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__NOTOC__
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{{SI}}                                                                 
{{Flock worker's lung}}                                                                 
{{CMG}} {{AE}}  
{{CMG}} {{AE}} {{USM}}
   
   
{{SK}} Synonym 1; Synonym 2; Synonym 3
{{SK}}
   
   
==Overview==
==Overview==
Flock Worker's Lung.  
Flock Worker's Lung(FWL) is an unusual disease [[interstitial disease]] characterized by [[lymphocytic bronchiolitis]] and [[peribronchiolitis]] in workers exposed to flock fibers. Flock is made for the application to adhesive-coated substrates by cutting short synthetic fibers from bundles of parallel nylon monofilaments or other polymers. They are usually prepared from synthetic materials.
The disease was identified initially in 1998 when a group of workers at a flocking plant developed unknown cause [[interstitial lung disease]]. The first cases to be identified were initially described as [[desquamative]] [[pneumonia]] and were attributed not with flock fibers, but to unspecified toxin exposure. As subsequent cases appeared, the clinical results with exposure to the flock seemed to be best characterized as [[lymphocytic]] [[bronchiolitis]]. Typically it presents with progressive [[dyspnea]], [[dry cough]], and constitutional symptoms. Some patients also show work-related symptoms, especially early in the process.


==Historical Perspective==
==Historical Perspective==
*Since 1975, published case reports have raised suspicion of a respiratory hazard associated with various synthetic fibers, including polyester, nylon, and acrylic dust.
 
*Early reports in 1974 and 1981 of workplace evaluations by National Institute of Occupational Safety and Health (NIOSH) investigators attributed respiratory symptoms among workers to irritant properties of nonrespirable flock fibers on the upper airways but did not pursue the possibility of lung disease associated with flock work <ref name="pmid23732577">{{cite journal |vauthors=Kreiss K |title=Occupational lung disease: from case reports to prevention |journal=Chest |volume=143 |issue=6 |pages=1529–1531 |date=June 2013 |pmid=23732577 |pmc=3673658 |doi=10.1378/chest.12-3001 |url=}}</ref>
*Since 1975, distributed case reports have raised doubt of a respiratory danger related with different manufactured strands, including polyester, nylon, and acrylic dust.
*During 1990 and 1991, five workers from a nylon flock processing plant in Ontario presented with cough and dyspnea.<ref name="pmid10351952">{{cite journal |vauthors=Eschenbacher WL, Kreiss K, Lougheed MD, Pransky GS, Day B, Castellan RM |title=Nylon flock-associated interstitial lung disease |journal=Am. J. Respir. Crit. Care Med. |volume=159 |issue=6 |pages=2003–8 |date=June 1999 |pmid=10351952 |doi=10.1164/ajrccm.159.6.9808002 |url=}}</ref>
 
*In 1995 and 1996, two workers from a similar nylon flock processing plant in Rhode Island presented separately to the same physician with cough and dyspnea
*Early reports in 1974 and 1981 of working environment assessments by National Institute of Occupational Safety and Health (NIOSH) agents ascribed respiratory manifestations among laborers to irritant properties of nonrespirable flock fibers on the upper airways but did not pursue the possibility of [[lung disease]] associated with flock work <ref name="pmid23732577">{{cite journal |vauthors=Kreiss K |title=Occupational lung disease: from case reports to prevention |journal=Chest |volume=143 |issue=6 |pages=1529–1531 |date=June 2013 |pmid=23732577 |pmc=3673658 |doi=10.1378/chest.12-3001 |url=}}</ref>
*The initial working diagnosis for the lung disease in these two workers was work-related hypersensitivity pneumonitis. With additional case finding investigation at the Rhode Island location, a total of eight cases among the approximately 150 workers at the plant were identified by January 1998 based upon a screening questionnaire (symptoms of cough and dyspnea), pulmonary function abnormalities (restrictive pattern with reduced diffusing capacity), radiographic findings and/or histological findings on tissue obtained by open lung or transbronchial lung biopsy .Based upon the aggregate histopathological results from biopsied cases, the disease process was not thought to be hypersensitivity pneumonitis.<ref name="pmid10351952">{{cite journal |vauthors=Eschenbacher WL, Kreiss K, Lougheed MD, Pransky GS, Day B, Castellan RM |title=Nylon flock-associated interstitial lung disease |journal=Am. J. Respir. Crit. Care Med. |volume=159 |issue=6 |pages=2003–8 |date=June 1999 |pmid=10351952 |doi=10.1164/ajrccm.159.6.9808002 |url=}}</ref>
*During 1990 and 1991, five workers from a nylon flock handling plant in Ontario presented with [[cough]] and [[dyspnea]].<ref name="pmid10351952">{{cite journal |vauthors=Eschenbacher WL, Kreiss K, Lougheed MD, Pransky GS, Day B, Castellan RM |title=Nylon flock-associated interstitial lung disease |journal=Am. J. Respir. Crit. Care Med. |volume=159 |issue=6 |pages=2003–8 |date=June 1999 |pmid=10351952 |doi=10.1164/ajrccm.159.6.9808002 |url=}}</ref>
*"flock worker's lung" formally came to known in 1998, when researchers from NIOSH published the results of an epidemiological investigation of outbreaks in Ontario and Rhode Island.
*In 1995 and 1996, two workers from a similar nylon flock handling plant in Rhode Island presented independently to the same doctor with [[cough]] and [[dyspnea]].
*Previously, interstitial lung disease in flock workers was incorrectly attributed to mycotoxins present in contaminated adhesive.<ref name="pmid23732577" />
*The underlying diagnosis for the lung ailment in these two employees was initially thought to be work-related [[Hypersensitivity pneumonitis]]. With additional case finding investigation at the Rhode Island location, a total of eight cases among the approximately 150 workers at the plant were identified by January 1998 based upon a screening questionnaire (symptoms of [[cough and dyspnea]]), [[pulmonary function]] abnormalities ([[restrictive pattern]] with [[reduced diffusion capacity]]), radiographic findings and/or histological findings on tissue obtained by open lung or [[transbronchial lung biopsy]]. Based upon the aggregate histopathological results from biopsied cases, the disease process was not thought to be [[hypersensitivity pneumonitis]].<ref name="pmid10351952">{{cite journal |vauthors=Eschenbacher WL, Kreiss K, Lougheed MD, Pransky GS, Day B, Castellan RM |title=Nylon flock-associated interstitial lung disease |journal=Am. J. Respir. Crit. Care Med. |volume=159 |issue=6 |pages=2003–8 |date=June 1999 |pmid=10351952 |doi=10.1164/ajrccm.159.6.9808002 |url=}}</ref>
*"Flock Workers's lung" officially came to known in 1998, when scientists from NIOSH distributed the aftereffects of an epidemiological examination of episodes in Ontario and Rhode Island..
*Previously, [[interstitial lung disease]] in flock workers was mistakenly ascribed to [[mycotoxins]] present in polluted adhesive.<ref name="pmid23732577" />
 
