A breathless builder

Extract

The patient was a 30-year-old male mason whose work frequently involved cutting and grinding brick and cement with powered tools. He was an active smoker (1–1.5 packs per day). He had worked in building construction since the age of 14 yrs, as a labourer then as a mason and had been a mason for the previous 13 years. He reported frequent exposure to cement and brick dust while removing stone floors with a jackhammer. From 8–2 months prior to presentation, he had been employed repairing exterior brick on three large apartment buildings (figure 1). This required cutting through brick and mortar with a powered, high-speed demolition saw and grinding mortar from between bricks with a powered hand-grinder, a common task known as “tuckpointing” (figure 2), while intermittently using a disposable particle mask. After completing this job, he felt well for ~2 months and then gradually began to develop a nonproductive cough, dyspnoea on exertion and an 11 kg weight loss without fever. Serial pulmonary function testing showed restriction and a marked reduction in diffusing capacity. Chest computed tomography (CT) showed bilateral diffuse infiltrates. A purified protein derivative test was negative. Bronchoalveolar lavage fluid was mucoid, and culture was negative. A transbronchial biopsy was nondiagnostic and the post-bronchoscopy chest film showed a very small right apical pneumothorax. An HIV test was negative.