Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Current Pulmonology Reports
Published in: Current Pulmonology Reports 2/2020

01-06-2020 | Bronchial Asthma | Environmental and Occupational Health (S Cherian, Section Editor)

Hard Metal Lung Disease: Update in Diagnosis and Management

Authors: Matthew Zheng, Robert M. Marron, Sameep Sehgal

Published in: Current Pulmonology Reports | Issue 2/2020

Login to get access

Abstract

Purpose of Review

Hard metal lung disease is a rare entity due to cobalt and tungsten carbide exposure. This review summarizes the literature focusing on pathogenesis, clinical features, diagnosis, and management.

Recent Findings

Theories for pathogenesis include immunogenic activation, oxidant injury, and induction of hypoxia-inducible factor in macrophages. Multinucleated giant cells with bizarre cannibalistic features are the most common pathological finding; however, it is not pathognomonic. Corticosteroids remain the mainstay of treatment based on data from small studies.

Summary

Hard metal lung disease exposure can lead to an occupational asthma or parenchymal lung disease, potentially leading to respiratory failure. A history of exposure and clinical findings along with appropriate radiographic and pathological findings are essential to establish a diagnosis. Treatment options include exposure cessation, corticosteroids, immunosuppressive therapies, and lung transplantation.
Literature
1.
Jobs H. Metalleramiks als Staubquelle vom arztlichen und technicheen Stnandpunkt. Vertrauensarzt Krankenkasse. 1940;8:142.
2.
Liebow AA. Definition and classification of interstitial pneumonias in human pathology1. In Alveolar interstitium of the lung 1975 (Vol. 8, pp. 1–33). Karger Publishers.
3.
Abraham JL. Lung pathology in 22 cases of giant cell interstitial pneumonia (GIP) suggests GIP is pathognomonic of cobalt (hard metal) disease. Chest. 1987;91:312.
4.
Abraham JL, Burnett BR, Hunt A. Development and use of a pneumoconiosis database of human pulmonary inorganic particulate burden in over 400 lungs. Scanning Microsc. 1991;5(1):95–104.PubMed
5.
Nemery B, Verbeken EK, Demedts M. Giant cell interstitial pneumonia (hard metal lung disease, cobalt lung). In Seminars in respiratory and critical care medicine 2001 (Vol. 22, No. 04, pp. 435–448). Copyright© 2001 by Thieme Medical Publishers, Inc.
6.
Cugell DW, Morgan WK, Perkins DG, Rubin A. The respiratory effects of cobalt. Arch Intern Med. 1990;150(1):177–83.PubMedCrossRef
7.
Sprince NL, Oliver LC, Eisen EA, Greene RE, Chamberlin RI. Cobalt exposure and lung disease in tungsten carbide production. A cross-sectional study of current workers. Am Rev Respir Dis. 1988;138(5):1220–6.PubMedCrossRef
8.
Wallner P, Kundi M, Moshammer H, Zimmerman SD, Buchanich JM, Marsh GM. Mortality among hardmetal production workers. J Occup Environ Med. 2017;59(12):e282–7.PubMedCrossRef
9.
Mizutani RF, Terra-Filho M, Lima E, Freitas CS, Chate RC, Kairalla RA, et al. Hard metal lung disease: a case series. J Bras Pneumol. 2016;42(6):447–52.PubMedPubMedCentralCrossRef
10.
Kim YH, Chung YK, Kim C, Suk Nam E, Kim HJ, Joo Y. A case of hypersensitivity pneumonitis with giant cells in a female dental technician. Ann Occup Environ Med. 2013;25(1):19.PubMedPubMedCentralCrossRef
11.
Santhosh L, Venado A, Blanc PD, Jones KD, Brush D, Ley BJ. Drilling down on hard metal lung disease: an unusual case of a dental lab technician with rapidly progressive interstitial lung disease. InC106. OCCUPATIONAL LUNG EPIDEMIOLOGY 2018 May (pp. A6085-A6085). American Thoracic Society.
12.
Elliott DR, Shah R, Hess CA, Elicker B, Henry TS, Rule AM, et al. Giant cell interstitial pneumonia secondary to cobalt exposure from e-cigarette use. Eur Respir J. 2019;1:54(6).
13.
Naqvi AH, Hunt A, Burnett BR, Abraham JL. Pathologic spectrum and lung dust burden in giant cell interstitial pneumonia (hard metal disease/cobalt pneumonitis): review of 100 cases. Arch Environ Occup Health. 2008;63(2):51–70.PubMedCrossRef
14.
Moriyama H, Kobayashi M, Takada T, Shimizu T, Terada M, Narita JI, et al. Two-dimensional analysis of elements and mononuclear cells in hard metal lung disease. Am J Respir Crit Care Med. 2007;176(1):70–7.PubMedCrossRef
