Document Bv7mVEnrZpjDzojDqxd8dwBRX

p. 1 - byo'j Journal o f Toxicology: C linical Toxicology Jan 1996 v34 n l p 2 1 ( 4 ) Page 1_________________________________________________________________ Pulmonary toxicity following exposure to an aerosolized leather protector. by Keith K. Burkhart, Andres Britt, Greg Petrini, Sandy O'Donnell and J. Ward Donovan Background: An aerosol spray for leather protection was reformulated to remove trichloroethane. The new form ulation contained isobutane, n-heptane, ethyl acetate and fluoroaliphatics. Retrospective Review: Thirty-nine patients reported symptoms to the regional poison center. Respiratory symptoms developed within hour's of exposure. Most symptoms resolved within two days. Abnormal pulmonary function tests, including obstructive disease or diminished diffusing capacity, were demonstrated in three of the four tested patients. Conclusions: The mechanism for the pulmonary toxicity has not been determined. COPYRIGHT 1996 M a rc e l D ekker, Inc. INTRODUCTION The Clean Air Act amendments of 1990 prohibited, effective January 1994, the sale or distribution of products containing trichloroethane, an ozone-depleting solvent. Aerosol shoe and leather protectors that relied upon this product subsequently developed new formulations. In December 1992 a new form ulation produced an acute respiratory illness, with 157 patients reporting symptoms.[1] The release o f another reformulated leather protector produced sim ilar symptoms in 39 patients reported in this series. The components present in these reformulations have chemical sim ilarities. The patients in this series were followed for longterm complications. Case Report On August 28, 1993 the Central Pennsylvania Poison Center received two calls concerning exposures to a leather, suede and fabric protector. Both patients were being treated by physicians with signs and symptoms consistent with pneumonitis. A review of the poison center log identified two additional patients exposed to the same product. Contacts with surrounding hospital emergency departments uncovered three more cases The product was Magic GuardfRJ distributed by Shirlo, Inc. and manufactured by Speer Products Inc. of Memphis, TN. The aerosol conditioner was a new form ulation that contained isobutane, ethyl acetate, n-heptane, and 12% fluoroaliphatic. The label contained a danger warning that recommended avoiding inhalation of vapors. The product directions specified use only in a well ventilated area away from open flame. It was discovered that the product was purchased from a regional shoe store chain. On the following day the product was removed from these stores. Shirlo, Inc. also began a voluntary recall o f the product that was distributed nationally An American Association of Poison Control Centers alert was initiated. Locally a media alert was released. These alerts helped identify additional cases. A total of 39 symptomatic patients (22 female, 17 male) or their family members provided information about their exposures. Most patients were from southcentral Pennsylvania. A few exposures occurred in North Carolina and Virginia The mean age was 23.3 years (range 6 months to 59 years). Symptomatic patients called within the two weeks following their exposure. Another telephone interview was conducted three months after the incident Two patients were lost to follow-up. The initial symptoms of these two patients are included in the following data analysis. One patient sprayed four pocketbooks, while the rest of the exposures occurred while spraying shoes Fifteen of 18 people who were in the area when someone else sprayed the product developed symptoms. In the majority of exposures one or two pairs of shoes were sprayed for one to two minutes Six applications involved up to five pairs o f shoes w ith longer exposures Two cases involved spraying on m ultiple occasions. No one reported using more than one five-ounce can of the product. Most exposures occurred indoors Five of the symptomatic sprayings occurred outdoors. Most patients reported symptoms immediately or within minutes of the application. Only six patients reported symptom onset later than two hours after use. Two of these patients awoke with symptoms after sleeping in the room where the aerosol was applied. The most common symptoms included chest pain, shortness of breath (SOB), and cough. Other reported symptoms are listed in Table 1 Tabla 1 Symptoma of 39 Patients Following Exposure to - Reprinted with permission. Additional copying is prohibited. GALE GROUP Information Integrity P-2 Journal of Toxicology: Clinical Toxicology Jan 1996 v34 n1 p21(4) _______________________________________________ Page Pulmonary toxicity following exposure to