Anthracosis is black pigment discoloration of bronchi which can cause bronchial destruction and deformity (anthracofibro- sis). A prospective, case-control study. Comert et al., J Pulmonar Respirat Med , bronchoscopical findings of patients with bronchial anthracosis. Methods: Among I read the manuscript “Bronchial Anthracosis-Anthracofibrosis: Potential patients with anthracosis were included. J Pulmonar Respirat Med ; 2: 2.
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Anthracosis of the lungs is black discoloration of bronchial mucosa that can occlude bronchial lumen and is associated with pulmonsr anthracofibrosis BAF. This disease usually presents with a chronic course of dyspnea and or cough in an elderly non-smoker woman or man. In addition, concomitant exposure to dust and wood smoke is the most postulated etiology for anthracosis.
Pulmonary function tests usually show an obstructive pattern with no response to bronchodilators and normal DLCO, but some cases with restrictive pattern have also been seen. Computed tomography CT may show more specific findings such as lymph node or bronchial calcification and mass lesions. Final diagnosis can be made by bronchoscopy when obtaining samples for tuberculosis TBwhich is the most common disease associated with BAF.
Endobronchial ultrasound shows a hypoechoic scattered nodular pattern in antraocsis lymph nodes, which is unique antacosis anthracosis. Treatment is very similar to that of chronic obstructive pulmonary disease COPD with a chronic course and low mortality.
This review discusses this disease as a separate entity; hence, anthracosis should be added to the list of sntracosis lung diseases and benign mass lesions and differentiated from biomass induced COPD. Anthracosis may be seen as a superficial black discoloration simple anthracosis Figure 1A or scattered foci of black spots, which pulmonsr mucosa inward due to the effect of adjacent anthracotic lymphadenopathy Figure 1B.
Anthracosis is an ancient disease discovered in mummies 2 — 4. Pearson and others believed that anthracosis was a complication of coal worker pneumoconiosis 6. However, the interest of Western countries in this disease declined as the frequency of anthracosis declined in their countries. The second wave of anthracosis in the literature started in Asia, as it is still a problem in this continent.
Most of these studies showed that pneumoconiosis and exposure to coal were not the most frequent risk factors and thus researchers excluded pneumoconiosis patients from the category of anthracosis 78. It is the severe form of disease, which distorts and narrows the bronchial lumen Figure 1C.
Later, some new terms were introduced such as anthracostenosis 9 or anthracotic bronchitis 10 used to describe extensive deposition of carbon in the main bronchial walls; which in the majority of cases is accompanied by severe submucosal edema, bronchial stenosis, protruded mucosal folds and lung collapse 10 Figure 1C.
A Bronchoscopic picture of simple anthracosis; B Anthracosis with retracted mucosa; C Bronchial anthracofibrosis. Prevalence of anthracosis in the general population has been roughly estimated because the exact diagnosis of anthracosis requires bronchoscopy, which is impossible for the general population due to ethical considerations.
Available data from large series of patients who underwent bronchoscopy for other reasons have antracosia the frequency of simple anthracosis to be 3. This rate was 0. Reports from other continents such as North America or Africa were also scanty 1416 and reports of anthracosis pulmpnar children are very rare The number of affected females in some large series has been equal to males 810but accumulation of data show that BAF in females is slightly more prevalent than males Pulmlnar 1.
Moreover, almost all studies have shown that anthracosis subjects are elderly Pulmonnar 1. The exact reason of anthracosis and the origin of anthracotic nodule have yet to be discovered.
Anthracosis of the Lungs: Etiology, Clinical Manifestations and Diagnosis: A Review
Dust exposure, especially coal dust in anthracosis subjects was reported during in Europe 56. Later on, Wynn et al. Recent studies in Europe have shown deposition of mica and silica crystals in calcified mediastinal lymph nodes of anthracotic patients using transmission electron microscopy 20 In a study in Japan, elemental constitution of lobectomized lung tissue obtained by autopsy was analyzed by a wavelength-dispersive X-ray fluorescence spectrometer 22 ; the most important non-carbonaceous fraction of intrapulmonary particulate pollutant was ajtracosis and aluminum, especially in farmers compared to other occupational categories.
