Bronchiolitis obliterans 3935481 216733476 2008-06-02T23:36:25Z Wjousts 400710 [[WP:UNDO|Undid]] revision 216671665 by [[Special:Contributions/147.240.236.9|147.240.236.9]] ([[User talk:147.240.236.9|talk]]) {{Infobox_Disease | Name = {{PAGENAME}} | Image = | Caption = | DiseasesDB = 1704 | ICD10 = | ICD9 = | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshID = D001989 | }} '''Bronchiolitis obliterans''', or '''Constrictive bronchiolitis''', one form of which is called '''Popcorn Workers' Lung''' or '''popcorn lung''', is a rare and life-threatening form of fixed obstructive [[lung]] disease in which the [[bronchiole]]s are plugged with [[granulation tissue]]. ''Bronchiolitis'' means [[inflammation]] of the [[bronchioles]] and ''Obliterans'' refers to the fact that the inflammation of the bronchioles partially obliterates the airways. There is no consensus classification scheme for bronchiolitis subtypes. One author describes four specific subtypes as follows: *cellular bronchiolitis *respiratory bronchiolitis *bronchiolitis obliterans *bronchiolitis obliterans with intraluminal polyps (proliferative bronchiolitis obliterans). In addition, because of similar names, Bronchiolitis obliterans is sometimes confused in the public mind with [[bronchiolitis obliterans organizing pneumonia]] (BOOP), a completely different pulmonary disorder. ==Etiology== Bronchiolitis obliterans has many possible causes, including: [[collagen vascular disease]], [[transplant rejection]] in [[organ transplant]] patients, viral infection ([[RSV]], [[adenovirus]], [[Pneumocystis pneumonia|PCP]], [[HIV]], [[CMV]]), drug reaction, aspiration and complications of prematurity ([[bronchopulmonary dysplasia]]), and exposure to toxic fumes, including: [[diacetyl]], [[sulfur dioxide]], [[nitrogen dioxide]], [[ammonia]], [[chlorine]], [[thionyl chloride]], [[methyl isocyanate]], [[hydrogen fluoride]], [[hydrogen bromide]], [[hydrogen chloride]], [[hydrogen sulfide]], [[phosgene]], polyamide-amine dyes, and [[ozone]]. Additionally, the disorder may be [[idiopathic]] (without known cause). {{ref label|Brant|1|^}}{{ref label|Webb|2|^}}{{ref label|Hazmap|5|^}}. ==Presentation== Bronchiolitis obliterans is a lung disease characterized by fixed airway obstruction. [[Inflammation]] and [[scarring]] occur in the airways of the lung, resulting in severe shortness of breath and dry cough. Standard lung capacity is normally around 80% lung usage. Bronchiolitis obliterans reduces this to 16% to 21%. Symptoms include: * dry cough * shortness of breath * wheezing The symptoms can start gradually, or severe symptoms can occur suddenly. {{ref label|CDC|3|^}} ==Diagnosis== Bronchiolitis obliterans is often misdiagnosed as [[asthma]], [[bronchitis]], [[emphysema]], or [[pneumonia]]. Diagnosis may include the following tests: * [[Chest X-rays]] tests. * Diffusing capacity of the lung ([[DLCO]]) tests are usually normal. * [[Spirometry]] tests show fixed [[airway obstructions]] and sometimes restriction. * [[Lung Volume]] tests may show hyperinflation (excessive air in lungs caused by [[air trapping]]). * High-resolution computerized [[tomography]] scans of the chest at full inspiration and expiration may reveal heterogeneous [[air trapping]] on the expiratory view as well as haziness and thickened airway walls. * [[Lung biopsies]] may reveal evidence of constrictive bronchiolitis obliterans (i.e., severe narrowing or complete obstruction of the small airways). An open lung biopsy, such as by thoracoscopy, is more likely to be diagnostic than a transbronchial biopsy. Special processing, staining, and review of multiple tissue sections may be necessary for a diagnosis.