Module 4: Cases in Occupational Medicine

CASE 3: An ex railway workshop welder

A 77 year former railway worker presents to his doctor with progressive breathlessness. A chest x-ray reveals a large pleural effusion.

Question #1:

What is the differential diagnosis?

(See the answer)

Question #2:

It transpires that he has a history of long term exposure to asbestos. Does this change the differential diagnosis?

(See the answer)

A pleura biopsy is taken and the report is "highly suggestive" of a malignant mesothelioma.

Question #3:

What features would the pathologist have looked for?

(See the answer)

A chest x-ray, shown below, was taken after the effusion was drained. It shows extensive pleural thickening encircling the right lung, with extension along the transverse fissure ending an irregular mass. There is also pleural thickening along the lateral wall of the left lung as well as calcification along the pleuro-pericardial surface of the heart and (faintly) over the left hemidiaphragm. (Clicking on one of the marked rectangular areas on the x-ray will provide a magnified view).

Question #4:

What is the significance of the findings in the left lung?

(See the answer)

His occupational history is as follows. He worked in the mechanical workshops of the South African Railways at Salt River from 1944-1952 and then in the steam sheds at Paarden Eiland from 1952-1982.

Question #5:

What is the association between railways and asbestos?

(See the answer)

Question #6:

What is the procedure with regard to compensation?

(See the answer)

Question #7:

He asks you what he can expect to receive, and what his wife would receive in the case of his death?

(See the answer)