Correct!
3. Obtain a detailed occupational / exposure history

99mTc-Methylene diphosphonate bone scan would not provide information that would clearly establish a diagnosis for this patient. It is possible that the upper lobe masses could show tracer accumulation on bone scan, but this finding is ultimately non-specific. 18FDG-PET scanning would not provide information that would help establish a diagnosis for this patient, regardless of whether the pulmonary opacities show increased, or lack of, tracer utilization. While pulmonary function testing would provide useful data, the results of this testing would not provide a diagnosis for this patient; rather, the data from pulmonary function testing in this patient would be useful more for following her disease once a diagnosis is established. Percutaneous transthoracic core biopsy of the lesion is unnecessary. While this procedure would undoubtedly provide more tissue for diagnostic evaluation, and the sample obtained with this procedure is typically larger than that obtained with bronchoscopic biopsy, tissue sufficient for diagnosis has already been obtained at bronchoscopy- the question now is, “what is the cause of the peribronchial and perivascular dust-filled macrophages with foreign body granulomas and talc particles found at bronchoscopic biopsy?”

A detailed occupational and environmental exposure history was performed. The patient worked in a bicycle shop, and had held this job for a number of years. No exposures in her home were found, and no hobbies or pastimes that could potentially be associated with an exposure or inhalational disorder were elicited. Further investigation into the patient’s duties at the bicycle shop found that she placed rubber inner-tubes within tires. During this process, a powder containing a substantial amount of talc, used to reduce friction, was employed by the patient, and it was not uncommon that the patient was immersed in a cloud of this powder during the course of her duties at work.

Diagnosis: Complicated chronic silicatosis

References

  1. Blum T, Kollmeier J, Ott S, Serke M, Schönfeld N, Bauer T. Computed tomography for diagnosis and grading of dust-induced occupational lung disease. Curr Opin Pulm Med. 2008 Mar;14(2):135-40. [CrossRef] [PubMed]
  2. Cox CW, Rose CS, Lynch DA. State of the art: Imaging of occupational lung disease. Radiology. 2014 Mar;270(3):681-96. [CrossRef] [PubMed]
  3. Cox CW, Lynch DA. Medical imaging in occupational and environmental lung disease. Curr Opin Pulm Med. 2015 Mar;21(2):163-70. [CrossRef] [PubMed]
  4. Sirajuddin A, Kanne JP. Occupational lung disease. J Thorac Imaging. 2009 Nov;24(4):310-20. [CrossRef] [PubMed]

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