Chest
ReviewsAsbestos and the Pleura: A Review
Section snippets
History, Mineralogy, and Geography
From the dawn of the Christian era, there have been sporadic references to objects or materials with unique fire-resistant properties that were both mystifying and bordered on the supernatural. Cloth woven from asbestos fibers, and known as “stone wool,” is described in ancient writings as magical because it could be tossed into a fire and removed intact.8 The word asbestos is derived from a Greek term for inextinguishable or unquenchable, and first appeared in the English language in the late
Exposure, Clearance, Tobacco, Latency, Threshold
Asbestos fibers enter the body either by skin contact, ingestion, or inhalation. When raw asbestos fibers were handled with impunity, “asbestos corns” sometimes developed in workers, localized areas on the hands with exuberant epidermal overgrowth due to the intracutaneous deposition of asbestos fibers. This manifestation of asbestos exposure is now solely of historical interest. For the public at large, asbestos is harmless if swallowed. In municipalities with asbestos-cement pipe for water
Pleural Effusion
Pleural effusions due to asbestos exposure vary from a completely asymptomatic event, with either total resolution or a blunted costophrenic angle as the only residual evidence, to an active, inflammatory pleuritis with fever, pleuritic type pain, and a substantial accumulation of bloody pleural fluid. The symptoms do not differ from those associated with other forms of acute pleuritis, including some dyspnea. The erythrocyte sedimentation rate is often elevated, but an elevated body
Pleural Plaques, Circumscribed
Circumscribed or localized pleural plaques are considered by some as benign markers of prior asbestos exposure, whereas others believe they cause functional impairment, indicate an immunologic deficiency, and are a harbinger of a future malignancy.464748 Circumscribed plaques are discrete areas of fibrous tissue limited to the parietal pleura, whereas diffuse pleural thickening or pleural fibrosis is much more widespread and usually extends into the costophrenic angles; additionally the
Diffuse Pleural Thickening and Diffuse Pleural Fibrosis
There is general agreement that diffuse pleural thickening, unlike circumscribed thickening or plaques, can cause significant restrictive ventilatory impairment.565765 Lilis et al66 reported seven such patients, of whom five succumbed from pulmonary failure that was attributed to a severe restrictive ventilatory deficiency. The hallmark of diffuse pleural thickening is involvement of the visceral pleura, with blunting of the costophrenic angle the most frequent radiologic clue. Localized or
Rounded Atelectasis
An unique form of pleural thickening is known as rounded atelectasis, folded lung, Blesovsky syndrome, and by its major radiologic feature: the comet tail sign. This type of pleural involvement is much less frequent than circumscribed plaques or diffuse pleural fibrosis. It has the appearance of a round, mass-like opacity and develops at one, occasionally at several, locations in the pleura with a characteristic curvilinear “tail” extending toward the hilum (the comet tail).69 Because it may
Mesothelioma
Mesothelioma is usually, but not always, related to the cumulative dose, to the specific mineral form of asbestos fiber, and to the elapsed time from first exposure. The incidence of this tumor has been increasing for many years, roughly parallel with the increase in the use of asbestos (Fig 1), but with a lag time of 25 to 40 years. The incidence among female subjects is 2 per million per year, but between 10 per million per year and 30 per million per year in unselected male populations.72
Pathogenesis
How asbestos fibers that have impacted the airway wall migrate to the pleural surface and, in the case of circumscribed pleural plaques, ignore the visceral pleura in the process is quite obscure. Why asbestos fibers that reach the pleural space induce an effusion in one patient, plaques or diffuse pleural fibrosis in another, or mesothelioma in yet another is equally obscure. An explanation probably lies in some combination of yet-to-be-determined mechanical, biochemical, and genetic events.
Public Policy, Past and Present
It seems ironic that following the initial imposition of asbestos fiber exposure limits in the United States at 5.0 fibers per cubic centimeter in 1971, followed by successive reductions to 0.1 fibers in 1994,10 that the number of claims for asbestos-related injury has increased dramatically. Claims filed with just one of the trusts established to compensate injured workers increased from a few hundred per year in 1980 to 1983, to 68,000 in 2000 (D.T. Austern, Esq; personal communication;
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Supported in part by Veterans Administration Merit Award (Dr. Kamp).