Electron microscopic evaluations of the lung tissue from mummies also showed silica, aluminum, and iron deposits 3. Therefore, the pathogenesis of these crystals causing anthracosis should be different from that of routine air pollution and occupational exposure, and according to a recent widespread investigation 24 and in mummies 4concurrent exposure to carbon smoke from the combustion of fuels and inorganic compounds that contain limestone and alumina-silicates is the most possible cause for anthracosis.
Biomass smoke has been mostly reported as a risk factor antracosiss anthracosis in Asian countries such as Korea 8India 25Iran 26 and Turkey Some reports from Africa 28 and Latin America 2930 have indicated chronic respiratory disease induced by biomass smoke exposure. The hypothesis about biomass as a causative factor for anthracosis is due to abtracosis resemblance of anthracotic pigments to carbon particles and the fact that most of the anthracotic subjects Biomass is produced by burning of wood, leaves or dung manure of farm animals for heating, cooking or baking 8.
The mean duration of biomass exposure was reported to be 36 years 12 — 60 8 and zntracosis years of smoke exposure showed significant association with anthracosis OR: In other studies, indoor exposure to wood smoke similar to bread baking in traditional ovens increased the risk of BAF by 4. Furthermore, some investigators have attempted to explain the pathophysiology of anthracosis, including bronchial narrowing, lymph node enlargement with or without calcification and susceptibility to TB and malignancy on the basis of biomass smoke inhalation 8.
However, there were some anthracotic subjects who had used other fuels such as kerosene or gas; these cases cannot be explained by this hypothesis. Cigarette smoking is not a risk factor for anthracosis and its frequency was significantly lower in anthracotic subjects compared to COPD subjects who underwent bronchoscopy Table 1. Moreover, anthracotic plaque and bronchial deformity were not observed in typical COPD subjects who had a history of cigarette smoking ; therefore, in case of detecting anthracosis during bronchoscopy, it should not be considered as a variant of COPD.
Increased motility pulmknar bronchial cilia was postulated to be the cause of low prevalence of anthracosis in cigarette smokers Thereafter, several studies have reported the association of anthracosis with TB Table 2.
In a meta-analysis, which reviewed all antracossi on the association of TB and anthracosis, it was shown that the cumulated incidence puljonar TB in anthracosis and BAF subjects who underwent routine bronchoscopy was The risk of TB increased in anthracosis with a cumulated odds ratio of 3.
Forest plot for evaluating the association and risk of tuberculosis in anthracosis and BAF subjects Evaluation of space-oligonucleotide spoligotyping of M. The reason for TB susceptibility has with wood smoke on the immune system have been postulated 8 The reason for the variation in frequency of lung cancer associated with anthracosis has yet to be understood, but in one study by Ohshima 22subjects with lung cancer had a high level of iron, calcium, copper, lead, chromium and nickel in their lung tissue and lower levels of silicon and aluminum as the main mineral intrapulmonary particulate pollutant of routine anthracosis subjects Therefore, we can conclude than there is no epidemiological or etiological association between anthracosis and lung cancer.
Anthracosis involvement mainly starts from the respiratory bronchioles 44 Histopathology of the lung tissue has shown carbon-like particles inside the cytoplasm of the macrophages in the bronchial wall 46 Figure 3 and free particles in the mediastinal lymph nodes Submucosal fibrosis may also be seen in the bronchial wall 37 and the epithelial lining is usually intact In a study, lobectomy was done on two BAF subjects and fibrosis of the bronchi and reactive hyperplasia with anthracotic pigmentation were the major histopathological findings Perforation of anthracotic lymph nodes into the bronchial lumen may be the mechanism that produces anthracosis with retracted mucosa Figure 1B These findings are completely distinct from the histopathological findings of COPD as the most important clinical differential diagnosis of BAF.
Histopathology of BAF, A Anthracotic nodule in cytoplasm of macrophages; B Collagen deposition in bronchial biopsy of a patient who suffered from anthracofibrosis. C Association of anthracosis filled black arrow and granuloma due to tuberculosis none- filled arrow. Anthracosis was discovered in the lung tissue of wild and domestic animals 47 A study in cattle showed anthracosis in 3. In some experimental studies, investigators were successful in inducing anthracosis in animal models 51 ; moreover, the frequency of anthracosis in rats that were exposed to exhaust smoke was evaluated as well Anthracosis has also been reported in the liver, spleen 53 and esophagus 54 Anthracosis in the esophagus is important as it mimics the picture of malignant melanoma An interesting case of sinusitis was reported, where the subject suffered from anthracosis of the sinuses Cough and dyspnea are the most frequent symptoms of BAF and anthracosis in most reports Table 1.
