Case Report Clinical Case Reports International Published: 14 Feb, 2020

Peritoneal Associated with Bladder and Occupational Exposure to Asbestos: A Case Report

Dorra Brahim1*, Najla Mechergui1, Hanene Ben Said1, Dhouha Cherif2, Nizar Ladhari1 and Imen Youssef1 1Department of Professional Pathology and Fitness for Work, Charles Nicolle Hospital, Tunisia

2Department of Gastroenterology and Hepatology, La Rabta Hospital, Tunisia

Abstract Introduction: Mesothelioma is a rare tumor which the occurrence is closely linked to asbestos exposure concerning pleural localization. However, this link of causality is not clearly established for peritoneal mesothelioma. Case report: We present the case of a 47 year-old man, versatile worker in a craft brickyard. He was exposed to asbestos fibers emitted of an oven used for the preparation of bricks. The patient presented abdominal pains and decreased sense of general state. An abdominal scanning was realized showing a diffuse infiltration in peritoneal fat and an effusion of the vesical wall. The histological examination showed a peritoneal mesothelioma associated with a vesical tumor. Occupational origin of the peritoneal mesothelioma was held in front of the chronic exposure to the asbestos. Thus, a statement of occupational disease in conformance with the legislation in force was made. Conclusion: In this case, the chronic and important asbestos exposures as well as the absence of other risk factors are towards the incrimination of this fiber in the emergence of peritoneal mesothelioma. Keywords: ; Mesothelioma; Asbestos; Profession

Introduction OPEN ACCESS Mesothelioma is a rare tumor that affects the cells of the mesothelium, a protective membrane *Correspondence: that covers most internal organs of the body including the pleura, peritoneum and pericardium [1]. Dorra Brahim, Department of Professional Pathology and Fitness for Several agents likely to induce this mesothelioma were reported such as exposure to erionitis, viral infections, vaccine products and/or genetic susceptibility [2,3]. Although the causal link Work, Charles Nicolle Hospital, 67 Golf between pleural mesothelioma and asbestos exposure is well established, this relationship is still Avenue, Arab Manzah, Tunisia, Tel: controversial for peritoneal mesothelioma. Thus, we report a case of peritoneal mesothelioma +216-95954312; observed in a worker who has an occupational exposure to asbestos. E-mail: [email protected] Received Date: 10 Jan 2019 Case Presentation Accepted Date: 11 Feb 2020 The patient was a 48-year-old, active smoker at 45 packages/year, without significant Published Date: 14 Feb 2020 pathological history. He had worked as a versatile worker in craft brickyard for 19 years. His duties Citation: included mixing raw materials intended to be placed in an oven containing friable asbestos used as Brahim D, Mechergui N, Ben Said a thermal insulator. This oven was old and worn, which could emit asbestos fibers under the effect H, Cherif D, Ladhari N, Youssef I. of shock and air movements. Then, the patient was responsible for molding, drying and waiting for Peritoneal Mesothelioma Associated the cooling of these bricks to take them out of the oven. At the end of the shift, he was cleaning the with and Occupational oven with a brush that contained asbestos dust. Exposure to Asbestos: A Case Report. However, the patient reported bad industrial hygiene conditions, and lack of protective Clin Case Rep Int. 2020; 4: 1138. respiratory devices. Also, no medical supervision in the context of occupational medicine was Copyright © 2020 Dorra Brahim. This provided to him. Besides and asbestos, anamnesis did not disclose other significant is an open access article distributed exposures to occupational or environmental . under the Creative Commons Attribution The history of the disease was marked by a gradual onset of and distension License, which permits unrestricted associated with , asthenia and weight loss. Physical examination found an abdominal use, distribution, and reproduction in distension without a palpable mass. The patient was investigated with thoraco-abdominopelvic any medium, provided the original work Computed Tomography (CT) which revealed a diffuse infiltration of peritoneal fat with animportant is properly cited. intra-peritoneal effusion and focal effusion of the left and lateral wall of the bladder.