{{ref label|NIOSH|4|^}} ==Prognosis/treatment== This disease is irreversible and severe cases often require a [[lung transplant]]. Evaluation of interventions to prevent bronchiolitis obliterans relies on early detection of abnormal [[spirometry]] results or unusual decreases in repeated measurements. ==Industrial inhalants== There are many industrial inhalants that are known to cause various types of bronchiolitis, including Bronchiolitis obliterans. {{ref label|Colby|5|^}} Industrial workers who have presented with bronchiolitis: *nylon-flock workers {{ref label|Hazmap|6|^}} *workers who spray prints onto textiles with polyamide-amine dyes {{ref label|Hazmap|6|^}} *battery workers who are exposed to thionyl chloride fumes *workers at plants that use or manufacture flavorings, e.g. diacetyl butter-like flavoring {{ref label|CDC|3|^}}{{ref label|Hazmap|6|^}}{{ref label|CalOSH|7|^}} ==Popcorn Workers Lung== In rare instances, bronchiolitis obliterans may be caused by inhalation of airborne [[diacetyl]] — a chemical used to produce the butter-like flavoring in many foods such as candy, microwave popcorn and wines. This first came to public attention when eight former employees of the Gilster-Mary Lee popcorn plant in [[Jasper, Missouri]], developed bronchiolitis obliterans. In 2000, the Missouri Department of Health called in [[NIOSH]] to make a determination of the cause, and to recommend safety measures. After surveying the plant and each patient's medical history, NIOSH recommended respiratory protection for all workers in microwave popcorn production. Due to this event, bronchiolitis obliterans began to be referred to in the popular media as "Popcorn Lung" or "Popcorn Workers Lung".{{ref label|NIOSH|4|^}}{{ref label|NEJM|8|^}}{{ref label|Egilman|9|^}} One heavy consumer of microwaved popcorn has been diagnosed with this disease, which is the first known case involving a consumer.{{ref label|Reuters|13|^}} On [[27 August]], 2007, Weaver Popcorn Company of [[Indianapolis]] promised to replace the diacetyl butter flavor ingredient in [[Pop Weaver]] popcorn with another flavoring.{{ref label|Weaver|14|^}} In September 2007, Dr. Cecile Rose, pulmonary specialist at Denver's National Jewish Medical and Research Center, warned federal agencies that consumers, not just flavoring or food factory workers, may be in danger of contracting bronchiolitis obliterans. David Michaels, of the [[George Washington University]] School of Public Health, first published Rose's warning letter on his blog.{{ref label|Yahoo|10|^}}{{ref label|letter|11|^}}{{ref label|PH|12|^}} On [[4 September]], 2007, the Flavor and Extract Manufacturers recommended reduction of diacetyl in butter-like flavorings. The next day [[ConAgra Foods]] announced that it would soon remove diacetyl from its popcorn products.{{ref label|ConAgra|15|^}} On [[16 January]], 2008, it was announced that Wayne Watson, the Denver consumer who developed "popcorn lung" after inhaling microwaved popcorn, was suing the [[Kroger]] grocery store chain and its affiliates. In the lawsuit, filed in U.S. District Court, Watson's attorney claimed that the companies "failed to warn that preparing microwave popcorn in a microwave oven as intended and smelling the buttery aroma could expose the consumer to an inhalation hazard and a risk of lung injury."{{ref label|Kroger|16|^}} Diacetyl is approved by the Food and Drug Administration as a safe flavor ingredient, but there is evidence to suggested that inhalation in large amounts is dangerous. There are currently no warnings from federal regulators about diacetyl. ==See also== * [[Diacetyl]] * [[Bronchiolitis obliterans organizing pneumonia]] ==Notes== #{{note label|Brant|1|^}}{{cite book | author=Brant & Helms| title=Fundamentals of Diagnostic Radiology | year=1999 | }} #{{note label|Webb|2|^}}{{cite book | author=Webb, et al| title=High Resolution CT of the Lung | edition=3rd Edition | year=2000 | }} #{{note label|CDC|3|^}}{{cite book | author=Center for Disease Control| title=Fixed obstructive lung disease in workers at a microwave popcorn factory | edition=7th Edition | year=2002 | }} #{{note label|NIOSH|4|^}}National Institute for Occupational Safety and Health. [http://www.cdc.gov/niosh/docs/2004-110/ Preventing lung disease in workers who make or use flavorings, 2004] #{{note label|Colby|5|^}} Colby, T.V. "Bronchiolitis, Pathologic Considerations". ''Am J Clin Pathology'' 1998;109:101-9 #{{note label|Hazmap|6|^}}National Institutes of