15.
Demedts M, Gheysens B, Nagels J, Verbeken E, Lauweryns J, Van Den Eeckhout A, et al. Cobalt lung in diamond polishers. Am Rev Respir Dis. 1984;130(1):130–5.PubMed
16.
• Adams TN, Butt YM, Batra K, Glazer CS. Cobalt related interstitial lung disease. Respir Med. 2017;129:91–7 Most recently published and in-depth review of cobalt lung disease with characterization of its pathology, epidemiology, and disease courses.PubMedCrossRef
17.
Lison D, Lauwerys R, Demedts M, Nemery B. Experimental research into the pathogenesis of cobalt/hard metal lung disease. Eur Respir J. 1996;9:1024–8.PubMedCrossRef
18.
Anard D, Kirsch-Volders M, Elhajouji A, Belpaeme K, Lison D. In vitro genotoxic effects of hard metal particles assessed by alkaline single cell gel and elution assays. Carcinogenesis. 1997;18(1):177–84.PubMedCrossRef
19.
Cirla AM. Cobalt-related asthma: clinical and immunological aspects. Sci Total Environ. 1994;150(1–3):85–94.PubMedCrossRef
20.
Balmes JR. Respiratory effects of hard-metal dust exposure. Occup Med (Philadelphia, Pa). 1987;2(2):327–44.
21.
Bernstein JA. Occupational asthma. In Allergy and asthma 2016 (pp. 253–270). Springer, Cham.
22.
Shirakawa T, Kusaka Y, Fujimura N, Goto S, Kato M, Heki S, et al. Occupational asthma from cobalt sensitivity in workers exposed to hard metal dust. Chest. 1989;95(1):29–37.PubMedCrossRef
23.
Rachiotis G, Savani R, Brant A, MacNeill SJ, Taylor AN, Cullinan P. Outcome of occupational asthma after cessation of exposure: a systematic review. Thorax. 2007;62(2):147–52.PubMedCrossRef
24.
Merget R, Reineke M, Rueckmann A, Bergmann EM, Schultze-Werninghaus GE. Nonspecific and specific bronchial responsiveness in occupational asthma caused by platinum salts after allergen avoidance. Am J Respir Crit Care Med. 1994;150(4):1146–9.PubMedCrossRef
25.
Pisati G, Zedda S. Outcome of occupational asthma due to cobalt hypersensitivity. Sci Total Environ. 1994;150(1–3):167–71.PubMedCrossRef
26.
Nureki SI, Miyazaki E, Nishio S, Ando M, Kumamoto T. Hard metal lung disease successfully treated with inhaled corticosteroids. Intern Med. 2013;52(17):1957–61.PubMedCrossRef
27.
Nemery B, Nagels J. Rapidly fatal progression of cobalt lung in a diamond polisherl• 2. Am Rev Respir Dis 1990;141:1373–1378.
28.
Gotway MB, Golden JA, Warnock M, Koth LL, Webb R, Reddy GP, et al. Hard metal interstitial lung disease: high-resolution computed tomography appearance. J Thorac Imaging. 2002;17(4):314–8.PubMedCrossRef
29.
30.
Enriquez LS, Mohammed TL, Johnson GL, Lefor MJ, Beasley MB. Hard metal pneumoconiosis: a case of giant-cell interstitial pneumonitis in a machinist. Respir Care. 2007;52(2):196–9.PubMed
31.
Hahtola PA, Järvenpää RE, Lounatmaa K, Mattila JJ, Rantala I, Uitti JA, et al. Hard metal alveolitis accompanied by rheumatoid arthritis. Respiration. 2000;67(2):209–12.PubMedCrossRef
32.
Kim KI, Kim CW, Lee MK, Lee KS, Park CK, Choi SJ, et al. Imaging of occupational lung disease. Radiographics. 2001;21:1371–91.PubMedCrossRef
33.
Dunlop P, Müller NL, Wilson J, Flint J, Churg A. Hard metal lung disease: high resolution CT and histologic correlation of the initial findings and demonstration of interval improvement. J Thorac Imaging. 2005;20(4):301–4.PubMedCrossRef
34.
Kaneko Y, Kikuchi N, Ishii Y, Kawabata Y, Moriyama H, Terada M, et al. Upper lobe-dominant pulmonary fibrosis showing deposits of hard metal component in the fibrotic lesions. Intern Med. 2010;49(19):2143–5.PubMedCrossRef
35.
Wahbi ZK, Arnold AG, Taylor AN. Hard metal lung disease and pneumothorax. Respir Med. 1997;91(2):103–5.PubMedCrossRef
36.
Takada T, Moriyama H. Hard metal lung disease. In A clinical guide to occupational and environmental lung diseases 2012 (pp. 217–230). Humana Press, Totowa, NJ.
37.
Ichikawa Y, Kusaka Y, Goto S. Biological monitoring of cobalt exposure, based on cobalt concentrations in blood and urine. Int Arch Occup Environ Health. 1985;55(4):269–76.PubMedCrossRef
38.
Kusaka Y, Nakano Y, Shirakawa T, Morimoto K. Lymphocyte transformation with cobalt in hard metal asthma. Ind Health. 1989;27(4):155–63.PubMedCrossRef
39.
