臨床医学に環境・労働の観点を

・前回ジアセチルという食品にバター風味をつける物質で、閉塞性細気管支炎がおこるという記事を書きました。今回その続きです。

・まずは、一般論から

細気管支炎という疾患の定義は、曖昧だとUpToDateにかいております。

INTRODUCTION — Bronchiolitis and bronchiolitis obliterans are general terms used to describe a nonspecific inflammatory injury that primarily affects the small airways, often sparing a considerable portion of the interstitium . The terms are often confusing because they describe both a clinical syndrome and a constellation of histopathologic abnormalities that may occur in a variety of disorders . Unfortunately, much of the literature about bronchiolitis consists of isolated case reports or small case series. In addition, tissue confirmation of the diagnosis has not been described in many of these reports . As a result, many uncertainties remain regarding the epidemiology, pathophysiology, long-term sequelae, and therapy of bronchiolitis.

・Haz-Mapの説明は

 "Bronchiolitis obliterans characteristically presents with the insidious onset of a nonproductive cough and dyspnea 2 to 8 weeks after an acute respiratory illness or toxic exposure." [Murray, p. 1297] "The spectrum of occupational COPD also encompasses exposure to toxic agents which cause irreversible inflammatory disease in the terminal bronchioles, respiratory bronchioles, and alveolar ducts. The unique histopathology features of bronchiolitis (B) and bronchiolitis obliterans (BO) clearly distinguish these airway diseases from other COPD entities. . . . Acute injury by toxic gases is a common cause of BO and has been reported after inhalation of high concentrations of nitrogen dioxide, sulfur dioxide, ammonia, hydrogen fluoride, phosgene, hydrogen bromide, and hydrogen chloride." Other possible causes of BO include methyl isocyanate and diacetyl. [Asthma in the Workplace, p. 697] BO has also been reported after hydrogen sulfide poisoning and in nylon-flock workers, textile workers (polyamide-amine dyes), and workers in microwave popcorn plants (diacetyl). [Ladou, p. 330] Chest x-ray findings are normal or show hyperinflation. Spirometry usually shows a mixed obstructive/restrictive defect. [Hendrick, p. 99] "The key HRCT findings described in constrictive obliterative bronchiolitis are; areas of parenchymal decreased attenuation giving rise to the so-called 'mosaic attenuation pattern', pulmonary vascular attenuation, bronchial wall thickening and dilatation and air trapping on expiratory CT." [Hendrick p. 497]

となっとります。

・UptoDateの臨床的な細気管支炎の分類が下の表です。さすが、UpToDate、ポップコーンのことが載っとります。

Clinical syndromes associated with bronchiolitis Inhalation injury Toxic fume inhalation Grain (organic) or mineral dusts Irritant gases or fumes (eg, welding) Cigarette smoke Volatile flavoring agents (popcorn factory) Postinfectious Viral Respiratory syncytial virus Adenovirus or rhinovirus Influenza or parainfluenza Measles or mumps Varicella zoster Cytomegalovirus Human immunodeficiency virus (HIV) Other infectious agents Mycoplasma pneumoniae Legionella pneumophila Serratia marcescens Bordetella pertussis Streptococcus Nocardia asteroides Pneumocystis carinii Drug-induced reactions Hexamethonium L-tryptophan Busulfan Free-base cocaine Gold Cephalosporin Sulfasalazine Amiodarone Acebutolol Sulindac Paraquat poisoning Idiopathic No associated diseases Cryptogenic constrictive bronchiolitis Respiratory bronchiolitis-associated interstitial lung disease Cryptogenic organizing pneumonia Diffuse panbronchiolitis Associated with other diseases Associated with organ transplantation Bone marrow Heart-lung Lung Associated with connective tissue disease Rheumatoid arthritis Sjogren's syndrome Systemic lupus erythematosus Polymyositis/dermatomyositis Drug reaction Distal to bronchial obstruction, "obstructive pneumonitis" Hypersensitivity pneumonitis Ulcerative colitis Chronic eosinophilic pneumonia Rare associations Irradiation or aspiration pneumonitis Idiopathic pulmonary fibrosis Malignant histiocytosis Adult respiratory distress syndrome (ARDS) Vasculitis, especially Wegener's granulomatosis Chronic thyroiditis Primary biliary cirrhosis Aspiration pneumonitis Lysinuric protein intolerance Paraneoplastic pemphigus Ataxia-telangiectasia

・Haz-Mapでは、閉塞性細気管支炎をおこす物質は、以下のようにあげられています。

• Ammonia
• Chlorine
• Bis(2-chloroethyl)sulfide
• Diacetyl
• Hydrogen bromide
• Hydrogen chloride
• Hydrogen fluoride
• Hydrogen sulfide
• Methyl isocyanate
• Nitrogen dioxide
• Ozone
• Phosgene
• Sulfur dioxide
• Thionyl chloride

・細気管支炎をみたら，職業を聴け，ですね．

（どんな疾病でも，そうですが）