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Correspondence |

The Natural History of Flock Worker’s LungFlock Worker’s Lung FREE TO VIEW

David G. Kern, MD, MOH; Robert S. Crausman, MD, FCCP; Kate T. H. Durand, MHS, CIH
Author and Funding Information

From Maine VA Medical Center (Dr Kern); Warren Alpert School of Medicine of Brown University (Dr Crausman); and Occupational Knowledge International (Ms Durand).

Correspondence to: David G. Kern, MD, MOH, Maine VA Medical Center, 1 VA Center, Augusta, ME 04330; e-mail: david.g.kern@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Kern reports to the ACCP that he and some of the authors have had previous serious disagreements over data, publication, and citation credit on research related to this topic. Dr Crausman and Ms Durand have reported 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. 2014;145(1):185-186. doi:10.1378/chest.13-1843
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To the Editor:

In a recent article in CHEST (June 2013), Turcotte et al1 presented incomplete, poorly defined, and uninterpretable data that contribute little to our understanding of flock worker’s lung. In 1995, when the authors first reported on five of these same patients,2 they erroneously characterized the pulmonary pathology as being that of desquamative interstitial pneumonitis and incriminated mycotoxin in the absence of evidence that inhalation exposure to mycotoxin has ever caused chronic interstitial lung disease.3-5 At the time, the authors reported chronic respiratory impairment and disability in three patients, two of whom remained oxygen dependent after a mean follow-up of 3 years.2 During the ensuing 2 decades, the patients with oxygen dependency experienced slowly progressive respiratory failure, culminating in death. That the one postmortem examination performed revealed findings of end-stage interstitial fibrosis and acute interstitial pneumonitis1 highlights the importance of eliciting occupational and avocational histories from patients with diffuse interstitial lung disease lest environmentally induced disease be ascribed to IPF. The autopsy findings support our contention that a workshop report on the pathology of flock worker’s lung underemphasizes the diffuse interstitial inflammation and fibrosis we observed with the more common, yet more striking, nodular peribronchovascular interstitial lymphoid infiltrates and lymphocytic bronchiolitis that we have described.3-5

The authors’ report of an excessive rate of decline in FEV1 among those continuing to work in the absence of recognized flock worker’s lung is difficult to interpret and not only for the numerous reasons acknowledged by the authors themselves. In the absence of additional information, it is difficult to ascribe much meaning to an average annual decline in FEV1 of 46 mL because baseline and follow-up spirometric data were obtained by two different groups using different spirometers. However, assuming this workforce did experience an excessive rate of decline in FEV1, it would be helpful for the authors to provide details as to the nature of the presumably ineffective engineering controls introduced during the decade in question. More specifically, it would be helpful to know (1) whether rotary cutters were still in use at the company’s facilities because such cutters are believed to generate much higher air concentrations of respirable-sized nylon fragments than do the guillotine cutters used by nearly every other nylon flock manufacturer in the world4 and (2) whether the company’s interventions have reduced exposure to those fragments. As they are, the air sampling results provided are uninformative.

The authors’ comment that no cases of lung cancer were identified in their cohort is unfortunately not reassuring. The authors defined neither a coherent cohort nor a mechanism for detecting lung cancer cases. Moreover, the majority of exposed workers were not followed beyond 40 years of age. We continue to believe that workers in this industry should be notified of their potentially increased risk of lung cancer.6 Finally, we urge the National Institute for Occupational Safety and Health investigators to determine whether, as suspected, air concentrations of respirable-sized nylon fragments are higher at facilities manufacturing or using rotary-cut vs guillotine-cut flock and hope that the Occupational Safety and Health Administration proceeds with its long-contemplated standard setting for this industry.

References

Turcotte SE, Chee A, Walsh R, et al. Flock worker’s lung disease: natural history of cases and exposed workers in Kingston, Ontario. Chest. 2013;143(6):1642-1648. [CrossRef] [PubMed]
 
Lougheed MD, Roos JO, Waddell WR, Munt PW. Desquamative interstitial pneumonitis and diffuse alveolar damage in textile workers: potential role of mycotoxins. Chest. 1995;108(5):1196-1200. [CrossRef] [PubMed]
 
Boag AH, Colby TV, Fraire AE, et al. The pathology of interstitial lung disease in nylon flock workers. Am J Surg Pathol. 1999;23(12):1539-1545. [CrossRef] [PubMed]
 
Kern DG, Kuhn C III, Ely EW, et al. Flock worker’s lung: broadening the spectrum of clinicopathology, narrowing the spectrum of suspected etiologies. Chest. 2000;117(1):251-259. [CrossRef] [PubMed]
 
Kern DG, Crausman RS, Durand KTH, Nayer A, Kuhn C III. Flock worker’s lung: chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129(4):261-272. [CrossRef] [PubMed]
 
Kern DG, Kern E, Crausman RS, Clapp RW. A retrospective cohort study of lung cancer incidence in nylon flock workers, 1998-2008. Int J Occup Environ Health. 2011;17(4):345-351. [CrossRef] [PubMed]
 

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Tables

References

Turcotte SE, Chee A, Walsh R, et al. Flock worker’s lung disease: natural history of cases and exposed workers in Kingston, Ontario. Chest. 2013;143(6):1642-1648. [CrossRef] [PubMed]
 
Lougheed MD, Roos JO, Waddell WR, Munt PW. Desquamative interstitial pneumonitis and diffuse alveolar damage in textile workers: potential role of mycotoxins. Chest. 1995;108(5):1196-1200. [CrossRef] [PubMed]
 
Boag AH, Colby TV, Fraire AE, et al. The pathology of interstitial lung disease in nylon flock workers. Am J Surg Pathol. 1999;23(12):1539-1545. [CrossRef] [PubMed]
 
Kern DG, Kuhn C III, Ely EW, et al. Flock worker’s lung: broadening the spectrum of clinicopathology, narrowing the spectrum of suspected etiologies. Chest. 2000;117(1):251-259. [CrossRef] [PubMed]
 
Kern DG, Crausman RS, Durand KTH, Nayer A, Kuhn C III. Flock worker’s lung: chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129(4):261-272. [CrossRef] [PubMed]
 
Kern DG, Kern E, Crausman RS, Clapp RW. A retrospective cohort study of lung cancer incidence in nylon flock workers, 1998-2008. Int J Occup Environ Health. 2011;17(4):345-351. [CrossRef] [PubMed]
 
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