4 3 2 1 uy2014 July 8 First Online Published 2014 June 25 Accepted 2014 June 24 Revised 2014 June 4 Received [email protected] UK; 6LR, SW3 London Road, Manresa 1b Hospital, Brompton Royal and (NHLI) College Imperial Medicine, Environmental and Occupational of Department Cullinan, Paul Dr to Correspondence Shef Road, Herries Outpatient, Brearley Hospital, General Northern UK London, Hospital, Park Northwick Medicine, UK London, UK London, Hospital, Brompton Royal and (NHLI) College Imperial Medicine, Environmental and etefrWrpaeHealth, Workplace for Centre Respiratory of Department Limited, Management Health Occupational of Department 1059 Thorax D cite: To ’ oz ,TnatR, Tennant E, Souza – cnt cesmore access to Scan 1060. 2014; ulnnP, Cullinan pnAccess Open fi recontent free l,UK eld, 69 : tal et . erd i V a nrae o24 ,hsFEV disap- his L, not same 2.41 to had increased dys- had the but FVC his improved his shop, peared; greatly in machine was the elsewhere pnoea from After away working work. company, his change months he 12 that recommended bronchioloalveolitis and allergic extrinsic occupational factory improve. to started had measurements tion tsmd er rvosy ohsbemusement, his to previously; years hos- 2 pneumon- third made hypersensitivity a that of at itis diagnosis established patient a a with we was pital this in turner Through metal worked another who area. employees same 250 the of survey tematic eouinC cno i ug eeldawide- a revealed air small lungs high his A of spread (79% scan predicted. CT L 170% 5.01 resolution RV/TLC was TLC and measurements a his predicted) function predicted), trapping; lung (45% gas Other indicated L 75%. 1.8 of of ratio FVC and predicted) Aspergillus working (bronchiolo) metal allergic and extrinsic alveolitis month: the of Lesson DISCUSSION BASED CASE in ecoentt eunt ok i months Six work. to speci return occupa- his any to his without that not later, by informed chose caused he being probability tion, all On in work. (new) was of at illness a not evidence when by was improved symptoms he occasioned little his that was noting with physician referral His cysteine success. N-acetyl mycophenolate and methylprednisolone, prednisolone, pulsed he with cyclophosphamide, machine work treated a to been for continuing had worked While he manufacturer. that parts only noted history work or home serum-speci of level high an posi- of the conjecture although suggested established been nature lavage tive not The had cause. this bronchoalveolar external of an to his exposure ongoing chronic in of lymphocy- diagnosis tosis marked a A For intersti- with pneumonitis. factory. specialist clinic hypersensitivity a same in disease patient the lung a in tial been had turner he metal years 2 a also was L. 5.36 to TLC his and L 1.45 to spir- His FEV work. a at with restrictive not breathlessness was was severe ometry he of when modern He history improved large, that parts. year a 2 machine in a turner described specialised of worked metal producing diagnosis had a a factory who as consider man years 20 to a for for asked asthma was occupational us of One INTRODUCTION Cullinan, Paul olwn the Following ormnh ae ewr eerdamnwho man a referred were we later months Four fi dnso natimn cenhdldto led had screen autoimmune an of ndings ulnnP, Cullinan ’ ‘ cuainlhat evc e oasys- a to led service health occupational s mosaic fl wosrcin emd igoi of diagnosis a made We obstruction. ow pce,ta xoueto exposure that species, tal et ’ ’ atr fatnainidctv of indicative attenuation of pattern ih erlvn;a occupational an relevant; be might 1 fi ‘ . autoimmune s igoi,dsuso ihthe with discussion diagnosis, rst Thorax v D Eva fi 2014; ramn,hsln func- lung his treatment, c ’ Souza, fi 69:1059 g nioisto antibodies IgG c ’ eilg,ado a of and aetiology, 1 2 – f13 (40% L 1.35 of 00 doi:10.1136/thoraxjnl-2014-205251 1060. ahlTennant, Rachel ‘ ol at mould 1 olelts(nti otx oeacrt emthan term pneumonitis), accurate hypersensitivity bronchio- more allergic a context extrinsic this of (in loalveolitis cause a as recognised netgto salse ute w ae of probable cases 2010 with in two onset bronchioloalveolitis further a occupational established specialist subsequent investigation and employees other of survey ln ihn vdneo atn bene lasting of evidence no prednis- of with doses olone high attribu- with probable intermittently, a