Home is Where the Harm Is: A Case of Hut Lung

Abstract Introduction: Pneumoconiosis is typically caused by inhaling particulate matter, leading to chronic inflammation and pulmonary fibrosis. Mixed-dust pneumoconiosis (MDP) arises from substantial inhalation of inorganic particulates, often seen in women and children who rely on biomass fuels for cooking in enclosed areas. We present a case of MDP in an Afghan refugee who undertook an arduous journey through the Middle East before arriving in San Antonio. Case Description A 62-year-old female with type II diabetes mellitus presented with three months of progressive dyspnea and dry cough. She had unintentional weight loss, decreased appetite, and fatigue. She denied tobacco, inhalational drug use, and reported three negative purified protein derivative (PPD) tuberculosis tests. On admission, she was tachypneic but saturating well on room air. Exam was notable for a thin, frail appearance and bibasilar crackles. Laboratory analysis revealed elevated inflammatory markers and a positive serum QuantiFERON-TB Gold test, though sputum testing was negative. Chest X-ray showed bilateral pulmonary nodules with hilar lymphadenopathy. Given the ongoing concern for TB or sarcoidosis, bronchoscopy was performed, with bronchoalveolar lavage (BAL) analysis showing 83% monocytes, 10% neutrophils, and 7% lymphocytes. All cytology and cultures were negative, as were non-TB PCR tests. Transbronchial biopsy of the left upper lobe demonstrated extensive interstitial and nodular fibrosis with entrapped histiocytes containing abundant anthracotic pigment (Figure 1). The histologic and radiographic findings, along with her history of biomass fuel exposure while cooking in Afghanistan, suggested domestically acquired particulate lung disease (Hut Lung). She was started on latent TB therapy and educated on avoiding further exposure. Discussion: As the geopolitical landscape continues to evolve in the Middle East, more refugees are migrating to Europe and the United States. This case highlights an important cause of pneumoconiosis related to the home environment, which should be considered in patients who have immigrated from developing countries where biomass fuels are still commonly used for cooking. This disease disproportionately affects women, who, due to traditional gender roles, are often responsible for domestic duties. It is also important to recognize that the diagnosis can be significantly delayed due to nonspecific symptoms and radiographic findings that mimic tuberculosis. Initially, our patient was started on active TB therapy while awaiting culture results, resulting in extensive medication side effects and mental stress from isolation precautions. Furthermore, patients with this condition may have an elevated risk of malignancy. Although no specific screening guidelines currently exist, close monitoring is recommended.