Kinoshita M, Sueyasu Y, Watanabe H, Tanoue S, Okubo Y, Koga T, et al. Giant cell interstitial pneumonia in two hard metal workers: the role of bronchoalveolar lavage in diagnosis. Respirology. 1999;4(3):263–6.PubMedCrossRef
40.
Forni A. Bronchoalveolar lavage in the diagnosis of hard metal disease. Sci Total Environ. 1994;150(1–3):69–76.PubMedCrossRef
41.
Nakamura Y, Nishizaka Y, Ariyasu R, Okamoto N, Yoshida M, Taki M, et al. Hard metal lung disease diagnosed on a transbronchial lung biopsy following recurrent contact dermatitis. Intern Med. 2014;53(2):139–43.PubMedCrossRef
42.
Magee F, Wright JL, Chan N, Currie W, Karr G, Hogg J, et al. Two unusual pathological reactions to nitrofurantoin. Histopathology. 1986;10(7):701–6.PubMedCrossRef
43.
Hargett CW, Sporn TA, Roggli VL, Hollingsworth JW. Giant cell interstitial pneumonia associated with nitrofurantoin. Lung. 2006;184(3):147–9.PubMedCrossRef
44.
•• Khoor A, Roden AC, Colby TV, Roggli VL, Elrefaei M, Alvarez F, et al. Giant cell interstitial pneumonia in patients without hard metal exposure: analysis of 3 cases and review of the literature. Hum Pathol. 2016;1(50):176–82 Important case series illustrating the existence of this pathology in exposures not related to classically described occupations. CrossRef
45.
Krajsova B, Tichý T. Giant cell interstitial pneumonia without exposure to hard metals. Cesk Patol. 2013;49(3):141–3.PubMed
46.
Radoycich GE, Zuppan CW, Weeks DA, Krous HF, Langston C. Patterns of measles pneumonitis. Pediatr Pathol. 1992;12(6):773–86.PubMedCrossRef
47.
Alexandersson R. Blood and urinary concentrations as estimators of cobalt exposure. Arch Environ Health. 1988;43(4):299–303.PubMedCrossRef
48.
Zanelli R, Barbic F, Migliori M, Michetti G. Uncommon evolution of fibrosing alveolitis in a hard metal grinder exposed to cobalt dusts. Sci Total Environ. 1994;150(1–3):225–9.PubMedCrossRef
49.
Maier LA. Clinical approach to chronic beryllium disease and other nonpneumoconiotic interstitial lung diseases. J Thorac Imaging. 2002;17(4):273–84.PubMedCrossRef
50.
Chiba Y, Kido T, Tahara M, Oda K, Noguchi S, Kawanami T, et al. Hard metal lung disease with favorable response to corticosteroid treatment: a case report and literature review. Tohoku J Exp Med. 2019;247(1):51–8.PubMedCrossRef
51.
Ratto D, Balmes J, Boylen T, Sharma OP. Pregnancy in a woman with severe pulmonary fibrosis secondary to hard metal disease. Chest. 1988;93(3):663–5.PubMedCrossRef
52.
Chiarchiaro J, Tomsic LR, Strock S, Veraldi KL, Nouraie M, Sellares J, et al. A case series describing common radiographic and pathologic patterns of hard metal pneumoconiosis. Res Med Case Rep. 2018;25:124–8.
53.
Tarabichi Y, Saggar R, Wallace WD, Lynch JP, Saggar R. Primary disease recurrence after single lung transplantation in a patient with prior hard metal exposure. J Heart Lung Transplant. 2015;34(9):1216–8.PubMedCrossRef
54.
Frost AE, Keller CA, Brown RW, Noon GP, Short HD, Abraham JL, et al. Erratum: Giant cell interstitial pneumonitis: disease recurrence in the transplanted lung (American Journal of Respiratory and Critical Care Medicine (1993) 148 (1401–1404)). Am J Respir Crit Care Med. 1994;1:149(1).
55.
Suh M, Thompson CM, Brorby GP, Mittal L, Proctor DM. Inhalation cancer risk assessment of cobalt metal. Regul Toxicol Pharmacol. 2016;79:74–82.PubMedCrossRef
56.
Moulin JJ, Wild P, Romazini S, Lasfargues G, Peltier A, Bozec C, et al. Lung cancer risk in hard-metal workers. Am J Epidemiol. 1998;148(3):241–8.PubMedCrossRef
57.
Sauni R, Oksa P, Uitti J, Linna A, Kerttula R, Pukkala E. Cancer incidence among Finnish male cobalt production workers in 1969–2013: a cohort study. BMC Cancer. 2017;17(1):340.PubMedPubMedCentralCrossRef
Metadata
Title
Hard Metal Lung Disease: Update in Diagnosis and Management
Authors
Matthew Zheng
Robert M. Marron
Sameep Sehgal
Publication date
01-06-2020
Publisher
Springer US
Published in
Current Pulmonology Reports / Issue 2/2020
Electronic ISSN: 2199-2428
DOI
https://doi.org/10.1007/s13665-020-00247-x

ACC 2024 Congress Coverage

Heart Failure Video

Year in Review: Heart failure and cardiomyopathies

Watch now

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits