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p. 1 370 7 Journal of Toxicology: Clinical Toxicology Jan 1996 v34 n7 p21(4) Page 7 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 formula tion contained isobutane, n-heptane, ethyl acetate and fluoroaliphatics . Retrospec tive Review: Thirty-nine pa ti ents 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 . m COPYRIGHT 1996 Marcel Dekker, Inc . INTRODUCTIO N 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 formulation produced an acute respiratory illness, with 157 patients reporting symptoms .[11 The release of another reformulated leather protector produced similar symptoms in 39 patients reported in this series . The components present in these reformulations have chemical similarities . 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 Guard[RJ distributed by Shirlo, Inc . and manufactured by Speer Products Inc . of Memphis, TN . The aerosol conditioner was a new formulation that contained isobutane, ethyl acetate, n-heptane, and 1 .2% 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 of 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 of shoes with longer exposures . Two cases involved spraying on multiple 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 . Table 1 Symptoms of 39 Patients Following Exposure to Reprinted with permission. Additional copying is prohibited . - GALE GROU P Information Integrity p. 2 Journal of Toxicology: Clinical Toxicology Jan 1996 v34 n1 p21(4) Page 2 Pulmonary toxicity following exposure to an aerosolized leather protector . Aerosolized Conditione r Symptom Patients cough 26 Chest pain 15 SOB Nausea Wheezing 15 9 5 Sore throat 5 Fever 3 Dizzy Headache 3 2 Eye Irritation I Rhiaorrhea 1 Thirteen patients were seen by their family physician or treated and released from an emergency department . Six patients (four adult, two pediatric) were admitted to the hospital ; three of these were exposed to the product outdoors . Three of the five patients who developed wheezing had preexisting histories of obstructive disease . These five patients did not require hospitalization . Two of the six smokers were admitted . Thirteen patients had chest radiographs ; four demonstrated infiltrates . All patients received follow-up calls at three months . If patients had persistent symptoms, they received an additional follow-up call at six months . Information was obtained from their treating physicians, when available . Symptoms lasted up to 24 h in ten patients, between one day and one week in 13 patients, and one week to a month in another seven patients Symptoms persisted in six patients . Detailed histories and evaluations of the patients who had persistent symptoms are presented below. A 35-year-old mate who was a half-pack per day smoker 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 dry cough and dyspnea on exertion . The administration of inhaled steroids and albuterol provided symptomatic improvement . A 34-year-old male without prior history of smoking or pulmonary disease noted cough, SOB, and wheezing within two hours after using the product indoors . He complained of a persistent morning cough and dyspnea on exertion . On pulmonary function testing he demonstrated mild airflow obstruction that improved with bronchodilation . A 21-year-old nonsmoking male without prior pulmonary disease sprayed one pair of shoes outdoors and developed a cough and SOB within an hour. The SOB has persisted . He has a slight decrease in his diffusing capacity and a positive methacholine 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 within minutes after spraying indoors . The patient has had persistently decreased exercise tolerance . She reported SOB on climbing two flights 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 of 66% of predicted . Another 39-year-old male sprayed one pair of shoes in a garage . He developed chest pain and SOB within 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 immediately developed coughing . The patient now reports twenty coughing spells per day, while her grandson recovered in two days . The patient reports that she is obese and suffers from chronic SOB and dyspnea on exertion . She has not followed up with her medical physician_ DISCUSSION - Reprinted with permission. Additional copying is prohibited. - GALE G R OU P Information Integrity p. 3 Journal of Toxicology: Clinical Toxicology Jan 1996 v34 n f p21(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 trichioroethane 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 of lung injury by systemically administered chemicals . Toxicol Appi 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 Wildt DJ . The mechanism of fluoride-induced hypocalcemia . Hum Exp Toxicol 1994 ;13:149-155 . - Reprinted with permission . Additional copying is prohibited . - GALE GROU P Information Integrity