tion

of

distress patient

cadmium

salts)

and

syndrome.9

No

oxygen

prior

The

to the

spaces

were

the

by

capillary

thinning

microorganisms viewed.

There

emphysema

debris.

There

alteration

of

endothelial

were

present

in

any

no

evidence

explain

the was

cellular

no

the

H:

Pneumothorax summary

1969, 2

pp

ob-

Spontaneous (part ) . Copenhagen,

Troncale

pulmonary

F:

disease

in

Myers

JA : Simple

Spontaneous

the

Med 62:1285, 1965 3 Robbins SL: Pathologic Saunders Co, 1974 4

of Ph.D. disMunksgaard,

165-172

EM,

Dwyer

pneumothorax

Marfan

Basis

syndrome.

of Disease.

spontaneous

and

Ann

Intern

Philadelphia,

pneumothorax.

WB

Dis

Chest

26:420-441,

1954 5 Lichter I, Gwynne JF: Spontaneous pneumothorax in young subjects: A clinical and pathological study. Thorax 26:409, 1971 6 Crofton J, Douglas A: Respiratory Diseases. Oxford, England, Blackwell Scientific Publications, Ltd, 1975 7 Fraser RG, Pare JAP : Diagnosis of Diseases of the Chest ( vol 2 ) . Philadelphia, WB Saunders Co, 1970 8 Grimes OF, Farber SM: Air cysts of the lung. Surg Gynecol

Obstet

1 13:720,

9 Bachofen M, Weibel human lungs following 145-195,

pattern injury.

This with

Medical

Center

roentgenograms,

with

which they

uncommon

were

abnormal

included found

to have

roentgenographic

tuberculosis

is the

findbilateral tuber-

finding

subject

of this

in

communi-

cation. CASE

was

REPORT

1

A 24-year-old admitted

fever,

joint

sion

physical

black woman with known to Morrisania City Hospital

pains,

night

sweats,

examination

anorexia, revealed

an

sickle cell anemia because of cough, and malaise. Admi.sill-appearing

young

woman with blood pressure of 1 10/70 mm Hg, pulse rate of 100 per minute, respiratory rate of 20 per minute, and rectal temperature of 103.8#{176}F( 39.8#{176} C ) . On cardiac examination she had evidence of cardiomegaly and a grade 2/6 systolic ejection murmur thought to be a flow murmur. Auseultation of her lungs revealed evidence of right lower lobe consolidation. The remainder of her physical examination was unremarkable. Admission laboratory data showed a hematoerit of 27 percent, white blood cell count of 6,500/cu mm with a differential of 42 percent polymorphonuelear leukocytes, 5 percent band forms, and 53 percent lymphocytes. Chest roentgenogram ( Fig 1 ) showed cardiomegaly and bilateral hilar

lymphadenopathy

with

evident The

in the right patient was

hours.

Examinations

lower

lobe

infiltrates

much

more

hemithorax. treated for sickle cell crisis with bed rest, hydration, analgesics, and erythromycin. Multiple blood, sputurn, and urine examinations for pyogenic and acid-fast organisms were unrevealing. An intermediate strength tubereulin skin test was implanted and was negative after 48 plasmosis

and

Frcua

1.

of tissue repair in Chest 65( suppl):

for

myeoplasma,

Epstein-Barr

virus

cytomegalovirus,

were

all

negative

toxo-

and

fe-

1974

Bilateral

Hilar

Uncommon #{149}r I

I

1961

ER: Basic unspecific

lymphadenopathy;

culosis.

edema,

alterations

English

in

hilar

CASE

sections

REFERENCES

sertation;

chest

No

served.

1 Nissen

and

on

adults

cells.

of

Hospital

ings

to indicate

of hemorrhage,

the

air

inclusions

level

or

to

to this

staining

or ultrastructural

was

tefiore

respiratory

within

densely

cellular

light

at

adult administered

macrophages

of phagocytosed

evidence

the

was

of biopsy.

alveolar

characterized

indicative

or

time

numerous

in

Lymphadenopathy:

Manifestation

An

of Adult

I

u ercuuosis

Arthur

I. Sakowitz,

Two

patients

with

which

included

sented.

After

tuberculous

ver

last

II levels.

Because

various lessening.’

