0
Correspondence |

Hypersensitivity Pneumonitis Due to Metalworking Fluid ExposuresMetalworking Fluid Hypersensitivity Pneumonitis FREE TO VIEW

Christopher M. Barber, MD; Clare M. Burton, MBChB; Edward Robinson, Bsc; Brian Crook, PhD; Gareth Evans, PhD; David Fishwick, MD
Author and Funding Information

From the Centre for Workplace Health, Health and Safety Laboratory.

Correspondence to: C. M. Barber, MD, Centre for Workplace Health, Health and Safety Laboratory, Buxton, SK17 9JN, England; e-mail: chris.barber@hsl.gov.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(4):1189. doi:10.1378/chest.12-2865
Text Size: A A A
Published online
To the Editor:

We read with interest the recent article by Lacasse et al1 (CHEST July 2012), which provided a comprehensive update on hypersensitivity pneumonitis (HP). We would like to comment, however, on the section relating to HP due to metalworking fluid (MWF) exposure and, in addition, highlight the experience in the United Kingdom in this area.2 Our group has recently published a review article summarizing the microbiologic and immunologic findings from all previously published MWF outbreaks.3 We have also investigated a number of MWF-HP outbreaks in the United Kingdom. In the most detailed of these, 17 workers met the case definition for MWF-HP,4 and in 14 of the 17 cases, the diagnosis was confirmed when reviewed by a panel of occupational respiratory disease experts.5 However, none of these workers (including one with a positive specific challenge to used MWFs from this workplace)4 or the other 112 workers tested had IgG precipitin responses to extracts of Mycobacterium immunogenum, chelonae, or fortuitum. In addition, mycobacteria could not be cultured from any of the 125 MWF samples taken from the workplace, and there was no evidence of mycobacterial DNA identified by polymerase chain reaction. Multiple MWF samples taken from two other workplaces with unrelated outbreaks of MWF-HP (C. M. Barton, MD, unpublished data) similarly showed no evidence of mycobacterial contamination or DNA.

Although the findings in hot-tub lung and from animal studies indicate it may be biologically plausible that opportunistic mycobacteria are also causative in MWF-HP, the human cytokine stimulation studies referred to by Lacasse et al1 have not been able to confirm a clear link.6 The presence of IgG to opportunistic mycobacteria is not sufficient to establish causation, because cases of MWF-HP also commonly demonstrate IgG to other bacteria and/or fungi.3 As an example, nine out of 13 of the French cases of MWF-HP also had measurable IgG arcs to Fusarium solani and/or Bacillus simplex, in addition to IgG arcs to M immunogenum.7

Establishing the true cause is clearly relevant to preventing outbreaks, but it is also vital to inform the metalworking industry about how best to monitor, manage, and design their MWFs. Based on the experience in the United Kingdom, it is clear that outbreaks of HP can also occur in “mycobacteria-free” workplaces, and, therefore, designing MWF systems to resist mycobacterial contamination will not prevent all cases of disease. Given the difficulties in establishing causation, and given the presence of chemical asthmagens in MWF, engineering controls aimed at preventing exposures to mist remain just as important as managing microbial contamination.

In summary, we would like to clarify to the wider respiratory audience that the existing published evidence does not as yet support a simple causative link between HP and opportunistic mycobacteriae and emphasize that further research in this area is required.

References

Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest. 2012;142(1):208-217. [CrossRef] [PubMed]
 
Barber CM, Burton C, Robinson E, Crook B, Evans G, Fishwick D. Re: Hypersensitivity pneumonitis and metalworking fluids contaminated by mycobacteria. Eur Respir J. 2011;38(2):486-487. [CrossRef] [PubMed]
 
Burton CM, Crook B, Scaife H, Evans GS, Barber CM. Systematic review of respiratory outbreaks associated with exposure to water-based metalworking fluids. Ann Occup Hyg. 2012;56(4):374-388. [CrossRef] [PubMed]
 
Robertson W, Robertson AS, Burge CB, et al. Clinical investigation of an outbreak of alveolitis and asthma in a car engine manufacturing plant. Thorax. 2007;62(11):981-990. [CrossRef] [PubMed]
 
Burton CM, Burge PS, Robertson AS, et al. Outbreak case definitions for extrinsic allergic alveolitis due to metal working fluids. Paper presented at: British Thoracic Society Winter Meeting; December 1-3, 2010; London, England.
 
Trout D, Weissman DN, Lewis D, Brundage RA, Franzblau A, Remick D. Evaluation of hypersensitivity pneumonitis among workers exposed to metal removal fluids. Appl Occup Environ Hyg. 2003;18(11):953-960. [CrossRef] [PubMed]
 
Tillie-Leblond I, Grenouillet F, Reboux G, et al. Hypersensitivity pneumonitis and metalworking fluids contaminated by mycobacteria. Eur Respir J. 2011;37(3):640-647. [CrossRef] [PubMed]
 

Figures

Tables

References

Lacasse Y, Girard M, Cormier Y. Recent advances in hypersensitivity pneumonitis. Chest. 2012;142(1):208-217. [CrossRef] [PubMed]
 
Barber CM, Burton C, Robinson E, Crook B, Evans G, Fishwick D. Re: Hypersensitivity pneumonitis and metalworking fluids contaminated by mycobacteria. Eur Respir J. 2011;38(2):486-487. [CrossRef] [PubMed]
 
Burton CM, Crook B, Scaife H, Evans GS, Barber CM. Systematic review of respiratory outbreaks associated with exposure to water-based metalworking fluids. Ann Occup Hyg. 2012;56(4):374-388. [CrossRef] [PubMed]
 
Robertson W, Robertson AS, Burge CB, et al. Clinical investigation of an outbreak of alveolitis and asthma in a car engine manufacturing plant. Thorax. 2007;62(11):981-990. [CrossRef] [PubMed]
 
Burton CM, Burge PS, Robertson AS, et al. Outbreak case definitions for extrinsic allergic alveolitis due to metal working fluids. Paper presented at: British Thoracic Society Winter Meeting; December 1-3, 2010; London, England.
 
Trout D, Weissman DN, Lewis D, Brundage RA, Franzblau A, Remick D. Evaluation of hypersensitivity pneumonitis among workers exposed to metal removal fluids. Appl Occup Environ Hyg. 2003;18(11):953-960. [CrossRef] [PubMed]
 
Tillie-Leblond I, Grenouillet F, Reboux G, et al. Hypersensitivity pneumonitis and metalworking fluids contaminated by mycobacteria. Eur Respir J. 2011;37(3):640-647. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543