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LETTER TO EDITOR
Year : 2019  |  Volume : 23  |  Issue : 3  |  Page : 147-148
 

A case of skin thickening with occupational lung disease


1 Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Dermatology, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission15-Jun-2019
Date of Acceptance15-Oct-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Dr. Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoem.IJOEM_146_19

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How to cite this article:
Mahendran AJ, Gupta N, Wadhwa D, Ish P. A case of skin thickening with occupational lung disease. Indian J Occup Environ Med 2019;23:147-8

How to cite this URL:
Mahendran AJ, Gupta N, Wadhwa D, Ish P. A case of skin thickening with occupational lung disease. Indian J Occup Environ Med [serial online] 2019 [cited 2020 May 27];23:147-8. Available from: http://www.ijoem.com/text.asp?2019/23/3/147/273028




Sir,

A 35-year-old male patient, stone crusher for 10 years, presented with history of cough, generalized body pain, and progressive respiratory distress for 1 year. There was history of intermittent nondocumented low-grade fever and generalized hyperpigmentation was present. On examination, there was skin thickening with salt and pepper pigmentation [Figure 1]a, [Figure 1]b and [Figure 1]c. On probing, he also had history suggestive of Raynaud's phenomenon and gastroesophageal reflux disease. Hence, a provisional diagnosis of scleroderma was made which was confirmed by rheumatologist. Examination revealed bilateral Velcro crackles and spirometry was suggestive of severe restriction. He underwent a CT Chest [Figure 2]a and [Figure 2]b followed by trans-bronchial lung biopsy (TBLB) [Figure 2]c, [Figure 2]d. The patient was strongly positive for scl-70 antibody.
Figure 1: (a) Clinical photograph of face showing binding down of skin with pinched nose and thin, pursed lips. (b) Clinical photograph of hands showing sclerodactyly (digital skin tightening), puffiness, and distal resorption of digits causing pseudo clubbing. Third digit of right hand also shows a digital tip ulcer healing with a scar. (c) Clinical photograph of right foot showing binding down of skin and early salt and pepper pigmentation

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Figure 2: (a) CT chest lung window showing bilateral perilymphatic nodules, few of them showing coalescence with interlobular septal thickening and subpleural cysts in bilateral lungs.(b) CT chest mediastinal window showing calcified right paratracheal (4R station) lymph node and subpleural areas of fibrosis in the right lung. (c) Hematoxylin and Eosin stain of the transbronchial lung biopsy showing Pink strands of fibrosis in 400 × magnification. (d) Polarized light microscopy showing crystal in 400 × magnification

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Thus, the final diagnosis of Erasmus Syndrome was made. There was history of silica exposure for 10 years associated with scleroderma confirming Erasmus syndrome. The TBLB showed features of fibrosis with crystalline changes with birefringence suggestive of silicosis.

A recent review article and a meta-analysis document occupational exposure of silica as a risk factor for Systemic sclerosis.[1],[2] Erasmus syndrome is systemic sclerosis with silica exposure with or without silicosis.[3] Originally described in gold miners of South Africa,[4] it was first reported from India in 1997.[5] Since then, there are few case reports from India, one having coexisting pulmonary tuberculosis.[6],[7],[8]

The mechanism is unclear; adjuvant effect of silica particles on antibody production and depressed cellular immunity have been postulated to cause autoimmune reaction. Silica increases lymphokine production by pulmonary macrophages causing collagen production and chronic inflammation. The risk is more in males and miners.[9] Rest of the clinical features are similar to idiopathic systemic sclerosis, and the diagnosis is based on exposure history.[10]

Scant literature suggests treating systemic sclerosis and avoiding further silica exposure. Few cases report a favorable response to steroids, immunosuppressant, and calcium channel blockers.[6] Our patient showed response to oral steroids in terms of respiratory failure and cough.

KEY POINT-Erasmus syndrome is a rare clinical entity presenting like idiopathic systemic sclerosis. Hence, a high index of suspicion should be kept and detailed exposure history should be sought.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal.

The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McCormic ZD, Khuder SS, Aryal BK, Ames AL, Khuder SA. Occupational silica exposure as a risk factor for scleroderma: A meta-analysis. Int Arch Occup Environ Health 2010;83:763-9.  Back to cited text no. 1
    
2.
Potential occupational and environmental factors in SSc onset. Ann Agric Environ Med 2018;25:596-601.  Back to cited text no. 2
    
3.
Cointrel C, Tillie-Leblond I, Lamblin C, Furon D, Tonnel AB, Wallaert B, et al. Erasmus syndrome: Clinical, tomographic, respiratory function and bronchoalveolar lavage characteristics. Rev Mal Respir 1997;14:21-6.  Back to cited text no. 3
    
4.
Erasmus LD. Scleroderma in goldminers on the Witwatersrand with particular reference to pulmonary manifestations. S Afr J Lab Clin Med 1957;3:209-31.  Back to cited text no. 4
    
5.
Khanna N, D'Souza P, Sud A, Pandhi RK. Systemic sclerosis in a stone cutter. Indian J Dermatol Venereol Leprol 1997;63:111-3.  Back to cited text no. 5
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6.
Chakrabarti S, Pan K. Erasmus syndrome in a 42-year-old male: A Rare case report. J Clin Diagn Res 2015;9:OD01-3.  Back to cited text no. 6
    
7.
Goyal A, Madan K, Singh N. Erasmus syndrome with pulmonary tuberculosis. BMJ Case Rep 2013;2013: pii: bcr2013010443.  Back to cited text no. 7
    
8.
Sharma RK, Sharma AK, Sharma A. Erasmus syndrome: Association of silicosis and systemic sclerosis. Indian Dermatol Online J 2018;9:185-7  Back to cited text no. 8
    
9.
Jain S, Joshi V, Rathore YS, Khippal N. Erasmus syndrome: Silicosis and systemic sclerosis. Indian J Occup Environ Med 2017;21:94-6  Back to cited text no. 9
    
10.
Mittal S, Madan K. A 21-year-old man with cough and skin thickening. Lung India 2018;35:437-8.  Back to cited text no. 10
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