an aerosolized leather protector. AeroaoXlzed Conditioner Symptom Cough Chest pain SOB Nausea Wheezing Sore throat Fever DizzyHeadache Bye irritation Rhinorrhea Patients 26 15 15 8 S 5 3 3 2 1 1 Thirteen patients were seen by their family physician or treated and released from an emergency departm ent Six patients L UrDa ie m iT h ^ f ,afr,'C) Wf [ l admitted t0 the h0spita,; three o f ,hese were P * * the product outdoors. T h re io f the preexisting histories of obstructive disease. These five patients did not require in fih ra ti T f * S'* Smokers were admltted Thirteen patients had chest radiographs; four demonstrated fii^>3t,entS l^fcf `ved fol,w -uP calls at three months If patients had persistent symptoms, they received an additional *a 3 f X lnforma,lon was obtained from their treating physicians, when available Symptoms lasted up S vm rio m i60 P ` one day and one week in 13 patients, and one week to a month in another seven patients p re s e n te d PrS'Sted m SIX P31'0*3 Detailed histories and evaluations of the patients who had persistent symptoms are i 2 i l f t af 0ld mf ' e Wh '? S 3 h3lf-Pack P day smke r developed a severe pneumonitis and was hospitalized for seven days after an outdoor application. His pulmonary function tests were within normal limits. He has a persistent drv couqh and dyspnea on exertion The administration o f inhaled steroids and albuterol provided symptomatic improvement. h r ! , t V! # r^ d ma,e w ithout prior history o f smoking or pulmonary disease noted cough, SOB, and wheezing within two urs after using the product indoors. He complained o f a persistent morning cough and dyspnea on exertion On pulmonary function testing he demonstrated mild airflow obstruction that improved with bronchodilation. ?n?ulhy!n r^ Q o n 0nSr 0kin9uma,e WithOUt prior pulmonary disease sprayed one pair of shoes outdoors and developed a a" hOUr The SOB has Persisted He has a slight decrease in his diffusing capacity and a positive m ethacholine challenge. He is symptomatically improved on inhaled steroids and albuterol An 18-year-old female with a two to three pack year smoking history developed SOB and chest tightness w ithin minutes 'nd rS. Tf]e P31'60* has had Peraistently decreased exercise tolerance. She reported SOB on climbing two ights of stairs. The chest pain recurred for a few seconds each day and was not related to the SOB The patient had a diffusing capacity o f 66% o f predicted. Another 39-year-old male sprayed one pair o f shoes in a garage. He developed chest pain and SOB w ithin two hours The chest pain and cough persisted for three weeks. His SOB has persisted with physical exertion. He has not sought medical evaluation for his symptoms. A 54-year-old female supervised her 7-year-old grandson spraying one pair of shoes indoors Both patients almost dvelPedcou9binTThe Patient now reports twenty coughing spells per day, while her grandson recovered fo" l,lowedd yup wTiithl hpear mnetdriecpaol prthsytshiacitasnh.e ls obese and suffers from chronic SOB and dyspnea on exertion She has not DISCUSSION - Reprinted with permission. Additional copying is prohibited. - GALE GROUP Information Integrity P-3 Journal of Toxicology: Clinical Toxicology Jan 1996 v34 n1 p 2 1 (4 ) Page 4________________________________________________________________________ Pulmonary toxicity following exposure to an aerosolized leather protector. the use of polytetrafluoroethylene. J Occup Med 1977;19:693-695. 9. Woo OF, Healey KM, Sheppard D, Tong TG. Chest pain and hypoxemia from inhalation of a trichloroethane aerosol product. J Toxicol Clin Toxicol 1983; 20:333-341 10. Aida S, Takahashi Y, Suzuki E, Kimula Y, Ito Y, Miura T. Electron-microscopic evidence for cytochrome P450 in Clara cells and type 1 pneumocytes of the rat lung Respiration 1992;59:201-210. 11. Philpot RM. Modulation of the pulmonary cytochrome P450 system as a factor in pulmonary-selective toxic responses, fact and fiction. Am J Respir Cell Mol Biol 1993;9:347-349. 12. Kikkawa Y. Diverse role of pulmonary cytochrome P450 monooxygenase Lab Invest 1992;67:535-539. 13. Yost GS. Buckpitt AR, Roth RA, McLemore TL. Mechanisms o f lung injury by systemically administered chemicals. Toxicol Appl Pharmacol 1989;101: 179-195.14. Rumack BH, ed Ethyl acetate. In: Poisindex Information System, Vol 81. Denver, Colorado: Micromedex Inc, 1994.15. Bosse GM. Nebulized sodium bicarbonate in the treatment of chlorine gas inhalation. J Toxicol Clin Toxicol 1994;32:233-241. 16. Boink AB, Werner J, Meulenbelt J, Vaessen HA, de W ildt DJ The mechanism of fluoride-induced hypocalcemia. Hum Exp Toxicol 1994;13:149-155. - Reprinted with permission. Additional copying is prohibited. GALE GROUP { Information Integrity