his pericarditis was asbestos-related.

Relevance To Clinical Practice: Similar to pleural thickening and plaque formation, asbestos may cause progressive fibrosis of the pericardium.

In plain English

This article is a case report of one man, with a table of 11 previously published cases for comparison. A 59-year-old boiler worker, who had worked around boilers at a power company from 1976 to 2005, saw his doctor in 2005 for breathing problems. At work he checked water pipes covered with asbestos insulation that was sometimes friable, and he changed packing valves made of asbestos-containing material. He was also exposed to fuel ash, sulfur dioxide and other emissions. He had a 20 pack-year smoking history but had quit 23 years earlier. Tests found calcification of the pericardium, the sac around the heart. Cardiac catheterization showed pressures consistent with constrictive pericarditis. A CT scan showed right pleural thickening and a right pleural plaque. He was treated with diuretics and remained stable, but with limited capacity for exertion. Finding no other apparent cause, the authors concluded that his pericarditis was asbestos-related. Among the 12 cases in their table, including this one, 58% had constrictive physiology and all had pleural findings. The authors noted that workplace medical records from the 1970s and 1980s were unavailable.

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 report of one patient, with a table summarizing 11 previously published cases of pericarditis associated with occupational asbestos exposure
• Who was studied: One 59-year-old man who worked around boilers for a power company from 1976 until March 2005 and was seen in 2005 (Massachusetts physicians and examiner); 20 pack-year smoking history, quit 23 years earlier
• Exposure: Asbestos pipe insulation (sometimes friable) and asbestos-containing valve packing while working around boilers at a power company; fiber type not stated. He was also exposed to fuel ash, sulfur dioxide and other emissions, and likely did not use respiratory protection for most of his career.
• Main results:
  • Cardiac catheterization in the patient showed hemodynamic findings consistent with constrictive pericarditis.
  • A high-resolution CT scan of the patient showed dense calcification of the anterior pericardium, right pleural thickening and nodularity, and a right pleural plaque without calcification.
  • Pulmonary function testing in December 2006 showed mild obstruction in the patient, along with a markedly elevated residual volume (air trapping) and a borderline diffusing capacity.
  • The patient was treated with diuretics and remained stable, but with limited capacity for exertion.
  • In an impartial examination for his workers compensation claim, the examiner diagnosed asbestos-related constrictive pericarditis, asbestos-related pleural disease and mild chronic obstructive lung disease. The examiner related these diagnoses to the patient's asbestos exposures as a boiler worker.
  • Other possible causes of pericardial fibrosis were considered: past tuberculosis, other infections, sarcoidosis, connective tissue disease and trauma. According to the authors, none was apparent in this patient other than asbestos exposure.
  • The authors tabulated 12 published cases, including this patient. All were over 40 years old and most were over 60. Constrictive physiology was seen in 58% of the cases; the rest had pericardial effusions.
  • All 12 tabulated cases had pleural findings, mostly benign, and one patient had a mesothelioma. Most of the cases (83%) did not report definitive evidence of parenchymal asbestosis.
• The authors' conclusion: The authors concluded that the patient's pericarditis was asbestos-related. They based this on his occupational history, his pleural findings consistent with asbestos, prior evidence that asbestos can affect the pericardium, and the absence of other likely explanations. They described constrictive pericarditis as an uncommon complication of asbestos exposure.
• Limitations the authors state:
  • Workplace medical surveillance records from the 1970s and 1980s were not available.
  • The authors stated that the patient's chronic obstructive lung disease was significantly related to his past smoking and chronic bronchitis.
  • The authors could not say whether earlier removal from exposure would have produced a better outcome.

Topics

Medical terms in this study, explained in our Lexicon: Environmental Exposure, Latency, Pathology, Asbestos Exposure, Asbestos-Related Pleural Disease, Pericardium, Chest X-Ray, Pericardial.

Related studies

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• Letter: Mesothelioma of the pericardium with cholesterol pericarditis — E. Argianas, K. Melissinos, et al. (1974)
• Safety and health of heavy equipment operators at Ground Zero — B.E. Lippy (2002)
• Chest pain and ST elevation: not always ST-segment-elevation myocardial infarction — S.A. Pyxaras, G. Lardieri, et al. (2010)
• An unusual case of cardiac tamponade following electrical cardioversion — G.A. Jessurun, H.J. Crijns, et al. (1996)
• Inter-reader variability in chest radiography and HRCT for the early detection of asbestos-related lung and pleural abnormalities in a cohort of 636 asbestos-exposed subjects — E. Ochsmann, T. Carl, et al. (2010)

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