Health. [http://hazmap.nlm.nih.gov/cgi-bin/hazmap_generic?tbl=TblDiseases&id=551 Haz-Map; Information on Hazardous Chemicals and Occupational Diseases by Jay A. Brown, M.D., M.P.H.] #{{note label|CalOSH|7|^}}[http://www.dhs.ca.gov/ohb/flavoringcases.pdf/ California Department of Health Services] #{{note label|NEJM|8|^}}E. Neil Schachter. "Popcorn Workers' Lung". ''New England Journal of Medicine'' 2002;347(5):360-1. #{{note label|Egilman|9|^}}David Egilman (2007). [http://www.ijoeh.com/pfds/IJOEH_1301_Egilman.pdf "Popcorn Workers Lung"] #{{note label|Yahoo|10|^}} [http://news.yahoo.com/s/ap/20070905/ap_on_he_me/popcorn_lung_consumer;_ylt=Apuf6TQn0o.P4GubPgYwzKGs0NUE "Doctor warns consumers of popcorn fumes"], Marcus Kabel, [[Associated Press]], [[September 5]], [[2007]], hosted by [[Yahoo! News]], retrieved [[2007-09-10]]. (dead link) #{{note label|letter|11|^}} [http://www.defendingscience.org/case_studies/upload/National_Jewish_FDA_Letter.pdf Letter from Cecile Rose to U.S. Food and Drug Administration], from ''www.defendingscience.org'' #{{note label|PH|12|^}} David Michaels (2007). [http://thepumphandle.wordpress.com/2007/09/04/popcorn-lung-coming-to-your-kitchen-the-fda-doesnt-want-to-know/ Popcorn Lung Coming to Your Kitchen? The FDA Doesn’t Want to Know], a blog post at ''thepumphandle.wordpress.com'' #{{note label|Reuters|13|^}}Reuters New Report: [http://uk.reuters.com/article/healthNews/idUKN0524254120070905 FDA to probe popcorn link in man's lung disease]. #{{note label|Weaver|14|^}} Weaver Popcorn Company Press Release: [http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=104&STORY=/www/story/08-28-2007/0004652723&EDATE= "Pop Weaver Introduces First Microwave Popcorn With Flavoring Containing No Diacetyl"], [[2007-08-27]], hosted at PRNewswire.com. {{PDFlink|[http://www.popweaver.com/NoDiacetylPressRelease.pdf "Pop Weaver introduces first microwave popcorn with flavoring containing no diacetyl"]|216&nbsp;[[Kibibyte|KiB]]<!-- application/pdf, 222148 bytes -->}}. #{{note label|ConAgra|15|^}} USA Today. [http://www.usatoday.com/money/industries/food/2007-09-05-popcorn-lung_N.htm ConAgra to drop popcorn chemical linked to lung ailment] #{{note label|Kroger|16|^}}[http://www.businessweek.com/ap/financialnews/D8U6Q82G0.htm "Man with 'popcorn lung' sues Kroger" by George Merritt,''Business Week''] Online edition, accessed Jan 18 2008. ==References== * Brant & Helms. ''Fundamentals of Diagnostic Radiology'' LWW, 1999. * Webb, et al. ''High Resolution CT of the Lung''. 3rd edition. LWW, 2000. * Harber, Philip; Saechao, Kaochoy; & Boomus, Catherine. ''Diacetyl-induced lung '' Toxicological Reviews 2006;vol 25(4):261-72. ==External links== * [http://www.epler.com/index.html Dynamics in Healthcare: Information about BOOP/BO and ILD ] * [http://hazmap.nlm.nih.gov/cgi-bin/hazmap_generic?tbl=TblDiseases&id=551 National Institutes of Health: Haz-Map Information on Hazardous Chemicals and Occupational Diseases by Jay A. Brown, M.D., M.P.H.: Bronchiolitis obliterans] * [http://www.cdc.gov/niosh/docs/2004-110/ National Institute for Occupational Safety and Health (NIOSH) Alert: Preventing lung disease in workers who make or use flavorings] * [http://www.ific.org/publications/qa/diactylqa.cfm International Food Information Council (a food industry organization): Questions and Answers about Diacetyl] * [http://defendingscience.org/case_studies/A-Case-of-Regulatory-Failure-Popcorn-Workers-Lung.cfm A Case of Regulatory Failure: Popcorn Workers' Lung], a case study from ''www.defendingscience.org'' * [http://www.usatoday.com/money/general/2002/06/20/popcorn-factory.htm Is butter flavoring ruining popcorn workers' lungs? By Stephanie Armour, USA TODAY. 2002-06-19. ] * [http://www.cdc.gov/niosh/topics/flavorings/ National Institute for Occupational Safety and Health: Flavorings-Related Lung Disease] * [http://www.popcornfacts.com ConAgra Foods Inc. - Popcorn Facts] [[Category:Pulmonology]] [[Category:Occupational diseases]] [[Category:Occupational safety and health| ]] [[Category:Industrial hygiene]] [[de:Bronchiolitis obliterans]]