Document 3LdpxbY6EjpVYJD7beOKk4Ba

CASE REPORT P-1 cute Pulmonary Toxicity Linked to Use of a Leather Protector From the Centre Anti-Poison du Quebec, Saintc-Foy, Quibec, Cjuipda. Receivedfor publication June 3, 1994 Revision received October 25, 1994. Acceptedfo r publication November 15.1994. Copyright b y the American College o f Emergency Physicians. Marti! Latibarta, MO, FRCPfC) 6ay Sanfafan. PhD Raa Blais. MO. FRCP(C) Leather protectors are used extensively for waterproofing leather garments. Inhalation exposure to this type of product is usually considered a benign incident We report two cases of acute pul monary toxicity associated with the use of a new leather protec tor recently introduced to the Canadian market. Emergency physicians must be aware of the potential acute toxicity of new leather protectors. [Laliberte M. Sanfagon G. Blais R: Acute pulmonary toxicity linked to use of a leather protector Ann Emetg MedJune 1995;25:841-844.| I NTRODUCTI ON Leather protectors are used extensively for waterproofing leather garments. Inhalation exposure to a leather pro tector is usually considered a benign event with litde evi dence of toxic effects reported in the medical literature. Wc report two cases of acute pulmonary' toxicity associ ated with the use of a new formulation of leather protector that was introduced to the Canadian market. In 1 month, 16 people reported the occurrence of acute respiratory symptoms after the use of this new leather protector CASE REPORTS Patient 1 A 27-year-old man called the Quebec Poison Control Center complaining of acute respiratory symp toms after the use of a leather protector called Oiled Nubuck Leather Protector. Earlier that day he had sprayed a pair of shoes with this leather protector in a large apart ment with the windows and doors closed. Fifteen minutes later, acute respiratory symptoms of dyspnea, a dry cough, and anterior chest pain developed. The patient felt dizzy and chilly; his temperature at that time was 38.5C. He went outside for fresh air, but came, back inside as he felt more dyspneic. A few minutes later, his 26-year-old wife, who had been silting within several feet of her husband when the leather protector was used, began to feel ill with JUNE IM S 7V6 A N N A LS OF EM ERG EN CY M EDICIN E t 4I PULM O NARY TOXICITY Lalibert. Sanfaon & Biais P-2 similar respiratory symptoms. Both patients were advised by the poison center to seek medical care immediately. Medical evaluation on arrival in the emergency depart ment later that day showed a man in moderate respiratory distress. His medical history was negative for asthma or chronic respiratory disorders. The history of acute respira tory symptoms occurring minutes after the use of the leather protector was confirmed. His symptoms included dyspnea at rest, dry cough, palpitations, and anterior chest pain. The patient appeared to be in moderate respi ratory distress w ithout evidence of cyanosis. Vital signs were blood pressure, 120/70 mm Hg; pulse, 108; respira tions. 28; and temperature, 37C Head and neck exami nation was normal. Cardiac examination showed tachy cardia without murmurs. Lung auscultation showed good air entry with diffuse bilateral wheezing. The chest radio graph was normal. Portable spirometry was performed before treatment and showed a mild obstructive syndrome (Table 1). The patient was treated with supplemental oxygen, 5 mg nebulized saibutamol in normal saline solution, and 40 mg of prednisone orally. His peak expiratory flow rate (PEFR) improved rapidly from 396 L/min before treat ment to 560 L/min after treatment. The patient was dis charged home after 8 hours. Outpatient treatment in cluded a saibutamol metered-dose inhaler and oral pred nisone. One week later, the patient complained only of mild shortness of breath on exercise. His physical exami nation was normal. Four weeks later, he was asymptom atic and his medication was discontinued. Pulmonary function tests obtained at 1 week were normal (Table l). Patient 2 The patients wife also had a medical history negative for respiratory disorders. She reported acute res piratory symptoms--severe shortness of breath at rest, dry cough, palpitations, and diaphoresis--that began a few minutes after her husband used the leather protector. Physical examination revealed a young woman in moder ate respiratory distress with tachypnea, diaphoresis, and mild cyanosis. Vital signs were blood pressure, 140/80 mm Hg; pulse, 120; respirations, 32; and temperature, 37.8"C Oxygen saturation was not recorded, but the cyanosis corrected rapidly after administration of 100% oxygen. Cardiac examination showed tachycardia without murmurs. Lung auscultation showed good air entry with diffuse, bilateral wheezing. A chest radiograph showed diffuse bilateral interstitial infiltrates consistent with pul monary edema. The patient!; PEFR was 250 L/min. She was treated with supplemental oxygen, 5 mg nebulized