SummaryOf 72 patients with radiological evidence of pulmonary emphysema, emphysema occurred either alone or in association with bronchitis in 61, and 8 of these (13%) were found to have a1-antitrypsin deficiency. The main features of this condition are: exertional dyspnoea of relatively early onset (generally between 30 and 45 years of age), severely impaired FEV1 and TLCO, and radiological emphysema predominantly affecting the lower zones of the lungs. It is probable that any patient with all the above abnormalities has a1-antitrypsin deficiency. There is evidence to suggest that cigarette smoking may hasten the onset of this type of emphysema.

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The ductus arteriosus holds major functional importance within the fetal circulation, and anomalies within the ductus arteriosus may interfere with the integrity of the fetal circulation. Ductus arteriosus aneurysm, previously considered a rare lesion, is now a well-reported finding in infancy with some reports describing this finding in the prenatal period. Postnatally, most ductus arteriosus aneurysms resolve spontaneously; however, a small group of infants show complications such as connective-tissue disorders, thrombo-embolism, compression of surrounding thoracic structures and life-threatening spontaneous rupture requiring surgical correction. As such, postnatal assessment in this group is recommended.

BackgroundCaplan's syndrome was first described in the coal miners of South Wales (UK). The specific cause for rheumatoid pulmonary nodules associated with coal dust exposure remains unknown. Coal dust exposure alone does not appear to explain Caplan's syndrome as almost all of these men were also smokers. Cigarette smoke is the most important environmental cause of cadmium exposure. We describe Caplan's syndrome in an ex-smoking kaolin worker associated with a significantly raised urinary cadmium level.ObjectivesA 65 year old Cornish kaolin worker and ex-smoker of 20 pack years with life limiting nodular erosive rheumatoid arthritis (RA), developed extra-articular manifestations including pulmonary nodules suggestive of Caplan's syndrome. We review the literature on kaolin, with respect to inhalation and mechanism of action for heavy metal adsorption and nodular disease development.MethodsPubmed searches were undertaken using the keywords “kaolinosis”, “kaolin”, “cadmium” “nodules”, “adsorption”, “coal”. First pass mid-stream urine was analysed for cadmium using inductively coupled plasma–mass spectrometry (ICP-MS).1ResultsUrinary cadmium was significantly raised at 0.66 μmol/mol creatinine (non-occupationally exposed UK male median 0.17μmol/mol creatinine1), 20 years post-industrial exposure and 35 years post-smoking cessation. Contemporary serology levels demonstrated a rheumatoid factor of 481.7 iu/ml (0–10 normal range) and an anti-cyclic citrullinated peptide of >500 u/ml (0–17 normal range). CT scan of the chest demonstrated multiple pulmonary nodules consistent with Caplan's syndrome.The prevalence of Caplan's syndrome in kaolin workers is the highest of any occupation ever reported.2 Elevated cadmium levels of 11.2–15.9 mg/kg have been observed in kaolin,3 fifty- fold higher than those reported in coal.4 Coal contains variable amounts of clays and minerals such as kaolinite. Cadmium content in coal is strongly associated with levels of kaolinite contamination.4 Cadmium nanoparticles have been observed to cause lung parenchyma inflammation and granuloma formation in an animal model.5ConclusionsKaolinite mineral capacity for adsorption of heavy metals, in particular cadmium, could explain the scale and pattern of Caplan's syndrome incidence seen in Welsh coal miners and Cornish kaolin workers, and further explains the interactive risk seen in sequential dust and cigarette smoke exposure.References Morton J, Tan E, Leese E, Cocker J. Determination of 61 elements in urine samples collected from a non-occupationally exposed UK adult population. Toxicol Lett. 2014;231(2):179–93.Wells IP, Bhatt RC, Flanagan M. Kaolinosis: a radiological review. Clin Radiol. 1985;36(6):579–82.Bonglaisin JN, Mbofung CMF, Lantum DN. Intake of Lead, Cadmium and Mercury in Kaolin-eating: A Quality Assessment. J Med Sci 2011;11(7):267–273.Song D, Wang M, Zhang J, Zheng C. Contents and occurrence of cadmium in the coals from Guizhou province, China. Ann N Y Acad Sci. 2008;1140:274–81.Coccini T, Barni S, Vaccarone R, et al. Pulmonary to...