==Classification==
==Classification==
The disease currently still has not been stratified.
The disease currently still has not been stratified.
==Pathophysiology==
*Flock consists of short fibers that are cut from long filaments and glued to a backing material such as cloth to provide a fuzzy, carpet-like surface texture. They are usually made from synthetic materials such as nylon, rayon, or polypropylene. The cutting process results in the formation of [[airborne particles]] or fibers in the respirable range. Inhalation of flock dust causes [[interstitial lung disease]].<ref name="urlCDC - NIOSH Program Portfolio : Respiratory Diseases : Risks">{{cite web |url=https://www.cdc.gov/niosh/programs/resp/risks.html |title=CDC - NIOSH Program Portfolio : Respiratory Diseases : Risks |format= |work= |accessdate=}}</ref>
*Preliminary toxicological findings indicate that ultrafine respirable nylon fragments after a single [[intratracheal]] instillation trigger an [[acute inflammatory]] [[lung injury]] in rats. Yet flock finishing agents or other particulate matter components found in the soil of flock processing plants can not yet be removed.
*We have studied [[interstitial pneumonitis]] among nylon flock processors with a histopathological pattern — bronchiolar and peribronchiolar lymphocytic [[inflammation]] and [[lymphoid hyperplasia]] — that indicates an [[inflammatory]] and possibly [[immunological]] response to a [[respiratory toxicant]]. <ref name="EschenbacherKreiss1999">{{cite journal|last1=Eschenbacher|first1=William L.|last2=Kreiss|first2=Kathleen|last3=Lougheed|first3=M. Diane|last4=Pransky|first4=Glenn S.|last5=Day|first5=Brian|last6=Castellan|first6=Robert M.|title=Nylon Flock–Associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=159|issue=6|year=1999|pages=2003–2008|issn=1073-449X|doi=10.1164/ajrccm.159.6.9808002}}</ref>
*In one study microscopic examination of polypropylene fiber-exposed lungs revealed a dose-dependent increase in cellularity (especially macrophage infiltration), but no [[fibrosis]]. In another study, the researchers found high serum [[IL-8]] and [[TNF-α]] levels in the polypropylene flocking workers. Furthermore, these levels showed a negative correlation with ''D''L, [[CO]] levels. These results suggest that [[IL-8]] and [[TNF-α]] may act as key mediators for [[inflammatory]] [[lung injury]] in the [[pathogenesis]] of  flock worker's lung.<ref name="Atis2005">{{cite journal|last1=Atis|first1=S.|title=The respiratory effects of occupational polypropylene flock exposure|journal=European Respiratory Journal|volume=25|issue=1|year=2005|pages=110–117|issn=0903-1936|doi=10.1183/09031936.04.00138403}}</ref>
[[File:SEM_flock_particles.png|300px|thumb|none|Electron Microscopic image showing Flock Fibers collected from the air sample of a card manufacturing factory. [https://http://onlinelibrary.wiley.com/doi/10.1002/ajim.20440/abstract]]]
==Causes==


*[Disease name] may be classified according to [classification method] into [number] subtypes/groups:
*FWL  results from the inhalation of airborne nylon fibers at work. Nylon fibers are used in making products for upholstery, automobiles, carpet, and apparel.
:*[group1]
:*[group2]
:*[group3]
*Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].
   
   
==Pathophysiology==
==Differentiating Flock Worker's Lung from other Diseases==


* Flock consists of short fibers that are cut from long filaments and glued to backing material such as cloth to provide a fuzzy, carpet-like surface texture. They are usually prepared from synthetic materials such as nylon, rayon, or polypropylene. The cutting process results in formation of airborne particles or fibers in the respirable range. Inhalation of flock dust causes an interstitial lung disease.<ref name="urlCDC - NIOSH Program Portfolio : Respiratory Diseases : Risks">{{cite web |url=https://www.cdc.gov/niosh/programs/resp/risks.html |title=CDC - NIOSH Program Portfolio : Respiratory Diseases : Risks |format= |work= |accessdate=}}</ref>
FWL presents like most Interstitial Lung Disease.
*Preliminary toxicologic studies suggest that ultrafine respirable fragments of nylon cause an acute inflammatory lung injury in rats after a single intratracheal instillation. However, flock finishing agents or other components of the particulate matter present in the air of flock processing plants cannot yet be ruled out.
Differentiating FWL from other '''similar interstitial lung diseases''' can be done based on a history of exposure and work environment.
*The interstitial pneumonitis we have studied among nylon flock processing workers has a histopathological pattern— bronchiolar and peribronchiolar lymphocytic inflammation and lymphoid hyperplasia—which suggests an inflammatory and possibly immunologic response to a respirable toxic agent <ref name="EschenbacherKreiss1999">{{cite journal|last1=Eschenbacher|first1=William L.|last2=Kreiss|first2=Kathleen|last3=Lougheed|first3=M. Diane|last4=Pransky|first4=Glenn S.|last5=Day|first5=Brian|last6=Castellan|first6=Robert M.|title=Nylon Flock–Associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=159|issue=6|year=1999|pages=2003–2008|issn=1073-449X|doi=10.1164/ajrccm.159.6.9808002}}</ref>
*In one study microscopic examination of polypropylene fibre-exposed lungs revealed a dose-dependent increase in cellularity (especially macrophage infiltration), but no fibrosis. In another study , the researchers  found high serum IL-8 and TNF-α levels in the polypropylene flocking workers. Furthermore, these levels showed a negative correlation with ''D''L,CO. These results suggest that IL-8 and TNF-α may act as key mediators for inflammatory lung injury in the pathogenesis of polypropylene flocking worker's lung.<ref name="Atis2005">{{cite journal|last1=Atis|first1=S.|title=The respiratory effects of occupational polypropylene flock exposure|journal=European Respiratory Journal|volume=25|issue=1|year=2005|pages=110–117|issn=0903-1936|doi=10.1183/09031936.04.00138403}}</ref>