saibutamol in nor mal saline solution, and 40 mg IV mthylprednisolone every 6 hours. Her subjective response to treatment was rapid, and her PEFR increased to 320 L/min 1 hour after admission. A second chest radiograph 24 hours later was normal. The patient's total leukocyte count on admission was 19,800 mm3 with 81% neutrophils; it rose to 29,300 mm3 at 24 hours w ith 88% neutrophils. The patient was discharged approximately 24 hours later on a saibuta mol metered-dose inhaler and oral prednisone. Four weeks after the event, the patient remained asymptomatic, physical examination was normal and her medication was discontinued. Pulmonary function tests at that time were normal (Table l). Oiled Nubuck Leather Protector (Panita Entreprises, Vancouver, British Columbia) was a new formulation first distributed in Canada in late 1993 and sold primarily in Quebec. This leather protector also was manufactured in the United States by Vanguard Chemical Corporation (St Louis, Missouri). The product was sold in Quebec in 237 mL pump spray containers under different store brand names (Simard et Voyer, Transit, Pegabo, Aldo, and Panita). According to the Canadian distributor, the for mulation of the leather protector was 95% Soltrol-10 iso- Table 1. P ulm onary fu nction tests. Patient t Parian! 2 Parameter Adaiitrioa_________________ I Week After E x p e s u r e ___________4 Weeks A lto Exposafa Measured % Predicted Maasared % Predicted Measured % Predicted Vital capacity 1L) forced vital capacity |L) Forced expiratoryvolume in 1second(L) Forced expiratoryvolume in 1second(LJ/ forced vital capacity|L) Peak expiratory flowrate (Usee) 4.18 3.85 2.96 77 396 67 4.90 62 5.02 57 3.94 -6 77 63 548 84 3.11 86 3.32 79 2.92 -7 88 90 349 76 81 84 f4 84 4 2 A N N A LS Of EM EH G fN C M ED ICIN E 25:6 JUNE 19)5 PULMONARY TOXICITY LaBbcrtc, Sanfaon & Blais P-3 for their illness is direct pulmonary toxicity of one or more of the ingredients Hydrocarbons, namely trimethylpemane or C7 and C8 isoparaffins, or the fluoropolymer resin might have played a role in the pulmonary toxicity. O ther commercially available leather protectors are made of various concentrations of trichloroethane as well as other hydrocarbons and chemical substances. Inhalation o f trichloroethane is known to cause central nervous sys tem symptoms, but there is little evidence of pulmonary toxicity. Woo et al*124 described acute respiratory symptoms and hypoxemia in a 25-year-old man after the use of a waterproofing aerosol product containing trichloroethane and a fluorocarbon resin.4 The authors attributed these effects to the trichloroethane portion of the formulation. O ther descriptions of pulmonary toxicity secondary to inhalational exposure to hydrocarbons can be found; some occurred in the context of professional exposures to kero sene5 or to naphtha distillate vapors.6 In the cases described in our report, the leather protec tor was used indoors in areas with limited ventilation, thereby increasing the risk of pulmonary toxicity. Cus tomers should be advised by manufacturers of sprayed leather protectors against indoor use of their products, a large, easily seen warning label should be placed on the can for this purpose. The information we report was ob tained primarily by telephone. Other unknown environ mental factors may have played a role in the acute pulmonary toxicity repotted. 5 PartonsH.Passera MA:Hydrocarbon arosol pneumonirtsin an adutl AaJttmemMe 1983101607-1608 6 WJson fW Toricology of petraleuni ruphtha disdilate vapors. J OcaipM ed 1976:18:921. Reprint no. 47/1/64104 Address (orrepriots: MartinLalibert, MO. FRCP(C) Departmentof EmergencyMedidne Royal Victoria Hospital 687West PineAvenue Montreal, Qubec Canada H3AIA1 SI4-842-1231 ext 4277 fax 514-B43-I638 SUMMARY Two cases of acute pulmonary toxicity associated with the use of a new leather protector are reported. We speculate that the effects of this exposure were secondary to direct pulmonary injury hy the hydrocarbon ingredients or the fluoropolymer resin. Both cases responded rapidly to sup portive treatment with bronchodilators and corticosteroids. More cases involving simitar formulations of leather protec tors have been reported. Emergency physicians should be aware of the potential acute pulmonary toxicity of leather protectors. REFERENCES 1. SmBotam MJ. Breton fit. Keen W. Acute respratoiy illness linked to use of aerosol leadter condittoMt MWMff 19934196S967 2. Kufg It Brent J. Ftrtlps S: Severe acote respiratory illness noted to use ot shoe spray 44MM47199342JtflS8B7. 3- Afcrecht WN. Btyaot CJ: Polymer fume fever associated with smoking and use el a mold release sprayrsmtaining polytetratluoniethvlene. JOccvpAked 1987:29:817 819 t- Woo OF. Healy KM. Sheppard D: Chest pain and hypoxemia from inhalation of a rrcftlareefhane aerosol product J laxicolO ta fare d! 1983:20:333 341 144 A N N A L S OF E M E R 6 E N C Y M E O IC IN f 75 S JUNE 1985