A 25-year-old young male patient presented in casualty department with severe respiratory distress on the fourth day from onset of symptoms. The patient was nonsmoker and had no antecedent medical or
drug history. Prior to
admission, patient had dry
cough and bilateral pleuritic
chest pain for the last three days. He was in severe respiratory distress with use of accessory muscles of respiration. On examination, he had heart rate of 120 beats/min, blood pressure (BP) of 150/80, respiratory rate of 48-52/min and central
cyanosis present. On systemic examination, reduced intensity of breath sounds with extensive
rhonchi and crepitation was found in both lung fields, with other examination being within normal limits. On pulse oximetry, oxygen saturation was 28% on room air, which increased up to 36% with the help of 4 L
oxygen via nasal prongs. PaO2/FiO2 ratio was 100. Chest X-ray analysis was suggestive of non-cardiac
pulmonary edema in view of bilateral fluffy opacity without
cardiomegaly. In view of 2/3 positive criteria, his provisional diagnosis was
Acute Respiratory Distress Syndrome (ARDS). He required mechanical ventilatory support and was gradually weaned over a period of 10 days. The patient was treated with broad spectrum
antibiotics and other supportive measures. On re-evaluation of history, we found that he was a goldsmith by occupation, smelting
silver and
gold for the past 8-10 years. On the day of onset of symptoms, while smelting
silver he was exposed to golden yellow fumes for around 15 minutes, with the quantum of exposure more than any other day earlier. From previous experience and analysis of similar
silver metals, he was able to tell us that the
silver was adulterated with large amount of
cadmium on that day than before. Serum level of
cadmium was 2.9 μg/L 6 days after initial exposure. At the time of discharge, he had residual opacities in the chest radiograph and resting oxygen saturation was 94% on room air.