This

clinical

they

years,

and

#{176}Fromthe Department wood, New Jersey. Reprint requests: Dr. New Jersey 07451

fall

of tuberculosis

from

officer

patients

CHEST, 71: 3, MARCH, 1977

Valley

pre-World

awareness

War

of the

manifestations were

of Medicine,

to have

is discussed.

incidence

house

Sakowitz,

are prefound

roentgenographic

roentgenologic two

roentgenograms,

infection

the

of this,

M.D.

were

uncommon

its dramatic

Recently,

on

tuberculous

20

Sakowitz,

lymphadenopathy,

workup,

of adult

continued

H.

findings hilar

extensive

has

Barry

abnormal

infections.

the

and

bilateral

presentation

O

M.D.,

admitted

Valley

Hospital,

Ho ital,

is to MonRidge-

Ridgewood,

lyrnphadenopathy

Chest

roentgenograrn and

lower

showing lobe

infiltrates

bilateral greater

hilar on

the

right.

BILATERAL HILAR LYMPHADENOPATHY

421

brile agglutinins, bone survey, lumbar puncture, and a simultaneous liver/lung scan were all noncontributory. A bone marrow biopsy and culture was negative for tuberculosis. Her

febrile

antil)iotics

course

to high

transferred

further

to

continued

unabated

despite

doses

of penicillin

and

kanamycin.

Montefiore

Hospital

and

Medical

evaluation.

Her

chest

roentgenogram

switching She

now

and mediastinoscopy a diagnosis. Subsequently,

with

lymph she had

biopsy which showed caseating granulornata hilar lymph nodes. Acid-fast bacilli were Neelsen

stains

of

her

lymph

nodes

and

seen

for

was

tin

showed

an

hours. The twelfth lymph Three

skin

were

A 26-year-old

nurse’s

aide

with

known

S-C hemoglobin

dis-

and Medical pain, cough, and anorexia.

Cenfever, Phys-

ical examination showed a slightly obese black woman with 1)100(1 pressure of 90/60 mm hg, pulse rate of 92/minute, respiratory rate of 20/minute, and a rectal temperature of 101.2#{176}F(38.4#{176}C). The remainder of the physical examination was non-contributory. Admission laboratory findings sho ved a hematocrit of 34 percent and a white blood cell count of 8,300 cu mm with a normal differential. Her chest roentgenogram ( Fig 2 ) showed bilateral hilar lymphadenopand

lower

lobe

infiltrates,

greater

on the

right.

with

bed

urine

negative,

the

rest,

blood the

and as

were

acid-fast

and

intermediate

strength

tubercu-

and

negative

after

all

sputum

for

of

were

48

patient continued to have a febrile course and on the hospital day she under vent mediastinoseopy with node biopsy. This showed caseating granulornata. days after this procedure, the patient had another intermediate strength tuberculin skin test which now showed 15 mm of induration after 48 hours. DIsCuSSIoN

successfully

2

were

implanted

in her lung and on the Ziehi-

were

crisis

sputum,

cultures

mumps,

tests

cell

sickle

organisms

and

Candida,

for

for

Multiple

pyogenic stains

bacilli.

Center

node biopsy; an open lung

treated

hydration.

Although

ease, was admitted to Montefiore Hospital ter because of right-sided pleuritic chest abdominal discomfort, diffuse arthralgias,

athy

was

and

cultures

cultured. CASE

patient

Ziehl-Neelsen

increase in the size of the left hilar nodes and the new development of right paratracheal lyrnphadenopathy. In an attempt to secure tissue for a diagnosis, she under vent fiberoptic bronchoscopy with transbronchial lung biopsy on

two occasions, neither gave

The analgesia,

tuberculosis

hilar

or mediastir al

sents

as

a cause

adults.

The

graphic

of bilateral

picture

most

infectious

and

for

commonly

histoplasmosis.

Several

prein

roentgenosarcoidosis,

pneumoconioses,

such

as

and

coccidioidomycosis

authors,

on its infrequent

this

involves

lymphomas, processes

of unilateral

lymphadenopathy

diagnosis

especially

mented

cause

it infrequently

hilar

differential

neoplasms, other

is a common

lymphadenitis,

however,

occurrence

have

in adult

corn-

tubereulous

infection.

Hodgson patients

et who

hilar

al,2

in

a

presented

lymphadenopathy,

tuberculous study

athy,

found

patients none

etiology.

