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Flock Worker's Lung: Chronic Interstitial Lung Disease in the Nylon Flocking Industry

David G. Kern, MD, MOH; Robert S. Crausman, MD; Kate T.H. Durand, MHS, CIH; Ali Nayer, MD; and Charles Kuhn III, MD
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Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(4):261-272. doi:10.7326/0003-4819-129-4-199808150-00001
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Background: Two young men working at a nylon flocking plant in Rhode Island developed interstitial lung disease of unknown cause. Similar clusters at the same company's Canadian plant were reported previously.

Objective: To define the extent, clinicopathologic features, and potential causes of the apparent disease outbreak.

Design: Case-finding survey and retrospective cohort study.

Setting: Academic occupational medicine program.

Patients: All workers employed at the Rhode Island plant on or after 15 June 1990.

Measurements: Symptomatic employees had chest radiography, pulmonary function tests, high-resolution computed tomography, and serologic testing. Those with unexplained radiographic or pulmonary function abnormalities underwent bronchoalveolar lavage, lung biopsy, or both. The case definition of “flock worker's lung” required histologic evidence of interstitial lung disease (or lavage evidence of lung inflammation) not explained by another condition.

Results: Eight cases of flock worker's lung were identified at the Rhode Island plant. Three cases were characterized by a high proportion of eosinophils (25% to 40%) in lavage fluid. Six of the seven patients who had biopsy had histologic findings of nonspecific interstitial pneumonia, and the seventh had bronchiolitis obliterans organizing pneumonia. All seven of these patients had peribronchovascular interstitial lymphoid nodules, usually with germinal centers, and most had lymphocytic bronchiolitis and interstitial fibrosis. All improved after leaving work. Review of the Canadian tissue specimens showed many similar histologic findings. Among the 165-member study cohort, a 48-fold or greater increase was seen in the sex-adjusted incidence rate of all interstitial lung disease.

Conclusions: Work in the nylon flocking industry poses substantial risk for a previously unrecognized occupational interstitial lung disease. Nylon fiber is the suspected cause of this condition.


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Figure 1.
Distribution of study participants by extent of evaluation.

Two additional former employees who were not members of the cohort were also clinically evaluated.

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Figure 2.
Patient 4.arrows

A. High-resolution computed tomographic scan showing micronodularity and patchy areas of mild ground-glass opacity. B. Open-lung biopsy specimen showing nodules of lymphocytes ( ) in inflamed and consolidated parenchyma (hematoxylin-eosin stain; original magnification, x96).

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Figure 3.
Patient 5.asterisk

A. High-resolution computed tomographic scan showing patchy areas of subtle ground-glass opacity. B. Transbronchial biopsy specimen showing lymphocytic infiltration of a bronchiole and a germinal center ( ) (hematoxylin-eosin stain; original magnification, x83).

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Figure 4.
Patient 8.

A. High-resolution computed tomographic scan showing patchy areas of consolidation and ground-glass opacity. B. Open-lung biopsy specimen showing organizing fibrous tissue within alveoli (thick arrows) and widespread lymphocytic infiltrates with perivascular lymphoid nodules (thin arrows) (hematoxylin-eosin stain; original magnification, x96).

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Figure 5.
Patient 2.arrow

A. High-resolution computed tomographic scan showing diffuse reticular densities and honeycombing consistent with interstitial fibrosis. B. Open-lung biopsy specimen showing a longitudinally sectioned bronchiole with severe lymphocytic bronchiolitis and parenchymal infiltrates (lower right) (hematoxylin-eosin stain; original magnification, x38). C. Higher magnification of a region similar to the lower right portion of panel B, showing lymphocytic infiltration of alveolar walls ( ) and intra-alveolar macrophages and multinucleated giant cells (hematoxylin-eosin stain; original magnification, x380).

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