{| class="wikitable" style="margin: 1em auto 1em auto"
|+
!Occupation||Causative Agent||Disease||Differences on  Imaging||Histopathology findings
|-
|Shipbuilding||Asbestos||[[Asbestosis]]||Affects Lower Lobes; Calcified supradiaphragmatic and [[pleural plaques]]||Asbestos Bodies
|-
|Dental technicians, jewelers, precious metal reclamation workers,||Beryllium||[[Chronic beryllium disease]]||Affects Upper lobes||[[Granulomatous]] histology
|-
|Glass manufacturing, Blue jean Manufacturing||Sand||[[Silicosis]]||Affects Upper lobes, nodular pattern; Eggshell calcifications of hilar lymph nodes||Fibrotic nodules with concentric "onion-skinned" arrangement of collagen fibers <ref name="pmid2838005">{{cite journal |vauthors= |title=Diseases associated with exposure to silica and nonfibrous silicate minerals. Silicosis and Silicate Disease Committee |journal=Arch. Pathol. Lab. Med. |volume=112 |issue=7 |pages=673–720 |date=July 1988 |pmid=2838005 |doi= |url=}}</ref>
|-
|Food Industry||Diacetyl||[[Bronchiolitis Obliterans]]||Patchy areas of decreased lung density, This pattern is often described as a "mosaic pattern" <ref name="pmid24806161">{{cite journal |vauthors=Barker AF, Bergeron A, Rom WN, Hertz MI |title=Obliterative bronchiolitis |journal=N. Engl. J. Med. |volume=370 |issue=19 |pages=1820–8 |date=May 2014 |pmid=24806161 |doi=10.1056/NEJMra1204664 |url=}}</ref>||Intraluminal buds called "Masson bodies" fill the lumen, which results in bronchiolar plugging <ref name="pmid26335918">{{cite journal |vauthors=Aguilar PR, Michelson AP, Isakow W |title=Obliterative Bronchiolitis |journal=Transplantation |volume=100 |issue=2 |pages=272–83 |date=February 2016 |pmid=26335918 |doi=10.1097/TP.0000000000000892 |url=}}</ref>
|-
|Domestic use for heating||Biomass fuel||[[Interstitial Lung Disease]]||Distribution of the nodules is seen to be [[centrilobular]]||Bronchoscopy reveals a large number of anthracotic pigments in the airways <ref name="urlBeyond pneumonoconiosis: Recently described occupational interstitial lung diseases | PNEUMON - Official Journal of Hellenic Thoracic Society">{{cite web |url=http://www.pneumon.org/july-september-2010-vol-23-issue-3/showfulltext789/1/newsid789/356 |title=Beyond pneumonoconiosis: Recently described occupational interstitial lung diseases &#124; PNEUMON - Official Journal of Hellenic Thoracic Society |format= |work= |accessdate=}}</ref>


|-
|Coal Industry||Coal dust||[[Coal Workers Pneumoconiosis]]||Affects Upper lobes, nodular pattern||[[Macrophages]] laden with carbon
|-
|Animal Breeding||Phytoset||[[Hypersensitivity Pneumonitis]]||Affects Middle and Lower lobes , nodular pattern||[[Multinucleated giant cell]]
|-
|Synthetic flock manufacturing||Nylon, rayon, or polypropylene||Flock Worker's Lung||Diffuse nodular opacities, very similar to [[Hypersensitivity Pneumonitis]]||Increase Eosinophil and Lymphocyte count seen in  BAL <ref name="EschenbacherKreiss1999">{{cite journal|last1=Eschenbacher|first1=William L.|last2=Kreiss|first2=Kathleen|last3=Lougheed|first3=M. Diane|last4=Pransky|first4=Glenn S.|last5=Day|first5=Brian|last6=Castellan|first6=Robert M.|title=Nylon Flock–Associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=159|issue=6|year=1999|pages=2003–2008|issn=1073-449X|doi=10.1164/ajrccm.159.6.9808002}}</ref>


|}


*The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
*The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
*On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
*On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
==Causes==
* FWL  results from the inhalation of airborne nylon fibers at work. Nylon fibers are used in making products for upholstery, automobiles, carpet, and apparel.
==Differentiating [disease name] from other Diseases==
*[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
:*[Differential dx1]
:*[Differential dx2]
:*[Differential dx3]
==Epidemiology and Demographics==
==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
 
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
*Cases have been reported in the United States, Canada, Turkey, and Spain.
*In a study flocking workers when compared to controls, whereas age, sex, tobacco use and working years were not found to be significantly associated with respiratory symptoms. <ref name="Atis2005" />
===Age===
 
