硬金属致巨细胞问质性肺炎一例并文献复习

Giant cell interstitial pneumonia asssociated with hard metals： a case report and review of the literature

目的提高对硬金属粉尘致巨细胞间质性肺炎的临床、胸部影像学和病理表现的认识。方法对1例经胸腔镜肺活检证实的巨细胞间质性肺炎患者的硬金属粉尘职业史、临床、胸部X线、CT、病理资料并结合有关文献进行回顾性分析。结果患者女，30岁，钨棒磨削工，接触含钴和钨等硬金属粉尘3年，咳嗽和活动后喘息40d。肺功能检查示混合性通气功能障碍，弥散功能明显下降（DLCO占预计值％为39％），X线胸片和高分辨率CT示两肺弥漫性分布的磨玻璃影和边界不清的小结节影。肺活检病理表现为巨细胞间质性肺炎，肺泡腔内可见巨噬细胞和大量的多核巨细胞聚集。位于肺泡腔内的多核巨细胞内可见被吞噬的炎症细胞；细支气管及周围肺泡腔可见慢性炎症细胞浸润和肺间质纤维化。结合患者的职业史及特征性病理改变，诊断为硬金属致巨细胞间质性肺炎和硬金属肺疾病。患者脱离接触金属粉尘工作后，经糖皮质激素治疗临床症状缓解，胸部异常阴影明显吸收。结论巨细胞间质性肺炎是硬金属肺疾病的特征性病理改变。在间质性肺疾病的诊断和鉴别诊断中需重视患者的职业暴露史。

Objective To highlight the clinical, radiological and pathological characteristics of giant cell interstitial pneumonia （GIP） associated with hard metals. Method The clinical, radiological and pathological data of a patient with hard metal lung disease confirmed by video-assisted thoracoscopic biopsy of the right lung were presented, and relevant literatures were reviewed. Results A 30-year-old female patient presented with cough and dyspnea on exertion for more than 40 days. She had worked for grinding tungsten rod,with exposure to metal dusts containing cobalt and tungsten for more than 3 years. Chest radiographs and CT demonstrated bilateral ground-glass attenuations and ill-defined small nodules. Lung function studies showed the mixed type of ventilation dysfunction with a low diffusion capacity （ DLCO of 39% of predicted）. Lung biopsy specimens showed desquamative interstitial pneumonia like reaction with alveolar macrophages and numerous large multinucleated histiocytes that ingested inflammatory cells in alveolar spaces, which was characteristics of GIP. The lung parenchyma also showed patchy chronic inflammatory-cell infiltrates centered predominantly around the bronchioles and interstitial fibrosis. Considering the exposure history and the histological findings of the lung, the diagnosis of hard metal lung disease and GIP associated with hard metals was made. Her cough, dyspnea, and radiological changes showed marked improvement after corticosteroid therapy and avoidance of further exposure to hard metals. Conclusions GIP is almost pathognomonic for hard metal lung disease. Meticulous history taking on occupational exposure is important for the diagnosis and differential diagnosis of suspected interstitial lung disease.