"Sarcoid Like" Granulomatous Pulmonary Disease in World Trade Center Disaster Responders
More than 20,000 responders have been examined through the World Trade Center (WTC) Medical Monitoring and Treatment Program since September 11, 2001. Studies on WTC firefighters have shown elevated rates of sarcoidosis. The main objective of this study was to report the incidence of "sarcoid like" granulomatous pulmonary disease in other WTC responders.
Cases of sarcoid like granulomatous pulmonary disease were identified by: patient self-report, physician report and ICD-9 codes. Each case was evaluated by three pulmonologists using the ACCESS criteria and only "definite" cases are reported.
Thirty-eight patients were classified as "definite" cases. Six-year incidence was 192/100,000. The peak annual incidence of 54 per 100,000 person-years occurred between 9/11/2003 and 9/11/2004. Incidence in black responders was nearly double that of white responders. Low FVC was the most common spirometric abnormality.
Sarcoid like granulomatous pulmonary disease is present among the WTC responders. While the incidence is lower than that reported among firefighters, it is higher than expected.
Available from: Francesco Varone
- "Other factors potentially involved could be silica, silicone and the fibers of the glass. Three recent longitudinal studies regarding the World Trade Center disaster have emphasized the role of airborne inorganic particulate exposure in sarcoidosis [4-6]. These studies showed an increase in sarcoidosis among firefighters and emergency first responders. "
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ABSTRACT: Sarcoidosis is a granulomatous multisystem disorder of unclear etiology that involves any organ, most commonly the lung and the lymph nodes. It is hypothesized that the disease derives from the interaction between single or multiple environmental factors and genetically determined host factors. Multiple potential etiologic agents for sarcoidosis have been proposed without any definitive demonstration of causality.
We report the case of two patients, husband (57 years old) and wife (55 years old), both suffering from sarcoidosis. They underwent a lymph node biopsy by mediastinoscopy which showed a “granulomatous epithelioid giant cell non-necrotising chronic lymphadenitis”. They had lived up to 3 years ago in the country in a farm, in contact with organic dusts, animals such as dogs, chickens, rabbits, pigeons; now they have lived since about 3 years in an urban area where there are numerous chemical industries and stone quarries. The aim of this case report was to focus on environmental factors that might be related to the pathogenesis of the sarcoidosis.
Available from: Carlos R R Carvalho
- "There is epidemiological evidence of the association of sarcoidosis and agricultural employment, exposures to insecticides, mold/mildew environments [Kucera et al., 2002; Newman et al., 2004]. An increased incidence of sarcoidosis was also observed in association with exposure to inorganic dusts at the World Trade Center on September 11, 2001 [Izbicki et al., 2007; Crowley et al., 2010], and with exposure to crystalline silica [Rafnsson et al., 1998], man-made mineral fiber [Drent et al., 2000], metal machining, indoor exposure to high humidity, and heavy construction [Kucera et al., 2002]. Excavation involves exposure to numerous pollutants, such as particulate matter, gases emitted by diesel trucks, and dusts from rock, concrete, and resins [Rappaport et al., 2003; Oliver and Miracle-McMahill, 2006]. "
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ABSTRACT: A definite cause of sarcoidosis has not been identified, however past research suggests that environmental factors may be triggers of the granulomatous response in genetically susceptible individuals.
A 22-year-old male non-smoker, presented with progressive exertional dyspnea and cough of 3 months duration. One year before, when he started working in tunnel excavation, he had a normal chest radiograph. Chest imaging revealed bilateral nodules and masses of peribronchovascular distribution plus mediastinal lymphadenomegaly. Histologic lymph node analysis revealed non-caseating confluent granulomas. Sarcoidosis was diagnosed. The patient was treated with corticosteroids and advised to change jobs. Complete remission of the disease was achieved and persisted for at least one year without steroid treatment.
Sarcoidosis is believed to have environmental triggers. The timing of the onset of sarcoidosis in this patient following intensive exposure to tunnel dust suggests an environmental contribution. The recognition that sarcoidosis may have occupational triggers have medical, employment, and legal implications.
Available from: Tee Guidotti
- "Other lower respiratory diseases have also been reported post-9/11 but their frequency is not known. Sarcoidosis, affecting approximately 100 individuals, has been reported by the three largest WTC responder monitoring programs [Izbicki et al., 2007; Miller and Palecki, 2007; Jordan et al., 2008; Bowers et al., 2010; Crowley et al., 2010] and cases are probably present in other series [Safirstein et al., 2003]. There has been a report of two cases of acute eosinophilic pneumonia [Rom et al., 2002]. "
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ABSTRACT: On September 11, 2001, events at the World Trade Center (WTC) exposed residents of New York City to WTC dust and products of combustion and pyrolysis. The majority of WTC-exposed fire department rescue workers experienced a substantial decline in airflow over the first 12 months post-9/11, in addition to the normal age-related decline that affected all responders, followed by a persistent plateau in pulmonary function in the 6 years thereafter. The spectrum of the resulting pulmonary diseases consists of chronic inflammation, characterized by airflow obstruction, and expressing itself in different ways in large and small airways. These conditions include irritant induced asthma, non-specific chronic bronchitis, aggravated pre-existing obstructive lung disease (asthma or COPD), and bronchiolitis. Conditions concomitant with airways obstruction, particularly chronic rhinosinusitis and upper airway disease, and gastroesophageal reflux, have been prominent in this population. Less common have been reports of sarcoidosis or interstitial pulmonary fibrosis. Pulmonary fibrosis and bronchiolitis are generally characterized by long latency, relatively slow progression, and a silent period with respect to pulmonary function during its evolution. For these reasons, the incidence of these outcomes may be underestimated and may increase over time. The spectrum of chronic obstructive airways disease is broad in this population and may importantly include involvement at the bronchiolar level, manifested as small airways disease. Protocols that go beyond conventional screening pulmonary function testing and imaging may be necessary to identify these diseases in order to understand the underlying pathologic processes so that treatment can be most effective. Am. J. Ind. Med. 54:649–660, 2011. © 2011 Wiley-Liss, Inc.
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