*Patients of all age groups may develop [disease name].
*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].
===Gender===
*[Disease name] affects men and women equally.
*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
===Race===
*There is no racial predilection for [disease name].
*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].
==Risk Factors==
==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
== Natural History, Complications and Prognosis==
The natural history of FWL includes the following patterns<ref name="TurcotteChee2013">{{cite journal|last1=Turcotte|first1=Scott E.|last2=Chee|first2=Alex|last3=Walsh|first3=Ronald|last4=Grant|first4=F. Curry|last5=Liss|first5=Gary M.|last6=Boag|first6=Alexander|last7=Forkert|first7=Lutz|last8=Munt|first8=Peter W.|last9=Lougheed|first9=M. Diane|title=Flock Worker's Lung Disease|journal=Chest|volume=143|issue=6|year=2013|pages=1642–1648|issn=00123692|doi=10.1378/chest.12-0920}}</ref>:


*complete resolution of symptoms;
*In textile workers, the lung of the flock worker is seen chronically exposed to short nylon fibers usually flocked onto textile products. Flock is created by cutting guillotine or rotary cutting. It has been believed that rotary cutting is more dangerous than guillotine cutting.<ref name="urlChronic Hypersensitivity Pneumonitis Associated with Inhaled Exposure to Nylon Powder for 3-D Printing: A Variant of Nylon Flock Workers Lung Disease? | D46. CASE REPORTS IN ENVIRONMENTAL AND OCCUPATIONAL HEALTH">{{cite web |url=https://www.atsjournals.org/doi/pdf/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A7071 |title=Chronic Hypersensitivity Pneumonitis Associated with Inhaled Exposure to Nylon Powder for 3-D Printing: A Variant of Nylon Flock Worker's Lung Disease? &#124; D46. CASE REPORTS IN ENVIRONMENTAL AND OCCUPATIONAL HEALTH |format= |work= |accessdate=}}</ref>.<ref name="Atis2005" />
*radiographic and pulmonary function abnormalities;  
*Working in manufacturing and maintenance, on a flocking scale, and more days and hours a week, cleaning with compressed air, and increased current and accumulated exposure to respiratory dust were found to be strongly correlated with disease symptoms.
*permanent, but stable symptoms and restrictive pulmonary function deficits;  
*Multivariate research found that becoming a worker flocking with polypropylene was a predictive factor for pulmonary function disability.<ref name="pmid23732577" />
*and progressive decline in pulmonary function, causing death from respiratory failure and secondary pulmonary hypertension. A low baseline diffusing capacity of the lung for carbon monoxide is associated with the persistence and progression of FWL
*An analysis showed that the risk of respiratory symptoms increased by almost 4 times in polypropylene flocking workers when compared to controls.<ref name="Atis2005">{{cite journal|last1=Atis|first1=S.|title=The respiratory effects of occupational polypropylene flock exposure|journal=European Respiratory Journal|volume=25|issue=1|year=2005|pages=110–117|issn=0903-1936|doi=10.1183/09031936.04.00138403}}</ref>
 
== Diagnosis ==
==Natural History, Complications and Prognosis==
FWL's natural history reflects the following trends
 
*Total Symptom Resolution;
*Abnormalities to both the radiographic and pulmonary functions;
*Permanent yet manageable signs and restrictive [[pulmonary function]] deficits;
*And progressive pulmonary deterioration, causing death from [[respiratory failure]] and [[secondary hypertension]]. The presence and development of FWL is correlated with low baseline diffusing potential of the lung for carbon monoxide. <ref name="TurcotteChee2013">{{cite journal|last1=Turcotte|first1=Scott E.|last2=Chee|first2=Alex|last3=Walsh|first3=Ronald|last4=Grant|first4=F. Curry|last5=Liss|first5=Gary M.|last6=Boag|first6=Alexander|last7=Forkert|first7=Lutz|last8=Munt|first8=Peter W.|last9=Lougheed|first9=M. Diane|title=Flock Worker's Lung Disease|journal=Chest|volume=143|issue=6|year=2013|pages=1642–1648|issn=00123692|doi=10.1378/chest.12-0920}}</ref>
*In general, after [[steroid therapy]] and leaving the place of operation, improvement occurred over a period of months or years, with some experiencing recurrent [[dyspnea]], activity restriction or chronic supplemental oxygen needs.<ref name="BarrosoIbañez2002">{{cite journal|last1=Barroso|first1=E.|last2=Ibañez|first2=M.D.|last3=Aranda|first3=F.I.|last4=Romero|first4=S.|title=Polyethylene flock-associated interstitial lung disease in a Spanish female|journal=European Respiratory Journal|volume=20|issue=6|year=2002|pages=1610–1612|issn=0903-1936|doi=10.1183/09031936.02.00030102}}</ref>
*There was also 3 times increase in [[lung cancer]] incidence. <ref name="KernKern2011">{{cite journal|last1=Kern|first1=David G.|last2=Kern|first2=Eli|last3=Crausman|first3=Robert S.|last4=Clapp|first4=Richard W.|title=A Retrospective Cohort Study of Lung Cancer Incidence in Nylon Flock Workers, 1998–2008|journal=International Journal of Occupational and Environmental Health|volume=17|issue=4|year=2011|pages=345–351|issn=1077-3525|doi=10.1179/oeh.2011.17.4.345}}</ref>
 
==Diagnosis==
===Diagnostic Criteria===
===Diagnostic Criteria===
A case of flock-worker's lung  is  defined as  
A case of flock worker's lung  is  defined as:
 
#A histological diagnosis of [[non-specific interstitial pneumonia]], with or without [[interstitial fibrosis]], characterized by [[bronchiolocentric]] [[nodular]] and diffuse [[interstitial lymphoid infiltration]] and non-uniform [[alveolar]] filling by [[macrophages]];
#Other histologic manifestations of [[Interstitial Lung Disease]] (ILD)  not attributable to another disease; or
#A grossly abnormal distribution of cell types on bronchoalveolar lavage (BAL) with restrictive lung function and HRCT findings of either diffuse ground-glass opacity or micronodularity, in the absence of a tissue specimen.<ref name="urlChronic Interstitial Lung Disease in Nylon Flocking Industry Workers -- Rhode Island, 1992-1996">{{cite web |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/00049601.htm |title=Chronic Interstitial Lung Disease in Nylon Flocking Industry Workers -- Rhode Island, 1992-1996 |format= |work= |accessdate=}}</ref>
 
