Fire-Eater's Asbestosis

To the Editor.—  The importance of a careful and complete history in the evaluation of patients with possible environmental lung disease is illustrated by the following case.A 56-year-old retired army sergeant was seen at the Madigan Army Medical Center in 1969 with right pleuritic chest pain and low-grade fever of three days' duration and was found to have a right-sided pleural effusion. Complete evaluation including thoracentesis and pleural biopsy examination did not show a cause for the effusion. He subsequently has been followed up as an outpatient and has developed bilateral pleural thickening (Figure) compatible with asbestos exposure. When initially queried about occupations generally considered pertinent to asbestosis, eg, asbestos-weaving and steam-pipe lagging, he denied any such occupation. However, when asked to go through his occupational history month-by-month including part-time jobs, he recalled working for nine months at age 16 as a fire-eater in a carnival. This entailed using