Background:
Patients presenting to Accident and Emergency (A&E) facilities with dyspnoea, coughing, wheezing and nasal blockage are presumed to have allergic asthma and/or rhinitis. Occupational asthma (OA), which has similar symptoms is rarely considered. Triggers of OA include exposure to diesel engine exhaust emissions exposure (DEEEE) that are carcinogenic. We report the case of a patient who presented to an A&E facility with asthma-like symptoms, was treated for allergic asthma. Frequent exacerbations were experienced. Upon investigations it was shown that were symptoms triggered by DEEE exposure.
Case presentation:
A 36-year-old female bank employee was referred for the evaluation of suspected asthma. She reported a 3-month history of symptoms suggestive of asthma and rhinitis, for which she had previously required A&E treatment. There was no history of atopy. The symptoms only occurred at work or after work. Their onset had coincided with changing offices to one located proximal to a diesel-powered electricity generator. A diagnosis of asthma had been made at the A&E facility and the appropriately used inhaled fluticasone and salbutamol provided limited relief. Skin prick testing was weakly positive for seasonal pollen and house dust mite allergens. Allergen specific IgE tests for 16 regionally relevant aeroallergens were negative. Tests to exclude connective tissue diseases were positive for the anti-Ro-52/TRIM-21 autoantibody. Baseline spirometry values were markedly reduced and bronchodilator administration showed limited reversibility, FEV1 (+ 8%), PEF (+ 5%). Following a 10-day discontinuation of work exposure, the symptoms abated and FEV1 and PEF increased by 10-14% from baseline. The recent onset of asthma, in a non-atopic adult, with workday related symptoms and improvement upon discontinuation of exposure were attributed to passive occupational exposure to DEEE. The diesel generator was relocated, a short course of inhaled fluticasone and oral prednisolone was prescribed and symptoms resolved. This is the first report of the health effects of DEEE mimicking asthma and rhinitis in Zimbabwe.
Conclusions:
Atypical presentations of adult onset asthma in the absence of a history of either atopy or allergen specific IgE antibody sensitization should trigger in-depth evaluation of occupational exposure in all cases including office workers. Serial monitoring of lung function values should be used for diagnostic and monitoring of the patients.