===History and Symptoms===
 
*The nylon flock exposed workers most commonly presented with [[chronic respiratory symptoms]] over several years, but [[subacute]] presentations also occurred. For example, in a Canadian outbreak, 5 of 88 exposed workers developed the disease after exposure occurring over several days
 
*[[Restrictive ventilatory defects]] are most common, but [[obstructive defects]] have been reported. <ref name="SaulerGulati2012">{{cite journal|last1=Sauler|first1=Maor|last2=Gulati|first2=Mridu|title=Newly Recognized Occupational and Environmental Causes of Chronic Terminal Airways and Parenchymal Lung Disease|journal=Clinics in Chest Medicine|volume=33|issue=4|year=2012|pages=667–680|issn=02725231|doi=10.1016/j.ccm.2012.09.002}}</ref>
 
A study showed 20 individual from different geographic locations  having FWL shared symptoms of
 
*[[dyspnea]] and [[cough]], with and without [[sputum production]].
*These symptoms were present for months to years before clinical presentation, which, for some cases, seemed precipitated by an acute exacerbation in the preceding few days. Symptom onsets for the patients occurred over a 15-yr period, with no apparent concentration of onsets for any plant location.
*Few nonrespiratory symptoms were noted. [[Weight loss]] was noted in two patients and two workers had [[arthralgia]] or [[myalgias]]. Eight of the 20 patients were noted to have [[asthma]], increased bronchial responsiveness to [[methacholine]], or increased [[bronchodilator]] responsiveness.<ref name="pmid10351952" />
 
===Physical Examination===
 
*Physical examination in one study showed that both patients with FWL and control groups were evaluated as normal.<ref name="Atis2005">{{cite journal|last1=Atis|first1=S.|title=The respiratory effects of occupational polypropylene flock exposure|journal=European Respiratory Journal|volume=25|issue=1|year=2005|pages=110–117|issn=0903-1936|doi=10.1183/09031936.04.00138403}}</ref>
*Others have reported
 
:*[[inspiratory crackles]] on [[auscultation]] <ref name="BarrosoIbañez2002">{{cite journal|last1=Barroso|first1=E.|last2=Ibañez|first2=M.D.|last3=Aranda|first3=F.I.|last4=Romero|first4=S.|title=Polyethylene flock-associated interstitial lung disease in a Spanish female|journal=European Respiratory Journal|volume=20|issue=6|year=2002|pages=1610–1612|issn=0903-1936|doi=10.1183/09031936.02.00030102}}</ref>
 
:*[[Pulmonary function test]] results revealing a [[restrictive pattern]] <ref name="EschenbacherKreiss1999">{{cite journal|last1=Eschenbacher|first1=William L.|last2=Kreiss|first2=Kathleen|last3=Lougheed|first3=M. Diane|last4=Pransky|first4=Glenn S.|last5=Day|first5=Brian|last6=Castellan|first6=Robert M.|title=Nylon Flock–Associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=159|issue=6|year=1999|pages=2003–2008|issn=1073-449X|doi=10.1164/ajrccm.159.6.9808002}}</ref>


# a histologic diagnosis of nonspecific interstitial pneumonia  characterized by bronchiolocentric nodular and diffuse interstitial lymphoid infiltrates and nonuniform alveolar filling by macrophages, with or without interstitial fibrosis;
===Laboratory Findings===
# Other histologic manifestations of Interstitial Lung Disease (ILD)  not attributable to another disease; or
# In the absence of a tissue specimen, a grossly abnormal distribution of cell types on bronchoalveolar lavage (BAL) with restrictive lung function and HRCT findings of either diffuse ground glass opacity or micronodularity.<ref name="urlChronic Interstitial Lung Disease in Nylon Flocking Industry Workers -- Rhode Island, 1992-1996">{{cite web |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/00049601.htm |title=Chronic Interstitial Lung Disease in Nylon Flocking Industry Workers -- Rhode Island, 1992-1996 |format= |work= |accessdate=}}</ref>


*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
*There are no specific laboratory findings associated with FWL.
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]
=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]
=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]
=== Laboratory Findings ===
*There are no specific laboratory findings associated with [disease name].


*A  [positive/negative] [test name] is diagnostic of [disease name].
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
===Imaging Findings===
===Imaging Findings===
*There are no [imaging study] findings associated with [disease name].
*[Imaging study 1] is the imaging modality of choice for [disease name].
*On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
*[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].
=== Other Diagnostic Studies ===
*[Disease name] may also be diagnosed using [diagnostic study name].
*Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].
== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
=== Prevention ===
*There are no primary preventive measures available for [disease name].
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].


*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].  
*[[High-resolution CT scan]] remained a highly [[sensitive diagnostic test]]. [[Pulmonary function tests]] and plain [[chest X-ray]] were less sensitive.<ref name="KernKuhn2000">{{cite journal|last1=Kern|first1=David G.|last2=Kuhn|first2=Charles|last3=Ely|first3=E. Wesley|last4=Pransky|first4=Glenn S.|last5=Mello|first5=Curtis J.|last6=Fraire|first6=Armando E.|last7=Müller|first7=Joachim|title=Flock Worker's Lung|journal=Chest|volume=117|issue=1|year=2000|pages=251–259|issn=00123692|doi=10.1378/chest.117.1.251}}</ref>
*The most common findings in FWL on [[CT scan]]  were ground-glass opacities and [[micronodules]], with a peripheral predominance in some.<ref name="WeilandLynch2003">{{cite journal|last1=Weiland|first1=David A.|last2=Lynch|first2=David A.|last3=Jensen|first3=Steven P.|last4=Newell|first4=John D.|last5=Miller|first5=David E.|last6=Crausman|first6=Robert S.|last7=Kuhn|first7=Charles|last8=Kern|first8=David G.|title=Thin-Section CT Findings in Flock Worker’s Lung, a Work-related Interstitial Lung Disease|journal=Radiology|volume=227|issue=1|year=2003|pages=222–231|issn=0033-8419|doi=10.1148/radiol.2271011063}}</ref>
 