The

only

bilateral

hilar

lymphadenopathy

gren

and

thy

and

tests

presented

with

screened

and

They the

in

found had

only

found.

one

other

Therefore,

mite

out

In

1946,

erythema

Lofgren5

He

tuberculosis hilar

that

and

of these

et

manifestations 28

,

al,6

pa-

with

skin fluid.

tuberculosis; of up

active

to two

tuberculosis with

found

hilar

178

was

bilateral

hilar

to have

a def-

of

lymph

described

patients

these

patients

had

7 (9 percent) the

adults

proved

had and

with

primary

node

enlargement

only

one

active bilateral

Twenty

clinical by

with to tuber-

roentgenogram.

studied were

adult

its relationship

78,

of 37

of which but

78

on chest

Stead

losis, cent)

Lof-

212

lavage

active

were

studied

noted

logic unilateral

two

by

lymphadenopa-

follow-up

patients

to ascertain

adenopathy

later,

surveyed

tuberculosis

with

involv-

done

etiology.

nodosum

culosis.

of note

with

of 422

only

tubereulous

study

of gastric

In the

patient

lymphadenopathy,

tubercu-

hilar

for

patient

sarcoidosis.

one

adenop-

had

bilateral

innoculations

with

in a retro-

hilar

They

of them

pig

only

others

years,

146

guinea

patient also

was

1952.

110

bilateral

patients

prospective

Lundbach4

one

bilateral 100

of

with

et al,3

with

ing

who

only

of their

bus

tients

Clinic

Winterbauer

of

that

survey

Mayo

reported

etiology.

speetive

retrospective

at the

culture.

case

years

roentgenotubercuThey

in of

16

noted (43

bilateral

perhilar

lymphadenopathy. Weber proven FIcunE nopathy

422

2. Chest roentgenograrn showing bilateral hilar adeand lower lobe infiltrates greater on the right.

SAKOWITZ, SAKOWITZ

et

a!7

studied

tuberculosis.

common

as compared

to

have

They lymph

to adults.

85

children,

found

that

node

enlargement

Eighty

of 83

all it (96

was

with

culture-

much

more

in this

group

percent)

ehil-

CHEST, 71: 3, MARCH, 1977

dren

had

regional

enlargement,

and

hilar

hilar

or

paratracheal

( 16

13 of 83

lymph

percent)

Silicosis

node

had

bilateral

Both

of our

patients

had

presented

and

cell

crisis,

with

thus

disorder

may

such

other

literatureshl

is

somewhat

In common with

etiology

for

or without

our

patients, negative

this

etiology.

be

has

stressed

bilateral

this the

infiltrate

is sarcoidosis.

arthralgias,

nonproductive

tuberculin

skin

this

diagnosis

However,

all

must

must

lymph

node

fever,

RR:

not

be

as-

be excluded

a private era.

2 Hodgson athy;

hospital

58:221-228,

CH,

Olsen

tation

RH,

of

Belie

bilateral

78:65-71, syndrome.

management.

hilar

hilar

Ann

in

adenop-

Intern

K: A clinical

adenopathy. H:

A study

sareoidosis

in 212

Ann

The

bilateral

of the

relationship

cases.

Acta

A : Erythema

pathogenesis

in

Med

spectrum

Intern

lymphoma

tuberculosis

Scandinav

GR,

primary

and

142:265-

the

on etiology

Acta

Med

and

Scandinav

Sehleuter

DP,

et al : The

adults.

in

clinical

Ann

KT,

with

Janower

particular

tracheobronehial

ML:

on

Am

J Roentgenol

tree.

affect-

changes

103:123

132, 1968 8

Weiss

Am

W,

Waife

SO:

Rev Tubere

review

Tuberculosis

65:735-743,

9 Barrett-Connor anemia;

and

EH,

infection

of 250 infections

of the literature.

Medicine Esterly

JR:

sickle

cell

diseases.

Am

Rev

11 River

GL,

Robbins

AB,

Schwartz

study.

