A rare case of anthracofibrosis complicated with pulmonary embolism

We present a case of anthracofibrosis with a challenging diagnostic approach, complicated with pulmonary embolism (PE). A coal exposed 71-year-old woman presented with acute respiratory failure. Lung cancer was suspected, as computed tomography (CT) findings included a mass. Apart from mild stenosis of the RUL bronchus, bronchoscopy failed to reveal significant endobronchial findings, while biopsy and cytology were negative for malignancy. Fine needle aspiration (FNA) was performed, leading to the diagnosis of anthracosis, based on the new cytologic findings which included soot particles. Although bronchoscopy is the gold standard, pigmented lesions or bronchial stenosis were not detected. Moreover, during her hospitalization the patient also presented aggravating respiratory failure and CT pulmonary angiography (CTPA) showed PE. There have been reports that anthracofibrosis might generate a hypercoagulant state. The pathophysiological mechanisms that explain this occurrence are presented in this case report. INTRODUCTION Anthracosis belongs to the greater group of environmental lung diseases, called pneumoconiosis1. Although quite frequent in Asia2,3, only few cases are reported in Greece annually. We present a case study in order to highlight the diagnostic challenges and clinical complications that we encountered. CASE PRESENTATION A 71-year-old refugee from Afghanistan presented with acute hypoxemic respiratory failure. She had recently been hospitalized due to fever, dyspnea and intense wheezing, that were treated with intravenous methylprednisolone. She was not a smoker; however, she was exposed to biomass fuels in a poorly ventilated household for at least 50 years and reported having chronic cough and dyspnea the last 5 years. She was also hospitalized 3 years ago for a lower respiratory tract infection. Her vital signs included a pulse rate of 84 beats per minute, body temperature of 37°C, and respiratory rate of 22 breaths per minute. Blood saturation was approximately 90% with a nasal cannula oxygen supply of 4 L/min, while blood pressure was normal. Physical examination of the chest revealed wheezing sounds during respiration in both lungs. Complete blood count showed elevated leukocytes (19400/μL) and neutrophils (93.8%), possibly due to recent corticosteroid treatment. C-reactive protein was slightly elevated at 4.03 mg/dL (normal range <0.8 mg/dL). B-natriuretic peptide, angiotensin converting enzyme and procalcitonin values were normal. Auto-antibodies screen was also negative. Pulmonary function tests showed restrictive ventilatory defects combined with small-airway obstruction with forced vital capacity (FVC) of 1.17 L (50% of predicted value), forced expiratory volume in 1 second (FEV1) of 0.85 L (44% of predicted value), FEV1/FVC ratio of 75.5%, and forced expiratory flow between 25% and 75% of vital capacity (FEF25–75%) of 0.76 L (30% of predicted values). Chest X-ray revealed masses in both hilar areas. Chest computed tomography (CT) (Figure 1) revealed: 1. Multiple enlarged mediastinal lymph nodes; many of them presented peripheral calcification. 2. A large disparate, calcified consolidation in the posterior part of the right upper lobe (RUL), which attracted the side pleura and caused stenosis of the bronchus for the right upper and the middle lobe. 3. Bilateral lung nodules of various sizes, with the largest presenting dimensions of 4×2.4 cm. 4. Ground glass infiltration in the RUL. 5. Bronchiectasis in the apical part of the left upper lobe (LUL) with fibrotic features and attraction of the mediastinal pleura. AFFILIATION 1 Respiratory Failure Unit, Medical School, Aristotle University of Thessaloniki, ‘G. Papanikolaou’ Hospital, Thessaloniki, Greece 2 Department of Respiratory Medicine, 'G. Papanikolaou' Hospital, Thessaloniki, Greece CORRESPONDENCE TO Asterios T. Tzinas. Respiratory Failure Unit, Medical School, Aristotle University of Thessaloniki, ‘G. Papanikolaou’ Hospital, Dimokritou 6, Epanomi 57500, Thessaloniki, Greece. E-mail: stergiostzinas@hotmail.com ORCID ID: https://orcid.org/0000-00033899-5624