[[File:Ct scan.jpeg|300px|thumb|none|A Normal CT Scan. [https://https://radiopaedia.org/articles/ct-chest-non-contrast-technique?lang=u;Radiology Reference Article &#124]]]
 
 
 
 
[[File:Flock workers Lung Ct scan.jpg|300px|thumb|none|CT Scan seen in hypersensitivity pneumonitis which is very similar to FWL. [https://https://commons.wikimedia.org/wiki/File:Neumonitis_por_hipersensibilidad_2.jpg]]]
 
===Other Diagnostic Studies===
 
*[[Transbronchial biopsy]] may prove helpful in the consideration of alternate diagnoses, but [[wedge biopsy]] by [[thoracotomy]] or [[thoracoscopy]] is necessary to adequately examine the characteristic lesion of this [[interstitial lung disease]] in relation to the [[pulmonary lobular architecture]]. <ref name="EschenbacherKreiss1999">{{cite journal|last1=Eschenbacher|first1=William L.|last2=Kreiss|first2=Kathleen|last3=Lougheed|first3=M. Diane|last4=Pransky|first4=Glenn S.|last5=Day|first5=Brian|last6=Castellan|first6=Robert M.|title=Nylon Flock–Associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=159|issue=6|year=1999|pages=2003–2008|issn=1073-449X|doi=10.1164/ajrccm.159.6.9808002}}</ref>
 
==Treatment==
===Medical Therapy===
 
*Cessation of nylon exposure and [[corticosteroid]] therapy, for exacerbation of [[respiratory]] problems, has been observed to lead symptomatic improvement but overall lung functions are still seen to decline in certain cases.<ref name="urlChronic Hypersensitivity Pneumonitis Associated with Inhaled Exposure to Nylon Powder for 3-D Printing: A Variant of Nylon Flock Workers Lung Disease? | D46. CASE REPORTS IN ENVIRONMENTAL AND OCCUPATIONAL HEALTH" /><ref name="BarrosoIbañez2002" />
 
===Prevention===
 
*Several observations affirmed that the exposure preceded the disease and that the disease improved with exposure cessation  to the implicated work environments.<ref name="pmid23732577" />
*NIOSH has made recommendations to companies that manufacture flock and make flock containing products that aim to reduce workers’ exposure to flock dust. These include: engineering controls and alternative methods to cleaning the workplace with compressed air, which re-aerosolizes settled dust, improved cutter maintenance, and implementation of [[medical surveillance]] programs have reduced the number of reported cases.<ref name="urlCDC - NIOSH Program Portfolio : Respiratory Diseases : Risks" /><ref name="SaulerGulati2012" />


==References==
==References==

Latest revision as of 15:49, 8 June 2021

Flock worker's lung Microchapters

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Flock Worker's Lung from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Associate Editor(s)-in-Chief: Usman Shah, M.B.B.S.[4]

Synonyms and keywords:

Overview

Flock Worker's Lung(FWL) is an unusual disease interstitial disease characterized by lymphocytic bronchiolitis and peribronchiolitis in workers exposed to flock fibers. Flock is made for the application to adhesive-coated substrates by cutting short synthetic fibers from bundles of parallel nylon monofilaments or other polymers. They are usually prepared from synthetic materials. The disease was identified initially in 1998 when a group of workers at a flocking plant developed unknown cause interstitial lung disease. The first cases to be identified were initially described as desquamative pneumonia and were attributed not with flock fibers, but to unspecified toxin exposure. As subsequent cases appeared, the clinical results with exposure to the flock seemed to be best characterized as lymphocytic bronchiolitis. Typically it presents with progressive dyspnea, dry cough, and constitutional symptoms. Some patients also show work-related symptoms, especially early in the process.

Historical Perspective

  • Since 1975, distributed case reports have raised doubt of a respiratory danger related with different manufactured strands, including polyester, nylon, and acrylic dust.
  • Early reports in 1974 and 1981 of working environment assessments by National Institute of Occupational Safety and Health (NIOSH) agents ascribed respiratory manifestations among laborers to irritant properties of nonrespirable flock fibers on the upper airways but did not pursue the possibility of lung disease associated with flock work [1]
  • During 1990 and 1991, five workers from a nylon flock handling plant in Ontario presented with cough and dyspnea.[2]
  • In 1995 and 1996, two workers from a similar nylon flock handling plant in Rhode Island presented independently to the same doctor with cough and dyspnea.
  • The underlying diagnosis for the lung ailment in these two employees was initially thought to be work-related Hypersensitivity pneumonitis. With additional case finding investigation at the Rhode Island location, a total of eight cases among the approximately 150 workers at the plant were identified by January 1998 based upon a screening questionnaire (symptoms of cough and dyspnea), pulmonary function abnormalities (restrictive pattern with reduced diffusion capacity), radiographic findings and/or histological findings on tissue obtained by open lung or transbronchial lung biopsy. Based upon the aggregate histopathological results from biopsied cases, the disease process was not thought to be hypersensitivity pneumonitis.[2]
  • "Flock Workers's lung" officially came to known in 1998, when scientists from NIOSH distributed the aftereffects of an epidemiological examination of episodes in Ontario and Rhode Island..
  • Previously, interstitial lung disease in flock workers was mistakenly ascribed to mycotoxins present in polluted adhesive.[1]

Classification

The disease currently still has not been stratified.

