04 February 2019

Cor pulmonale in multi-facet miner lung disease: should we lower the standard echo thresholds

Background:

Lung disease has been well-documented in coal miners of the Western world, and of South Africa. However, it remains that prevention is fundamental in avoiding complications; due to the difficulty in treatment, and the unpredictable responses to existing treatment modalities. In developing countries, diagnosis and management is even more challenging due to the difficulty in accessing expensive tests, frequently; as well as the expertise to articulate management flow. In further detriment, accuracy of 2D- or Doppler measurements is often compromised by suboptimal echo viewing due to the underlying lung pathology and air entrapment.

We describe the case of an overground-miner whose out-door exposure to mining dust none-the-less led to severe associated respiratory disease that proved challenging to monitor.

Case Study:

We present a 45-year old male, who, after several months of symptoms, was thought to have asthma; with the differential of chronic obstructive airway disease (COPD). Over the next two-year period, his symptoms would progress; responding poorly to treatment for common and atypical infective sequelae of obstructive airway disease. Sequential radiology suggested pneumoconiosis, with differential of silicosis, and interstitial lung disease (ILD). However, initial echo showed no significant right-sided disease. 12-months later, the patient rapidly deteriorated into cor-pulmnale; with pulmonary pressures still appearing only modestly raised. Despite treatment, he experienced several COPD exacerbations, and fluctuated in and out of cor-pulmonale, even without COPD exacerbations; until it became almost refractory after another 12-month period. In all this time, pulmonary pressures never exceeded modest values, when clinically his right-heart failure had progressed. Sadly, his condition did not enable him to undergo cardiac catheterization for right heart studies.

Conclusion:

Cor-pulmonale resulting from mining-dust-related restrictive and obstructive lung disease is a severely debilitating condition. Although prevention of the underlying lung disease is most recommended, difficulties in diagnosis and management make this impractical. Cor-pulmonale appears to hasten clinical deterioration, but inability to confirm standard echo-criteria for right-heart disease can mis-lead clinicians away from the diagnosis. Applying or devising revised echo criteria specific to these patients may be beneficial in improving symptoms, and perhaps outcome, by enabling stricter management earlier on.

Key Contributors

Kemi Tibazarwa : LHC, Dar es Salaam, Tanzania


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