A 52-year-old man presents to his physician with complaints of cough and difficulty breathing during exercise. He also endorses weight loss and night sweats that he noticed over the past few months. The patient has a history of diabetes and takes metformin. He works at a stone quarry, does not smoke or drink alcohol, and does not use any illicit drugs. A chest x-ray shows multiple small nodules in the upper lobes of each lung and multiple areas of calcification around lymph nodes.
Which of the following is the most appropriate next step in management?
A. Measure serum angiotensin-converting enzymeAdminister a tuberculin skin test. The diagnosis of silicosis is made by taking a history concerning for silica exposure, obtaining chest imaging that is consistent with silicosis, and ruling out other diseases that may mimic silicosis. Common environmental exposures to silica include stone quarries, mining, sand blasting, and construction. Chest imaging is somewhat variable based on the type of presentation (acute, chronic, or accelerated); however, it will typically show small nodules within the upper lobes. There may also be calcifications around lymph nodes (“eggshell calcifications”). Buzzwords like eggshell calcifications are good to know, but the test does not always give the buzzwords and may instead describe the findings!
Patients with silicosis may be asymptomatic or may present with cough and dyspnea on exertion. They are at an increased risk for tuberculosis, and therefore patients with a diagnosis of silicosis should undergo tuberculin skin testing with purified protein derivative (PPD). They are also at an increased risk of lung cancer, similar to other pneumoconiosis. (A) Elevated ACE may be seen in sarcoidosis, but this patient’s occupational history and chest x-ray suggest silicosis as the diagnosis. (B) Preventive therapy is the key in pneumoconiosis, and treatment after silicosis develops is typically based on symptom management. There are mixed results about the usefulness of glucocorticoids in the treatment of silicosis. (D) Additional workup is not necessary to make the diagnosis of silicosis.