reactive airways dysfunction syndrome ( rads ) is a non - immune mediated type of asthma - like disease characterized by the immediate onset of symptoms of cough , chest tightness , audible wheeze , and breathlessness after a toxic single exposure to an agent with irritating properties in the atmosphere in the form of dust , vapor , fume , or smoke . the most common agents implicated in the causation of rads include chlorine , toluene diisocyanate , and oxides of nitrogen . the brazilian standard describes porcelain tile as any ceramic tile made of clay , feldspar , and other inorganic raw materials that is either pressed or extruded and contains water absorption of less than 0.5% . however , porcelain tile dust as a cause of rads has not been previously reported . we present a 45-year - old male laborer with an acute onset of asthma after his first time heavy exposure to porcelain tile dust within 5 hours of exposure whose symptoms persisted for 5 months after the incident . to the best of our knowledge , this is the first reported case of rads as a result of porcelain tile dust exposure . a 45-year - old man , non - smoking laborer presented with an acute onset of cough , chest tightness , audible wheeze , and breathlessness within 5 hours of heavy exposure to tile dust . the laborer was engaged in some construction work in our hospital associated with fitting of tiles . he had neither worked with a tile cutter nor had been exposed to a high concentration of tile dust in the past . he never had any such symptoms in the past or any allergic history like seasonal allergic rhinitis , hay fever , or atopic dermatitis . laboratory tests , including blood gas analysis , chest radiography , and ecg , were unremarkable . serum total ige level was 40 iu / ml ( normal level 10 - 179 iu / ml ) . spirometry revealed mild obstruction ( [ forced expiratory volume in 1 second ] fev1=72% of predicted ) with significant bronchodilator reversibility ( 14% ) . however , his spirometry improved with an fev1 of 88% of predicted at 4 months from the incident ( table1 ) . due to the persistence of the symptoms , bronchoscopy , performed 4 months after the initial episode , revealed diffuse hyperemia and bronchial biopsy revealed a chronic inflammatory response with lymphocytic and plasma cell infiltration and absence of eosinophils . spirometry parameters at one and four months after the incident bdrt = bronchodilator reversibility test , showing an increase in fev1 over the baseline ( 14% here ) done 15 minutes after inhalation of 400 g of salbutamol through a metered dose inhaler ( mdi ) . fev1=forced expiratory volume in 1 s ; fvc = forced vital capacity ; =spirometry was done at 4 months from the incident just before performing bronchoscopy . bdrt was not carried out at that time the patient was managed similar to acute bronchial asthma . he received intravenous hydrocortisone ( 100 mg ) every 8 hours for the first few days along with salbutamol inhalations via a nebulizer . once his symptoms improved , he was put on formoterol and budesonide rotacaps . on follow - up , the patient s symptoms had persisted for 5 months , after which he had only occasional cough , not of a magnitude to impair his routine activities . our case report met all the criteria of rads as laid classically by brooks et al . which include a documented absence of preceding respiratory complaints ; onset of symptoms occurring after a single specific exposure incident or accident ; exposure to a gas , smoke , fume , or vapor , present in very high concentrations and with irritant qualities to its nature ; onset of symptoms occurring within 24 hours after the exposure and persisting for at least 3 months ; symptoms simulating asthma with cough , wheezing , and dyspnea predominating ; pulmonary function tests probably showing airflow obstruction ; positive methacholine challenge test [ an indication of non - specific bronchial hyperresponsiveness ] ; and other types of pulmonary diseases being ruled out . chlorine , toluene diisocyanate , and oxides of nitrogen are the most commonly implicated ones . others include hydrofluoric acid , thermal degradation products of fluorocarbons , ozone , etc . , and many more are yet to be discovered . in 2002 , an outbreak of rads / irritant - induced asthma ( iia ) was reported among firefighters exposed to irritants in the atmosphere during and after the world trade center disaster . this has since led to the concept of  world trade center cough  , which is characterized by a persistent cough that develops among firefighters after such exposure . the acute pathological changes of rads have been studied by subjecting mice to a high concentration of chlorine in the atmosphere . the findings include flattening of bronchial epithelium , necrosis , and evidence of epithelial regeneration , while bronchoalveolar lavage reveals an increased number of neutrophils . due to the persistence of the symptoms , the bronchial biopsy in our patient was done after 4 months and it revealed a chronic inflammatory response with lymphocytic and plasma cell infiltration and the absence of eosinophils . the diagnosis is likely when there is acute onset of respiratory tract symptoms such as cough , breathlessness , chest tightness , etc . . clinical examination may show hyperinflation of lungs , use of accessory respiratory muscles , and wheeze . lung function may reveal mild obstruction or a significant bronchodilator reversibility response or a positive bronchoprovocation test such as positive methacholine test . however , our patient showed a mild obstruction with an fev1 of 72% of predicted and a significant bronchodilator reversibility test ( 14% increase in fev1 above the baseline ) and his spirometry showed an improvement in fev1 to 88% at 4 months from the incident . the management of rads is the same as that for patients suffering from asthma from any other cause . for the first few days , he received intravenous hydrocortisone ( 100 mg ) every 8 hours along with oxygen and salbutamol nebulization . once his symptoms improved , he was switched to inhaled rotacaps , containing formoterol fumarate ( 6 mcg ) and budesonide ( 400 mcg ) . , the symptoms may persist for months or even years . in our case , however , the prognosis was better . our patient s symptoms persisted for 5 months , after which he had only occasional cough , which did not affect his routine work . we have herein described a classic case of rads due to exposure to porcelain tile dust , the like of which has not been previously reported to the best of our knowledge . the present case was rads as a result of first time heavy exposure to porcelain tile dust , which was diagnosed according to the criteria laid by brooks et al.our case report draws attention towards the recognition of this entity ; otherwise , most of these patients are wrongly labeled as bronchial asthma by the majority of general physicians .
reactive airway dysfunction syndrome ( rads ) is a type of non - immunologically mediated asthma - like disease . 
 it usually occurs after a massive exposure to an irritating substance in the atmosphere in the form of smoke , fumes , gases , and vapor . unlike bronchial asthma 
 , there is no latency to the symptoms seen in rads . 
 a number of agents are known to cause rads , but tile dust , as an etiological agent , has not been previously reported . 
 we report a 45-year - old male laborer , who presented with an acute onset of cough , chest tightness , breathlessness , and audible wheeze after his first time exposure to porcelain tile dust within 5 hours of exposure . 
 lab tests , including , chest x - ray , electrocardiogram , air blood gas analysis , and serum ige , were unremarkable . 
 spirometry showed a mild obstruction [ forced expiratory volume in 1 second ( fev1)=72% of predicted ] , while the bronchodilator reversibility test was significant(14% increase in fev1 above the baseline).bronchial biopsy revealed a chronic inflammatory reaction with lymphocytic and plasma cell infiltration and more importantly a striking absence of eosinophils . to the best of our knowledge , 
 this is the first reported case of rads as a result of exposure to tile dust ( porcelain ceramics ) .