The importance of asking a thorough social history; a case report of aluminum pneumoconiosis

Aluminum induced lung disease is associated with pulmonary fibrosis, granulomatous pneumonia, and pulmonary alveolar proteinosis. Recognizing aluminum pneumoconiosis remains important as demand for aluminum production continues to rise. The case presents a 53-year-old woman with incidentally noted lung nodules and hilar lymphadenopathy on CT imaging. Despite being asymptomatic, imaging findings prompted referral to a pulmonologist with CT chest demonstrating bulky mediastinal lymphadenopathy with dominant right paratracheal mass as well as several lung nodules in the bilateral lungs. The patient underwent PET scan revealing hypermetabolic lymph nodes bilaterally in the neck, bones, mediastinum, bilateral hila, retroperitoneal lymph nodes, and spleen. Transbronchial biopsy with nodal aspiration of the mediastium revealed granulomatous inflammation. Treatment was started with prednisone 40 mg daily for presumed sarcoidosis, however she had steroid induced hyperglycemia necessitating multiple hospital admissions. This therapy was then stopped. After eliciting a detailed history, it was noted she worked for 15 years as a powder metal laborer exposed to fine aluminum dust. The case highlights a rare presentation of aluminum pneumoconiosis with diffuse systemic manifestations. Though the exact mechanism of aluminum pathogenesis that produces a sarcoid-like granulomatous reaction remains unclear, metal elements have been implicated in acting as antigens stimulating the immune system. Imaging appearance varies, and CT findings can include alveolitis, small ill-defined centrilobular opacities, lung nodules, and pulmonary fibrosis. Unfortunately, no definitive treatment exists for aluminum pneumoconiosis and limiting ongoing exposure is paramount. Periodic lung function testing and thorax imaging remain staples for monitoring disease progression. Therefore, obtaining a thorough occupational history and awareness of possible manifestations of aluminum pneumoconiosis remains essential as aluminum production and manufacturing demand increases.