Diagnostische Herausforderungen bei Mischstaub-Pneumokoniosen – 5 Fallbeispiele

 

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Zusammenfassung

Die Exposition gegenüber granulären und faserförmigen anorganischen alveolengängigen Stäuben führt zu inflammatorischen und fibrosierenden Lungenveränderungen. Außerdem geht sie mit einem erhöhten Lungenkrebsrisiko einher. Unter Berücksichtigung einer eingehenden Arbeitsanamnese bereitet die Diagnose der relativ häufigen Pneumokoniosen Silikose und Asbestose bei vorherrschender Ausprägung mit vorwiegend rundlichen bzw. irregulären Verschattungen und Betonung der Ober- bzw. Unterfelder kaum Schwierigkeiten. Jedoch liegt im einzelnen Erkrankungsfall selten eine Monoexposition vor. Vielmehr finden sich praktisch immer gleichzeitig Mischexpositionen, z. B. im Steinkohlenbergbau Quarz und Kohlenstoff, im Baugewerbe Quarz, Asbest, verschiedene weitere Zement- und Betonbestandteile, z. T. auch Hartmetalle und Schweißrauche. Des Weiteren kommt es im Laufe eines Arbeitslebens durch Veränderungen der Produktionsprozesse und der Ausgangsmaterialien und infolge Arbeitsplatz-/Berufswechsel zu Variationen der Art und Intensität solcher Belastungen. Die damit einhergehende Heterogenität der Exposition und der damit verbundenen intrapulmonalen Deposition hat Einfluss auf die resultierenden strukturellen Lungenveränderungen, d. h. es kommt zu mehr oder weniger ausgeprägten Abweichungen der morphologischen Strukturen von in den Lehrbüchern als typisch dargestellten Pneumokoniosebildern. Dadurch kann sich die Diagnostik schwierig gestalten, insbesondere die Abgrenzung zu idiopathischen interstitiellen Lungenerkrankungen gelingt oft nicht mehr sicher. Zu berücksichtigen sind außerdem genetische Einflüsse hinsichtlich der Krankheitssuszeptibilität und des Ausmaßes der pathohistologisch und radiologisch feststellbaren Veränderungen.

Es werden 5 Fallbeispiele dargestellt, die durchwegs initial als idiopathische Lungenfibrose gedeutet wurden, deren genaue Aufarbeitung – großteils im Rahmen der Sozialgerichtsbarkeit − durch den Autor jedoch stets eine Mischstaub-Pneumokoniose wahrscheinlich machte.

Abstract

Exposure to granular or fibrous inorganic dusts of the alveolar dust fraction initiates inflammatory and fibrotic lung processes. Furthermore, such exposures are associated with an increased risk for lung cancer. By taking a detailed occupational history into consideration the diagnosis of relatively frequent pneumoconioses such as silicosis or asbestosis with dominating pictures, i. e. with its predominant rounded or irregular opacities located especially in the upper and lower lung fields, respectively, is mostly not difficult. However, rarely exposure to a single agent exists. Rather, mixed dust exposures occurring at the same time or in the follow-up have to be taken into consideration, e. g. quartz and carbon in hard coal mines, quartz, asbestos, various other components of cement and concrete dusts in the construction industry. It is also important that during the working life, changes of working processes and used raw materials as well as changes of jobs are associated with variations of type and intensity of exposures. This heterogenicity of exposures and of the associated intrapulmonary depositions result in variations of the pulmonary structural changes, i. e. more or less modifications of the pictures of pneumoconioses as described being typical in textbooks. This is associated with diagnostic difficulties, especially with regard to the differential diagnosis of idiopathic interstitial lung diseases. There is also evidence for genetic influence on disease susceptibility and on the degree of pathohistological changes.

This publication includes 5 case reports; all of them were initially diagnosed as idiopathic pulmonary fibrosis, but a detailed workup of the author, mostly during social court litigations, showed that mixed dust pneumoconioses were the most likely diagnoses.

Publication History

Received: 10 November 2019

Accepted: 23 December 2019

Article published online:
12 February 2020

© Georg Thieme Verlag KG
Stuttgart · New York

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