treated, them, to kept never tion had he since ol novsteueo W i h Kalso UK the (in MWF com- of as grinding use known the and involves shaping monly Metal machinist. cutter setter, and tool turner, grinder, control numerical as elsewhere control themselves and and describe UK computer the may a in by machinists controlled a metalworking done tools often of is cutting manufacture this using components; the of variety in wide very used occupation skilled widely not is association physicians. respiratory the by appreciated that experience, this omn l eemtlmciit nasingle a metal of mists in to exposure machinists working entails that metal job a were factory, all common; These DISCUSSION ocryaa h at ea ( metal waste the away and carry temperature its to control to process, the lubricate u owtrcnann Wsdt akt the con to studies back challenge date with 1980s, MWFs late conditions water-containing limit respiratory to and due Allergic performance growth. their microbial additives enhance chemical to of range designed wide oil; a semisynthetic contain or also synthetic they mineral, a and water be may and enclosed reduce generally to exhaust-ventilated are machines ocnrtoso W iti h i fteshop the of higher of volume air far the higher in to fl mist far led MWF a of probably concentrations used changes and These h MWF. continu- 24 operated in for being ously of new installed the capable replaced, been were they machines those had with contrast lathes the in 2010; new In to contamination. above, and microbial factory effectiveness of its levels maintain monitor required and are replenish with management to MWF often of recirculated, Systems common ervoir. a and sharing machines collected several is MWF — oor. 3 ahnn or Machining otmdr Wsaecmlxeusosof emulsions complex are MWFs modern Most h saeo W itit h atmosphere. the into mist MWF of escape the fl hi Barber Chris uids fi ’ emnhdadanssada cuainin occupation an and diagnosis a had men ve prtr.Ohrtrsicuecomputer include terms Other operators. fl ‘ birds’ is(Ws.Ihlto fMFi well is MWF of Inhalation (MWFs). uids ‘ coolant’ – 2011. ‘ turning a enmd.H a been had He made. been had 4 , ‘ cutting ’ ea at naltei a is lathe a on parts metal — 12 ‘ optrnumerical computer u aeyeliminate rarely but fl u tapas from appears, it but uid hs clinic Chest ’ ‘ ‘ sump or swarf fi mn cases rming ‘ suds ’ fi ’ .The ). .The t. rres- or

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Protected by copyright. by Protected guest. by 2021 30, September on Chest clinic Chest clinic rmMFmyhv ubr(oeie eea ude)of exposures. hundred) similar several (sometimes with number and a colleagues have employment may MWF maintain from to role. work non-exposed made safe, diseases, a occupational be to workers all affected should relocate expo- with further as effort of outcome; prevention every best the the and offer recognition sures early EAA, of htsadhumidi extrinsic and of bron- asthma, chitis cases occupational US (EAA), with in (bronchiolo)alveolitis workers, reported allergic MWF-exposed been have European disease and respiratory of outbreaks large rasadtedmntaino g nioist ag of of disease). range without serum a and the (with to out- in workers to mycobacteria antibodies exposed the environmental IgG of and Evidence of fungi nature demonstration bacteria, use. unpredictable the the prolonged and from breaks comes and this occurring recirculation control contamination support poor microbial to their with due linked be during to mists, thought MWF is of outbreaks the of aetiology oolelts ihoeo oeo rudgasoaiis small trapping gas opacities, of glass areas ground lobular most and of nodules more the bronch- otherwise centrilobular or of probably features one been typical is with show ioloalveolitis, symptomatic may has a This is tool. in diagnostic patient diagnosis views useful expiratory the the and when inspiratory period here, with HRCT chest A as recurrent explained. to or or, in COPD asthma, delays infections; to symp- attributed because Long often uncommon are loss. not toms are weight diagnosis correct unexplained the reaching and with malaise constitutional, pre- predominantly general the been cases have some symptoms In senting work-related. clearly than rather non-speci gressive, often are symptoms the as exposure etadepsr otos n osre h remaining the survey to