Pathophysiology

  • Flock consists of short fibers that are cut from long filaments and glued to a backing material such as cloth to provide a fuzzy, carpet-like surface texture. They are usually made from synthetic materials such as nylon, rayon, or polypropylene. The cutting process results in the formation of airborne particles or fibers in the respirable range. Inhalation of flock dust causes interstitial lung disease.[3]
  • Preliminary toxicological findings indicate that ultrafine respirable nylon fragments after a single intratracheal instillation trigger an acute inflammatory lung injury in rats. Yet flock finishing agents or other particulate matter components found in the soil of flock processing plants can not yet be removed.
  • We have studied interstitial pneumonitis among nylon flock processors with a histopathological pattern — bronchiolar and peribronchiolar lymphocytic inflammation and lymphoid hyperplasia — that indicates an inflammatory and possibly immunological response to a respiratory toxicant. [4]
  • In one study microscopic examination of polypropylene fiber-exposed lungs revealed a dose-dependent increase in cellularity (especially macrophage infiltration), but no fibrosis. In another study, the researchers found high serum IL-8 and TNF-α levels in the polypropylene flocking workers. Furthermore, these levels showed a negative correlation with DL, CO levels. These results suggest that IL-8 and TNF-α may act as key mediators for inflammatory lung injury in the pathogenesis of flock worker's lung.[5]


Electron Microscopic image showing Flock Fibers collected from the air sample of a card manufacturing factory. [1]

Causes

  • FWL results from the inhalation of airborne nylon fibers at work. Nylon fibers are used in making products for upholstery, automobiles, carpet, and apparel.

Differentiating Flock Worker's Lung from other Diseases

FWL presents like most Interstitial Lung Disease. Differentiating FWL from other similar interstitial lung diseases can be done based on a history of exposure and work environment.

Occupation Causative Agent Disease Differences on Imaging Histopathology findings
Shipbuilding Asbestos Asbestosis Affects Lower Lobes; Calcified supradiaphragmatic and pleural plaques Asbestos Bodies
Dental technicians, jewelers, precious metal reclamation workers, Beryllium Chronic beryllium disease Affects Upper lobes Granulomatous histology
Glass manufacturing, Blue jean Manufacturing Sand Silicosis Affects Upper lobes, nodular pattern; Eggshell calcifications of hilar lymph nodes Fibrotic nodules with concentric "onion-skinned" arrangement of collagen fibers [6]
Food Industry Diacetyl Bronchiolitis Obliterans Patchy areas of decreased lung density, This pattern is often described as a "mosaic pattern" [7] Intraluminal buds called "Masson bodies" fill the lumen, which results in bronchiolar plugging [8]
Domestic use for heating Biomass fuel Interstitial Lung Disease Distribution of the nodules is seen to be centrilobular Bronchoscopy reveals a large number of anthracotic pigments in the airways [9]
Coal Industry Coal dust Coal Workers Pneumoconiosis Affects Upper lobes, nodular pattern Macrophages laden with carbon
Animal Breeding Phytoset Hypersensitivity Pneumonitis Affects Middle and Lower lobes , nodular pattern Multinucleated giant cell
Synthetic flock manufacturing Nylon, rayon, or polypropylene Flock Worker's Lung Diffuse nodular opacities, very similar to Hypersensitivity Pneumonitis Increase Eosinophil and Lymphocyte count seen in BAL [4]

Epidemiology and Demographics

  • Cases have been reported in the United States, Canada, Turkey, and Spain.
  • In a study flocking workers when compared to controls, whereas age, sex, tobacco use and working years were not found to be significantly associated with respiratory symptoms. [5]

Risk Factors

  • In textile workers, the lung of the flock worker is seen chronically exposed to short nylon fibers usually flocked onto textile products. Flock is created by cutting guillotine or rotary cutting. It has been believed that rotary cutting is more dangerous than guillotine cutting.[10].[5]
  • Working in manufacturing and maintenance, on a flocking scale, and more days and hours a week, cleaning with compressed air, and increased current and accumulated exposure to respiratory dust were found to be strongly correlated with disease symptoms.
  • Multivariate research found that becoming a worker flocking with polypropylene was a predictive factor for pulmonary function disability.[1]
  • An analysis showed that the risk of respiratory symptoms increased by almost 4 times in polypropylene flocking workers when compared to controls.[5]

Natural History, Complications and Prognosis

FWL's natural history reflects the following trends

  • Total Symptom Resolution;
  • Abnormalities to both the radiographic and pulmonary functions;
  • Permanent yet manageable signs and restrictive pulmonary function deficits;
  • And progressive pulmonary deterioration, causing death from respiratory failure and secondary hypertension. The presence and development of FWL is correlated with low baseline diffusing potential of the lung for carbon monoxide. [11]
  • In general, after steroid therapy and leaving the place of operation, improvement occurred over a period of months or years, with some experiencing recurrent dyspnea, activity restriction or chronic supplemental oxygen needs.[12]
  • There was also 3 times increase in lung cancer incidence. [13]

Diagnosis

Diagnostic Criteria

A case of flock worker's lung is defined as:

  1. A histological diagnosis of non-specific interstitial pneumonia, with or without interstitial fibrosis, characterized by bronchiolocentric nodular and diffuse interstitial lymphoid infiltration and non-uniform alveolar filling by macrophages;
  2. Other histologic manifestations of Interstitial Lung Disease (ILD) not attributable to another disease; or
  3. A grossly abnormal distribution of cell types on bronchoalveolar lavage (BAL) with restrictive lung function and HRCT findings of either diffuse ground-glass opacity or micronodularity, in the absence of a tissue specimen.[14]

History and Symptoms

  • The nylon flock exposed workers most commonly presented with chronic respiratory symptoms over several years, but subacute presentations also occurred. For example, in a Canadian outbreak, 5 of 88 exposed workers developed the disease after exposure occurring over several days

A study showed 20 individual from different geographic locations having FWL shared symptoms of

  • dyspnea and cough, with and without sputum production.
  • These symptoms were present for months to years before clinical presentation, which, for some cases, seemed precipitated by an acute exacerbation in the preceding few days. Symptom onsets for the patients occurred over a 15-yr period, with no apparent concentration of onsets for any plant location.
  • Few nonrespiratory symptoms were noted. Weight loss was noted in two patients and two workers had arthralgia or myalgias. Eight of the 20 patients were noted to have asthma, increased bronchial responsiveness to methacholine, or increased bronchodilator responsiveness.[2]

Physical Examination

  • Physical examination in one study showed that both patients with FWL and control groups were evaluated as normal.[5]
  • Others have reported

Laboratory Findings

  • There are no specific laboratory findings associated with FWL.