Blood

sickle

cell

18:385-416,

CHEST, 71: 3, MARCH, 1977

Respir

and

sickle

in 166 patients 50:97-112, Pulmonary Dis

in the

in and

around

SO: 1961

changes

S-C hemoglobin:

abnormal

centuries.

pain

Cyanosis,

in varying

numbers in 85

cases.

in

indus-

Various

components

physi-

of dust

produce

most

common

lungs. offender

and

is the

Improvement

as wet and

In India,

have

small-scale

employees

in

hy-

prevented

silicosis

industries

are

measures. a study of the

disease

of small-scale

Mandsaur,

industrial

drilling, efficient ventilain some countries the use of

prophylaxis

of these preventive report, we present

occurs

are

cell and

a

1971

103:858-59,

for

extent.

for

dis-

and

as pneumoconiosis

chemical

pneumoconioses.

dust

found were

existed

in the

dyspnea,

symptoms.

were

main

Mandsaur

industries

large-

as it located

India. AND

METHODS

to

the

M.C.M.

Medical

College,

Indore.

To

study

cases.

anemia.

1952

E : Bacterial

an analysis

10 Oppenheimer

clinical

and

Cough,

films

in slate-pen-

in the

this problem, a group of respiratory workers from the M.G.M. Medical College went to Mandsaur in December 1973. One hundred and fifty-one eases were studied. A detailed oceupational survey, clinical examination, x-ray films, eleetrocardiogram, tests of ventilatory function, studies of sputum, and routine examinations of blood and urine were obtained in all

tuberculosis

Primary

emphasis

M.D.

working

important

known has

is the

attached

Intern

1968

Bird

childhood

: studies

eases.

tuberculosis

68:731-745, AL,

adult

M.D.;t

Mandsaur is a small township with a population of about 75,000, situated 150 miles to the northwest of Indore, India. Its peculiar geophysical condition has given rise to deposits of sedimentary rock in a strip measuring 10 square miles. The rock known as Binota shale is soft and can be split into layers 3 to 1 inch thick. It has a silica content of 68.83 percent. Slate pencils are manufactured by cutting slices from these rocks. During cutting and sharpening, a heavy dusty atmosphere is created. The workers are employed on daily wages or on a contract basis. A total of 1,200 persons are employed in six such industries. Our index of suspicion was based on the admission of patients from these industries into the MY Hospital, Indore,

Med

1946

Kerby of

7 Weber

nodosurn

185

174:1-197,

WW,

Med

hazard

changes

ly devoid In this

persons

India.

MATERIALS

interpre-

hilar to

Sepaha,

V. S. Dubey,

located

x-ray

workers

Med

1952

5 Lofgren Suppl

chest

all

the

giene, techniques such tion, personal protection,

postsanitarium

CA : Bilateral

N, Moores

S, Lundbaeh

6 Stead

The

of

1973

4 Lofgren

ing

in the

were

1955

3 Winterbauer

273,

Good

and

of cases.

Silicosis

1975

AM,

its significance

43:83-99,

in

teaching

urban

Am J Med

crepitations

dust

151

Pradesh,

and

different

by

tuberculosis

of

chest

to some with

C.

and

industries

rhonchi,

aluminum

experience

F.C.C.P.;

a study

cal properties

biopsy.

A year’s

F.C.C.P.;#{176}#{176} G.

M.D.,

of Madhya

trial

REFERENcES

1 MacGregor

Study

in the

or elmical

sometimes

M.D.,

present

T he

In

supported

of a roentgenographie

etiologies

most

cough, tests

Khare,

frict

proved.

that

lain,

C.

We

area,

been

M.

K.

cil manufacturing

The

parenehymal

or mediastinal

lung

association

on the basis

other

picture;

to tuberculous in

S.

*

Workers

this

tuberculosis.

Iymphadenopathy

initial

only

sumed

of

hilar

the

and

patients

that

controversial

should

it

of sickle

possibility

forms

no definitive

conclusion,

hemoglobinop-

symptoms

the

predispose or

and

and

suggesting

adenopathy however,

a “sickling”

signs

Pencil

A Clinicoradiologic

enlargement.

athy

in Slate

Only clinicoradiologic features and their presented here. Other features of this

#{176}Fromthe lege,

in 1971

**Reader tProfessor Lecturer

a

§Resident

Reprint M.P.,

Department

Indore,

Madhya

in Medicine.

of Medicine,

Pradesh,

M.G.M.

Medical

Col-

of Medicine.

Medicine. Medical Officer. requests: Dr. fain,

india

India.

interrelationships study, especially

in

452004

27

Bairathi

Colony

1,

Indore,

SILICOSIS IN SLATE PENCIL WORKERS

423