assess- and risk controls, their review exposure to and workplace the ment prompt should case ethanola- deodorants. as oil such pine chemicals and by caused mine asthma occupational of 1060 xoue,o hwapteno ies oesgetv fnon- of suggestive more disease of pattern speci low a relatively show of periods or during exposure), (particularly normal appear may last this hs clinic Chest nadtoa osdrto sta h ain h a EAA has who patient the that is consideration additional An ihidxo upco srqie nEAdet MWF to due EAA in required is suspicion of index high A fi ruulitrtta nuoii.A ihayohrcause other any with As pneumonitis. interstitial usual or c fi dn sntspeci not is nding fi rfever. er fi .I te ae oee,teHRCT the however, cases other In c. 2 lhuhdif Although 2 oercnl,anme of number a recently, More 3 h igoi fasingle a of diagnosis The fi 3 fi utt rv,the prove, to cult n a epro- be may and c 4 although rpryctdadteuei o-omril e:http://creativecommons.org/ is See: work non-commercial. original is the provided use licenses/by-nc/4.0/ the terms, non-commercially, different and work on cited this properly works upon derivative build their adapt, license which remix, and license, distribute, 4.0) to BY-NC others (CC permits Commercial Non Attribution Commons Creative Access Open review peer and Provenance interests Competing CB. and ED of assistance Contributors ies pcait,ocptoa elhpoiesadoccupa- and lung providers occupational hygienists. health tional including occupational specialists, team should disease possible multidisciplinary where a and involve challenging, large logistically Investigating is workers. affected outbreaks other identify to workforce is.Teato hi Barber Chris author The First. notice with Correction possible as centre. soon disease as exposures, lung discussed MWF occupational are an cases about potential asked all inter- routinely that of UK, are and patterns disease) other the recommend (and lung We EAA in stitial suspected cases. with all EAA patients of all occupational that half approximately of for cause responsible reported cases. further commonly no been have shop there mists the MWF control of to con works area was problem small the a that indicated employees exposed utnC,CokB cieH, Scaife B, Crook CM, Burton diseases respiratory other and 2 pneumonitis hypersensitivity Asthma, KD. Rosenman 1 REFERENCES at ,Mntl ,GrioG, Girbino F, Minutoli M, Gaeta E, Robinson 4 CM, Burton CM, Barber 3 oeto ,RbrsnA,BreCB, Burge AS, Robertson W, Robertson 5 ulnnP, Cullinan vrtels eae W xouehsbcm h most the become has exposure MWF decade, last the Over soitdwt xouet ae-ae metalworking water-based to exposure with associated metalworking by caused metalworking rnhoa obstruction. bronchiolar 2012;56:374 leltsadatm nacregn auatrn plant. manufacturing engine car a in asthma and alveolitis a scan: CT inspiratory tal et CadR identi RT and PC hsi nOe cesatcedsrbtdi codnewt the with accordance in distributed article Access Open an is This – . fl 88. Thorax i exposures. uid hsatcehsbe orce ic twsPbihdOnline Published was it since corrected been has article This 5 None. nteotra bv,crflsrtn fall of scrutiny careful above, outbreak the In fi 2014; dn foltrtv rnhoii n te assof causes other and bronchiolitis obliterative of nding utdsi eprMed Respir Multidiscip fl uids. ’ saf 69:1059 fi Chest fi dtecssadwoetemnsrp ihthe with manuscript the wrote and cases the ed o omsind nenlype reviewed. peer internally commissioned; Not tal et urOi leg lnImmunol Clin Allergy Opin Curr ito a enamended. been has liation tal et fl ytmtcrve frsiaoyoutbreaks respiratory of review Systematic . o;floigetnieremedial extensive following oor; 2013;143:1189. xiaoyC cni ainswt normal with patients in scan CT Expiratory . tal et – 00 doi:10.1136/thoraxjnl-2014-205251 1060. tal et yesniiiypemntsdeto due pneumonitis Hypersensitivity . lnclivsiaino notra of outbreak an of investigation Clinical . 20013;8:1 fl uids. – Thorax 86. n cu Hyg Occup Ann 2009;9:97 2007;62:981 – fi 102. e to ned

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Thorax: first published as 10.1136/thoraxjnl-2014-205251 on 8 July 2014. Downloaded from from Downloaded 2014. July 8 on 10.1136/thoraxjnl-2014-205251 as published first Thorax: http://thorax.bmj.com/ on September 30, 2021 by guest. Protected by copyright. by Protected guest. by 2021 30, September on