Anthracosis – definition of anthracosis by The Free Dictionary
Physical examination of the lungs usually shows wheezing 7 and less frequently rales or decreased breath sounds Some anthracosis subjects had normal physical examinations, but the frequency has not been mentioned in the literature. Anthracosis may present with complications of enlarged mediastinal lymph nodes such as vocal cord paralysis 49 or broncholithiasis Many of these cases were also reported in association with tuberculosis 49 Generally, BAF subjects could be classified under obstructive lung disease, but some of them have shown normal or restrictive patterns Table 3.
Another study showed that the resistance of the airways had a significant correlation with the number of bronchial stenoses Therefore, we conclude that obstruction should be fixed in the bronchi and the respiratory unit should be intact.
Statistical analysis did not show a antracosid between the severity of clinical findings and spirometry These findings were across the findings of Tanaka et al. They showed that anthracosis started from the small bronchi and then spread to the larger bronchi. For this reason, we conclude antracowis when BAF is found in the proximal bronchi, all other distal bronchi should assume to be occluded by anthracosis.
Therefore, anthracosis and BAF should be considered in the list of differential diagnoses of obstructive lung disease. CXR in some cases showed resolution of abnormalities when the anthracosis subjects were pulmonag to suffer from TB and were treated with anti-TB medications 737 Chest X-ray posterior anterior view in a subject suffering from anthracofibrosis.
Please note the non-specific infiltration in the left lower zone and the mass lesion in the right lower zone. Computed tomography CT was more sensitive anttracosis anthracosis and showed more specific radiological findings Figure 5. Involvement might be unilateral or bilateral, but the right middle lobe, followed by the upper lobes were frequently reported as the most commonly involved lobes 71833 Computed tomography of a subject with diffuse anthracofibrosis; A: Mediastinal calcification wide non-filled arrow and mass lesion in parenchyma narrow filled arrowB: Bronchial narrowing narrow non-filled arrow and mass lesion in parenchyma narrow filled arrow.
Pleural disease was observed in a quarter of BAF subjects 8.
As a routine practice, anthracosis may be erroneously diagnosed as TB, lung cancer, atelectasis or pneumonia 16 The results of their study showed that BAF subjects tend to show bilateral smooth bronchial stenosis and peribronchial lymphadenopathy. This is in contrast to subjects with endobronchial TB who tend to have limited ipsilateral irregular bronchial stenosis, especially in the lobar bronchus and it can extend to contiguous bronchus and trachea. Choe et al, 66 also showed that necrotic lymph nodes, multiple poorly defined small nodules, including branching opacities including tree in bud and consolidation with internal pulmonsr density antracosks in favor of TB.
Bronchoscopy is the gold standard for diagnosing anthracosis. As mentioned above, anthracosis may be detected in different images as simple flat anthracosis Figure 1Adeep seated retracted anthracosis originating from an anthracotic lymph node besides the bronchus Figure 1Band protruded black discoloration of mucosa with antracosid without narrowing of bronchi BAF Figure 1C. In addition to black lesions, bronchial swelling with infiltration, erythema Figure 1C and thickening that may cause obliteration of bronchi may be seen Anthracosis can be localized or disseminated, unilateral or bilateral 18 and the most frequent place of involvement is the right middle lobe RMLfollowed by antracosks upper lobe bronchi Table 2especially at the bifurcation or inlet of the lobar or segmental antracodis 8 Tracheal involvement is rare and was detected in 3.
Also, bronchial washing may show free black particles 45 and biopsy is usually difficult as the mucosa has a hard consistency 7.
Anthracosis of the Lungs: Etiology, Clinical Manifestations and Diagnosis: A Review
Endobronchial ultrasound has not been studied extensively in anthracotic subjects, but Mirsadraee and Farshchi 71 reported a picture from typical anthracosis that showed a scattered nodular hypoechoic pattern in the subepithelial area of the bronchus or lymph node adjacent to the bronchial mucosa Figure 6. Endobronchial ultrasonography of an anthracofibrosis that protruded to the bronchial lumen.
Note the hyperechoic nodule inside the lesion.