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\begin{document}

\title{Silicosis unveiled: Improving diagnostic accuracy and distinguishing it
from tuberculosis: A case report from a low and middle-income country}



\author[1]{Sanskriti Chapagain}%
\author[2]{Abhigan  Shrestha}%
\author[3]{shumneva shrestha}%
\author[4]{sajina shrestha}%
\author[5]{Vikash Jaiswal}%
\author[6]{Hritik Yadav}%
\author[7]{Nilasma Shrestha}%
\affil[1]{Devdaha Medical College and Research Institute}%
\affil[2]{M Abdur Rahim Medical Medical College Hospital}%
\affil[3]{Tribhuvan University Institute of Medicine Maharajgunj Medical Campus}%
\affil[4]{KIST Medical College}%
\affil[5]{AMA School of Medicine}%
\affil[6]{M Abdur Rahim Medical College}%
\affil[7]{Kathmandu Medical College}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\textbf{Silicosis unveiled: Improving diagnostic accuracy and
distinguishing it from tuberculosis: A case report from a low and
middle-income country}

Chapagain, Sanskriti\textsuperscript{1} , Shrestha,Abhigan
Babu\textsuperscript{2} ,Shrestha ,shumneva
\textsuperscript{3},Shrestha, sajina\textsuperscript{4},jaiswal
,vikash\textsuperscript{5},yadav,Hritik Raj \textsuperscript{2},
Shrestha ,Nilasma\textsuperscript{6}

1. Devdaha Medical College and Research Institute, Bhaluhi, Rupandehi,
Nepal

2.M Abdur Rahim Medical Medical College Hospital, Department Of Internal
Medicine

Dinajpur, Bangladesh

3. Tribhuvan University Institute of Medicine Maharajgunj Medical Campus
,Nepal

4. KIST Medical College, Department Of Internal Medicine, patan Imadol,
Lalitpur,Nepal

5. Medical AMA School of Medicine, Medicine Bangkal makati, Philippines
Makati City, Luzon

6.Kathmandu Medical College,Kathmandu,Nepal

\textbf{Corresponding author} :Chapagain,Sanskriti

Devdaha Medical College and Research Institute, Bhaluhi, Rupandehi,
Nepal

sanskritichapagain527@gmail.com

\textbf{Abstract}

Silicosis is an occupational lung disease caused by exposure to
crystalline quartz particles, leading to lung inflammation and scarring.
Pulmonary tuberculosis is an infectious disease caused
by\emph{Mycobacterium tuberculosis} , primarily affecting the lungs.
Silicosis increases the risk of developing tuberculosis in high-burden
settings. We present the case of a 40-year-old smoker male, with a
history of stone crushing for 10 years, who presented to the emergency
department with dyspnea and cough which increased progressively for the
past nine months with sputum production. All pulmonary TB patients
should have their sputum examined by microscopy to determine if they are
infectious or not but in this case the sputum examination is negative,
posing a diagnostic challenge and previously diagnosed as active TB
based on X-ray abnormalities and clinical findings and had a full course
of TB treatment. This case emphasizes the difficulty in differentiating
silicosis from tuberculosis, as tuberculosis can mask the symptoms and
radiological features of silicosis. Thus, a comprehensive occupational
history, clinical features, and radiological evaluation are crucial for
an accurate diagnosis.

\textbf{Keywords}

Occupational, Silicosis, Tuberculosis

\textbf{Introduction}

Silicosis is an irreversible and fibrotic interstitial lung disease that
is frequently brought on by inhaling crystalline silica or silicon
dioxide.\textsuperscript{1}According to the Global Burden of Disease
(GBD) report, silicosis continued to be the most important risk factor
for pneumoconiosis in 2017 with 39\% of cases being attributed to it. It
is manifested by a range of respiratory symptoms such as cough,
shortness of breath, chest tightness, and sputum
expectoration\textsuperscript{2}. Since there is no complete cure for
the illness, prevention and early diagnosis through clinical features
and radiological features are essential.\textsuperscript{3}

Patients with silicosis are three to four times more likely to get TB
than those who do not have silicosis.\textsuperscript{4}There may be
difficulty in differentiating silicosis from tuberculosis, as
tuberculosis can mask the symptoms and radiological features of
silicosis. Here, we report the case of a 40-year-old man with silicosis
having a history of stone crushing for 10 years he was previously
misdiagnosed with tuberculosis based on X-ray abnormalities and clinical
findings and had a full course of TB treatment.