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However, radiological investigations of the thorax did not reveal previously among workers in different jobs. In the literature, the age any signs of asbestos impregnation. Histopathological examination of patients ranged from 45 years to 75 years. Job tenure ranged from 7 of bioptic samples performed on peritoneal and bladder lesions led years [9] to 40 years [10]. Our patient was working for 19 years before to a diagnosis of malignant peritoneal mesothelioma of the epitheloid the onset of his illness. The main occupations were: A hairdresser type associated with urothelial bladder carcinoma. The patient was using hair dryers emitting asbestos dust [11], a mine worker [10], treated with hyperthermic intraperitoneal and six a former soldier [12] and a worker in buildings handling asbestos sessions of systemic chemotherapy and endoscopic treatment of cement [9]. Besides asbestos exposure, these patients with peritoneal his bladder tumor. The initial evolution was marked by a partial mesothelioma had no other risk factors. improvement of its general state. In the absence of medical coverage The development of bladder carcinoma and peritoneal at work, the patient resumed his usual professional activity. mesothelioma in the same patient is utterly exceptional. Another Approximately three years later, the patient was hospitalized for case was previously observed in a 75-year-old man with significant continuous, slowly worsening abdominal pain. Total body Positron occupational exposure to asbestos [12]. Bladder cancer preceded Emission Tomography (PET) showed diffuse epiploic mesenteric infiltration associated with peritoneal thickening and an important five-year peritoneal mesothelioma. In our case, the diagnosis of ascites evoking a recurrence of peritoneal mesothelioma. No signs urothelial carcinoma was concomitant with that of peritoneal of recurrence of the bladder tumor were objectified. The patient mesothelioma. This association could signal a possible relationship was referred to a department of occupational pathologies to study between exposure to asbestos classified as a certain for the accountability of this illness to his profession. The occupational humans by the International Agency for Research on Cancer (IARC) origin of this peritoneal mesothelioma was found in front of the [13] and bladder cancer. Nevertheless, the histological type, which is chronic asbestos exposure present in the ovens of the brick factory, different from the two tumors, eliminates the hypothesis of peritoneal objectified by a post office study carried out by the occupational mesothelioma metastasized in the bladder. Similarly, the presence of doctor. Tunisian Judicial Authority recognized the occupational active smoking in our patient would be the most implicated etiological origin of mesothelioma. factor in bladder cancer. Another association with renal carcinoma with clear cells has been described by Candura et al. [8] in 2016. The Discussion modalities of expression of the disease were abdominal pain as was Malignant Peritoneal Mesothelioma (MPL) is a rare disease the case for our patient, hemorrhagic ascites, [14] a cutaneous nodule whose spontaneous evolution remains fatal [4]. Its epidemiology [12] or a fortuitous finding [15]. Chrysotile was the form of asbestos is complicated because of the possible geographical and temporal most implicated in the occurrence of peritoneal mesothelioma. There variations. In all , peritoneal mesothelioma occurs, in was no documented exposure to products containing amphiboles order of frequency, the second place after pleural localization. [16]. About the histological type, diffuse malignant mesothelioma of the epitheloid type was the most common type and no case of pure In addition, peritoneal malignant mesothelioma accounts for Sarcomatoid mesothelioma was reported [16]. Nevertheless, two 10% to 30% of malignant mesotheliomas with an annual incidence cases of biphasic mesothelioma were reported by Candura et al. [8] estimated at 1 in 500000 in France and 1 in 200000 in certain regions and Cabibi et al. [16] respectively. of Europe (Italy) [5]. It occurs preferentially in the elderly with an average age ranging from 47 years to 60.5 years [6]. Three forms Finally, our observation is similar to the cases described in the of mesothelioma are described with different physiopathology, literature from standpoint of exposure to asbestos, the time of onset of morphology, and prognosis: diffuse malignant mesothelioma, the disease, the absence of other risk factors and the histological type well-differentiated papillary mesothelioma, and multi-cystic revealed. Regarding occupational origin, peritoneal mesothelioma mesothelioma. Among the malignant mesotheliomas, three types is recognized in our country by our system of compensation as an are individualized: The diffuse epithelioid mesothelioma (the occupational disease, once the criteria for recognition are established. most common) and which was observed in our case, sarcomatoid Conclusion mesothelioma and biphasic mesothelioma [6]. Exposure to asbestos is the main risk factor for pleural mesothelioma. However, this causality Peritoneal malignant mesothelioma is a rare tumor, for which the is not clearly established for peritoneal mesothelioma and the debate etiological role of asbestos exposure is very likely concerning the mechanism of exposure of peritoneal cells to asbestos Thus, and given the rapidly evolving nature of this tumor making remains open. On the other hand, several studies have established early detection difficult, setting up technical protection means with a relationship between asbestos exposure and the occurrence of monitoring facilities containing asbestos proves essential. peritoneal mesothelioma [7]. References The latter appears, usually as a tumor secondary to a primary source of malignancy, which is pleural mesothelioma. Inhaled 1. Unit Cancer annd Environment. Mésothéliome; 2019. asbestos fibers in the lungs would be transported by the lymphatic 2. Cicala C, Pompetti F, Carbone M. 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5. Glehen O. Mésothéliome péritonéal malin. 2011. 11. Abban C, Viglione M. Peritoneal mesothelioma presenting as a skin nodule. J Cutan Pathol. 2009;36(6):675-9. 6. Mery E, Hommel-Fontaine J, Capovilla M, Chevallier A, Bibeau F, Croce S, et al. Mésothéliome malin péritonéal : mise au point et données actuelles. 12. Classification du CIRC – Cancer et environnement. Disponible sur. Ann de Pathol. 2014;34(1):26-33. 13. Barth Z, Thiele H, Frenzel H, Kohler B. [A rare cause of malignant ascites- 7. Survie au Cancer. Mésothéliome péritonéal malin - faits importants pour -peritoneal mesothelioma]. Dtsch Med Wochenschr. 2001;126(27):779-82. que vous sachiez. 2013. 14. Pott F, Ziem U, Reiffer FJ, Huth F, Ernst H, Mohr U. Carcinogenicity 8. Candura SM, Boeri R, Teragni C, Chen Y, Scafa F. studies on fibers, metal compounds, and some other dusts in rats. Exp and malignant peritoneal mesothelioma after occupational asbestos Pathol. 1987;32(3):129-52. exposure: Case report. Med Lav. 2016;107(3):172-7. 15. Kradin RL, Eng G, Christiani DC. Diffuse peritoneal mesothelioma: A case 9. Egilman D, Menéndez LM. A case of occupational peritoneal mesothelioma series of 62 patients including paraoccupational exposures to chrysotile from exposure to tremolite-free chrysotile in Quebec, Canada: A black asbestos. Am J Ind Med. 2017;60(11):963-7. swan case. Am J Ind Med. 2011;54(2):153-6. 16. Cabibi D, Tutino R, Salamone G, Cocorullo G, Agrusa A, Gulotta G. 10. Dahlgren J, Talbott P. Case report: Peritoneal mesothelioma from asbestos Diffuse malignant biphasic peritoneal mesothelioma with cystic areas. in hairdryers. Int J Occup Environ Health. 2015;21(1):1-4. Ann Ital Chir. 2016;87.

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