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SAEM Clinical Image Series: Dysphagia and Dyspnea in a Well Digger

Posted by Moises Gallegos, MD MPH on

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Chief Complaint: Pain with swallowing

History of Present Illness: A 43-year-old male presented to the emergency department with progressing pain upon swallowing. He described a sensation of food becoming stuck and creating a fullness in his chest. Review of symptoms was positive for dyspnea on exertion worsening over several months, but negative for cough, fevers, or weight change. He reported no medical history and had recently emigrated from Guatemala where he worked as a well digger.

Physical Exam

The patient was well appearing, without respiratory distress, and without overt physical findings. Oropharynx was clear, neck was without tenderness or masses, and lungs were clear to auscultation.

Laboratory Data

None applicable

Case Question: What pulmonary condition can develop due to occupational exposures in caves and underground settings?

Pneumoconiosis is caused by irritants such as silica, often in the context of coal mining, but can develop with chronic cave and underground exposures.

Case Answer/Discussion

Progressive massive fibrosis is the coalescence of fibrotic lung tissue into large masses. Severe lymphadenopathy and fibrosis can lead to mass effect and compression of thoracic structures. The anteroposterior radiograph of the chest demonstrates a tortuous trachea with rightward deviation. Computed tomography of the chest shows multifocal areas of fibrosis. A mass of fibrotic tissue and lymph nodes causes tracheal deviation and compresses the esophagus (red arrow). Pulmonary bronchoscopy was negative for infectious pathogens and was consistent with a fibrotic inflammatory process. The patient revealed that he had a 21 year old relative who died of “lung problems” after working the same job as a well digger.

Progressive massive fibrosis is a chronic progression and complication of pneumoconiosis. Large masses of fibrotic tissues and enlarged lymph nodes can lead to dysphagia and dyspnea through compression of esophagus and airway structures.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.

Author information

Moises Gallegos, MD MPH

Editor, ALiEM
Clinical Assistant Professor of Emergency Medicine
Stanford University School of Medicine

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