Imaging Findings

A Normal CT Scan. Reference Article &#124



CT Scan seen in hypersensitivity pneumonitis which is very similar to FWL. [2]

Other Diagnostic Studies

Treatment

Medical Therapy

  • Cessation of nylon exposure and corticosteroid therapy, for exacerbation of respiratory problems, has been observed to lead symptomatic improvement but overall lung functions are still seen to decline in certain cases.[10][12]

Prevention

  • Several observations affirmed that the exposure preceded the disease and that the disease improved with exposure cessation to the implicated work environments.[1]
  • NIOSH has made recommendations to companies that manufacture flock and make flock containing products that aim to reduce workers’ exposure to flock dust. These include: engineering controls and alternative methods to cleaning the workplace with compressed air, which re-aerosolizes settled dust, improved cutter maintenance, and implementation of medical surveillance programs have reduced the number of reported cases.[3][15]

References

  1. 1.0 1.1 1.2 1.3 Kreiss K (June 2013). "Occupational lung disease: from case reports to prevention". Chest. 143 (6): 1529–1531. doi:10.1378/chest.12-3001. PMC 3673658. PMID 23732577.
  2. 2.0 2.1 2.2 Eschenbacher WL, Kreiss K, Lougheed MD, Pransky GS, Day B, Castellan RM (June 1999). "Nylon flock-associated interstitial lung disease". Am. J. Respir. Crit. Care Med. 159 (6): 2003–8. doi:10.1164/ajrccm.159.6.9808002. PMID 10351952.
  3. 3.0 3.1 "CDC - NIOSH Program Portfolio : Respiratory Diseases : Risks".
  4. 4.0 4.1 4.2 4.3 Eschenbacher, William L.; Kreiss, Kathleen; Lougheed, M. Diane; Pransky, Glenn S.; Day, Brian; Castellan, Robert M. (1999). "Nylon Flock–Associated Interstitial Lung Disease". American Journal of Respiratory and Critical Care Medicine. 159 (6): 2003–2008. doi:10.1164/ajrccm.159.6.9808002. ISSN 1073-449X.
  5. 5.0 5.1 5.2 5.3 5.4 Atis, S. (2005). "The respiratory effects of occupational polypropylene flock exposure". European Respiratory Journal. 25 (1): 110–117. doi:10.1183/09031936.04.00138403. ISSN 0903-1936.
  6. "Diseases associated with exposure to silica and nonfibrous silicate minerals. Silicosis and Silicate Disease Committee". Arch. Pathol. Lab. Med. 112 (7): 673–720. July 1988. PMID 2838005.
  7. Barker AF, Bergeron A, Rom WN, Hertz MI (May 2014). "Obliterative bronchiolitis". N. Engl. J. Med. 370 (19): 1820–8. doi:10.1056/NEJMra1204664. PMID 24806161.
  8. Aguilar PR, Michelson AP, Isakow W (February 2016). "Obliterative Bronchiolitis". Transplantation. 100 (2): 272–83. doi:10.1097/TP.0000000000000892. PMID 26335918.
  9. "Beyond pneumonoconiosis: Recently described occupational interstitial lung diseases | PNEUMON - Official Journal of Hellenic Thoracic Society".
  10. 10.0 10.1 "Chronic Hypersensitivity Pneumonitis Associated with Inhaled Exposure to Nylon Powder for 3-D Printing: A Variant of Nylon Flock Worker's Lung Disease? | D46. CASE REPORTS IN ENVIRONMENTAL AND OCCUPATIONAL HEALTH".
  11. Turcotte, Scott E.; Chee, Alex; Walsh, Ronald; Grant, F. Curry; Liss, Gary M.; Boag, Alexander; Forkert, Lutz; Munt, Peter W.; Lougheed, M. Diane (2013). "Flock Worker's Lung Disease". Chest. 143 (6): 1642–1648. doi:10.1378/chest.12-0920. ISSN 0012-3692.
  12. 12.0 12.1 12.2 Barroso, E.; Ibañez, M.D.; Aranda, F.I.; Romero, S. (2002). "Polyethylene flock-associated interstitial lung disease in a Spanish female". European Respiratory Journal. 20 (6): 1610–1612. doi:10.1183/09031936.02.00030102. ISSN 0903-1936.
  13. Kern, David G.; Kern, Eli; Crausman, Robert S.; Clapp, Richard W. (2011). "A Retrospective Cohort Study of Lung Cancer Incidence in Nylon Flock Workers, 1998–2008". International Journal of Occupational and Environmental Health. 17 (4): 345–351. doi:10.1179/oeh.2011.17.4.345. ISSN 1077-3525.
  14. "Chronic Interstitial Lung Disease in Nylon Flocking Industry Workers -- Rhode Island, 1992-1996".
  15. 15.0 15.1 Sauler, Maor; Gulati, Mridu (2012). "Newly Recognized Occupational and Environmental Causes of Chronic Terminal Airways and Parenchymal Lung Disease". Clinics in Chest Medicine. 33 (4): 667–680. doi:10.1016/j.ccm.2012.09.002. ISSN 0272-5231.
  16. Kern, David G.; Kuhn, Charles; Ely, E. Wesley; Pransky, Glenn S.; Mello, Curtis J.; Fraire, Armando E.; Müller, Joachim (2000). "Flock Worker's Lung". Chest. 117 (1): 251–259. doi:10.1378/chest.117.1.251. ISSN 0012-3692.
  17. Weiland, David A.; Lynch, David A.; Jensen, Steven P.; Newell, John D.; Miller, David E.; Crausman, Robert S.; Kuhn, Charles; Kern, David G. (2003). "Thin-Section CT Findings in Flock Worker's Lung, a Work-related Interstitial Lung Disease". Radiology. 227 (1): 222–231. doi:10.1148/radiol.2271011063. ISSN 0033-8419.