\textbf{Case description}

A 40-year-old male, a stone crusher for the past 10 years, presented to
the emergency department with a complaint of shortness of breath at rest
for 4 hours. He also presented with an exaggeration of cough for about
10 years which increased progressively for the past nine months. There
was no history of fever, night sweats, anorexia, weight loss, joint
pain, or skin rashes. He did not report any chest pain and hemoptysis.
Notably, the individual had been clinically diagnosed with active TB
based on X-ray abnormalities and clinical findings and had a full course
of TB treatment. There was no history of smoking and alcohol
consumption. On examination, the patient was with a modified medical
research council (MMRC) dyspnea scale of 4, a blood pressure of 130/95
mmHg, a rapid pulse rate of 140 bpm, respiratory rate of 30 breaths per
min, temperature of 98.6 degrees F and an oxygen saturation level of
83\% without supplemental oxygen. On the chest, examination revealed
tracheal deviation towards the right, accompanied by diminished
vesicular breath sounds and diffuse crepitations. The patient was
admitted with a provisional diagnosis of silicosis based on clinical
examinations and a chest X-ray.

\textbf{Investigation}

A complete blood count showed potassium elevation but no other
abnormality. A sputum examination yielded negative results for acid-fast
bacilli. A chest x-ray illustrated profuse, multifocal, poorly defined
consolidations predominantly localized in the upper and middle lung
lobes. Additionally, a ground-glass appearance was observed in the lower
lobes, concomitant with tracheal deviation towards the right as shown in
the figure. Due to the invasive procedure of High-Resolution Computed
Tomography (HRCT) and the financial constraints faced by the patient, he
made the decision not to proceed with HRCT and explore alternative
diagnostic options that were more affordable and less invasive. Based on
the above findings differential diagnosis includes pneumoconiosis,
pulmonary tuberculosis, emphysema, sarcoidosis, rheumatoid arthritis,
and other interstitial diseases.

The absence of AFB in sputum, -ve for test gen expert and characteristic
chest x-rays favor the diagnosis of silicosis. The patient was admitted
to the ward, and high-flow oxygen therapy and steroid administration
were given. Furthermore, bronchodilators and leukotriene antagonists
were employed to relax the airways and reduce inflammation. Two samples
of sputum, one from one spot and another from another morning were
negative for AFB. The patient was discharged with an improvement in
symptoms. The patient could not follow up due to non-compliance.

\textbf{Discussion}

Individuals working in occupations such as sandblasting, mining,
quarrying, flour milling, glass manufacturing, building construction,
brick manufacturing, road repairs, and concrete manufacturing often
experience the adverse effects of silicosis.\textsuperscript{5}The
crystalline silica particles measuring less than 1 \selectlanguage{greek}μ\selectlanguage{english}m are widely
considered to be the most pathogenic.\textsuperscript{6,7}Worldwide,
silicosis caused more than 12.9 thousand fatalities, and in 2019 it was
responsible for 655.7 thousand disability-associated life years (DALY)
.\textsuperscript{2}Along the disease's spectrum, chronic forms,
accelerated forms, and acute silicosis are found.\textsuperscript{8}One
case report has documented similar chief complaints to those observed in
our case.\textsuperscript{9}Exposure to silica results in the activation
of alveolar macrophages and induces reactive oxygen (ROS) and nitrogen
(RNS) which results in elevated susceptibility to bacterial infections
due to a decrease in antioxidant defense mechanism, particularly those
caused by\emph{Mycobacterium tuberculosis} .\textsuperscript{10 ,11,12}

According to the WHO Global TB Report 2021, 43\% of people living in the
South-East Asia (SEA) Region have an incidence of
TB.\textsuperscript{13}In this case, the patient had a previous
tuberculosis diagnosis based on the disease's prevalence and
radiological features, even though the sputum test for acid-fast bacilli
(AFB) and gene expert test were negative. The patient received anti-TB
treatment, however, it did not relieve his symptoms. People with
silicosis had a 2.8 ratio chance of developing pulmonary tuberculosis
and a 3.7 ratio risk of developing extra-pulmonary tuberculosis compared
to those without the condition.\textsuperscript{14}However, among those
who had silicosis, the prevalence of TB was significantly higher at 917
cases per 100,000 individuals.\textsuperscript{15}.In this case, having
a thorough occupational history is essential for establishing an
accurate diagnosis. There are no specific treatment modalities for
silicosis. The primary goals of treatment revolve around slowing down
the progression of the disease and alleviating symptoms. Strategies
include eliminating silica and lung irritants exposure, quitting
smoking, oxygen therapy, and screenings.\textsuperscript{3}Recently,
Pirfenidone and nintedanib, both approved by the US Food and Drug
Administration (FDA), have been extensively examined in silicosis
models, yielding substantial evidence.\textsuperscript{16 ,17} In severe
cases where the disease has significantly progressed and lung function
is severely compromised, lung transplantation is
done.\textsuperscript{18}One of the challenges associated with silicosis
and tuberculosis is the potential for misdiagnosis due to similar
presentations and inadequate occupational histories. All pulmonary TB
patients should have their sputum examined by microscopy/Xpert MTB/RIF
to determine if they are infectious or not but in this case the sputum
examination is negative, posing a diagnostic challenge and diagnosed as
active TB based on X-ray abnormalities and clinical findings and had a
full course of TB treatment. Chest X-ray and high-resolution computed
tomography (HRCT) are usually used to diagnose pneumoconiosis but due to
financial constraints, the patient did not go for HRCT and multiple
differential diagnoses had been proposed based on our patient's clinical
presentation and chest x rays such as silicosis, bronchitis, bronchitis,
emphysema, pulmonary tuberculosis, Sarcoidosis, and rheumatoid
arthritis. Our patient's clinical features and occupational exposure to
stone crushers for 10 years, different physical findings, sputum
negative for acid-fast bacilli on microscopy/Xpert MTB/RIF, which later
suggests a diagnosis of silicosis.

As silicosis progresses, improper or postponed disease management can
have negative effects on patients and result in treatment failure. In
addition, patients' financial, psychological, and emotional effects
shouldn't be disregarded because they could feel anxious, frustrated, or
lose faith in the healthcare system. Healthcare professionals should be
encouraged to improve diagnostic methods, including thorough
occupational histories, and radiological imaging, and, to effectively
differentiate between the two conditions in high-risk industries
associated with silicosis.

\textbf{Conclusion}

This case report highlights the diagnostic challenge posed by silicosis
and the importance of considering occupational exposure history,
characteristic radiographic findings, and clinical presentation for an
accurate diagnosis. With an abnormal chest X-ray, an anti-TB drug
shouldn't be started in a high TB area unless we make a diagnosis.
Hence, prompt recognition, early intervention, and occupational safety
measures are crucial to prevent the occurrence and progression of
silicosis among workers exposed to crystalline silica.

\textbf{AUTHOR CONTRIBUTIONS}All authors contributed equally to this
manuscript, conceptualization, writing, editing, and preparation of the
manuscript, and reviewed it before submission. A.B.S supervised the
manuscript.

Declaration of patient consent

Written informed consent was obtained from the patient for the
publication of this case report and

accompanying images. A copy of the written consent is available for
review by

the Editor-in-Chief of this journal on request.

Sources of funding

N/A

Conflicts of Interest disclosure

No conflict of interest

Provenance and peer review

Not commissioned, externally peer-reviewed.

Acknowledgments

No acknowledgments.

Ethical approval

N/A

Consent

Written informed consent was obtained from the patient for publication
of the case report. A copy of the written consent is available for
review by Editor-in-chief of the journal on request.

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