Document b54a2QGkyZonNGNBqL52zwz1Z

CASE REPORT p. 1 ~70 9 Acute Pulmonary Toxicity Linked to Use of a Leather Protecto r s From the Centre Anti-Poison du trlaFtu tatie.n:,, MD, FRCP(C) Leather protectors are used extensively for waterproofing leather Quekc' S'"&-Foy, Q"&", Ca"d . G"y Saa ,9ao. Pb o garments . Inhalation exposure to this type of product is usually Receiv ed/r puwkarion June 3. l999 Rcvictaa rudred Octobcr 25, 1999. Re.ii el .s, Mn . FRCP(c) considered a benign incident . We report two cases of acute pul- a<cepudror p,,briwao,t monary toxici ty associated with the use of a new leather protec- November ts. t99a. tor recently introduced to the Canadian market_ Emergency Copyright by the American College physicians must be aware of the potential acute toxicity of new of Emergency Physicians. leather protectors . [Laliberte M, SanfKon G . Blais R: Acute pulmonary toKicity linked to use of a leather protector . Ann Ernerg MedJune 1995;25 :841-844 . j INTRODUCTION Leather protectors are used extensively for waterproofing leather garments . Inhalation exposure to a leather protector is usually considered a benign event with little evidence of toxic effects reported in the medical literature . We report two cases of acute pulmonary toxicity associated with the use of a new formulation of leather protector that was introduced to the Canadian market . In I month, 16 people reported the occurrence of acute respiratory symptoms after the use of this new leather protector CASE REPORT S Patient 1 A 27-year-old man called the Quebec Poison Control Center complaining of acute respiratory symptoms 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 apartment 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 hack inside as he felt more dyspneic. A few minutes later, his 26-year-old wife, who had been sitting within several feet of her husband when the leather protector was used, began to feel ill wit h JUNE ISIS 75 6 ANNALS OF EMERGENCY MEDICINE *41 PULMONARY TOXICIT Y tallbertE, SanJacon & Olais p. 2 similar respiratory symptoms . Both patients were advised Physical examination revealed a young woman in moder- by the poison center to seek medical care immediately. ate respiratory distress with tachypnea, diaphoresis, and Medical evaluation on arrival in the emergency depart- mild cyanosis . Vital signs were blood pressure, 140/8 0 merit later that day showed a man in moderate respiratory mm Hg; pulse, 120 ; respirations, 32 : and temperature, distress . His medical history was negative for asthma or 37 .8C. Oxygen saturation was not recorded, but the chronic respiratory disorders. The history of acute respira- cyanosis corrected rapidly after administration of 100% tory symptoms occurring minutes after the use of the oxygen . Cardiac examination showed tachycardia without leather protector was confirmed . His symptoms included murmurs. Lung auscultation showed good air entry with dyspnea at rest, dry cough, palpitations, and anterior diffuse, bilateral wheezing . A chest radiograph showed chest pain . The patient appeared to be in moderate respi- diffuse bilateral interstitial infiltrates consistent with pul- ratory distress without evidence of cyanosis. Vital signs monary edema . were blood pressure, 120/70 mm Hg ; pulse, 108 ; respira- The patfent~ PEFR was 250 Umin . She was treated with tions, 28 ; and temperature, 37C . Head and neck exami- supplemental oxygen . 5 mg nebulized salbutamol in nor- nation was normal. Cardiac examination showed tachy- mal saline solution, and 40 mg IV methylprednisolonc cardia without murmurs . Lung auscultation showed good every 6 hours . Her subjective response to treatment was air entry with diffuse bilateral wheezing. The chest radio- rapid, and her PEFR increased to 320 Umin 1 hour after graph was normal . Portable spirometry was performed admission . A second chest radiograph 24 hours later was before treatment and showed a mild obstructive syndrome normal . The patient's total leukocyte count on admission (Table 1) . was 19,800 mm3 with 8l% neutrophils, it rose to 29,300 The patient was treated with supplemental oxygen, 5 mm3 at 24 hours with 88% neutrophils . The patient was mg nebulized salbutamol in normal saline solution, and discharged approximately 24 hours later on a salbuta- 40 mg of pn:dnisone orally. His peak expiratory flow rate mol metered-dose inhaler and oral prednisone . Four (PEFR) improved rapidly from 396 Umin before treat- weeks after the event, the patient remained asymptomatic, ment to 560 Umin after treatment . The patient was dis- physical examination was normal and her medication was charged home after 8 hours . Outpatient treatment in- discontinued . Pulmonary function tests at that time were cluded a salbutamol metered-dose inhaler and oral pred- normal (Table 1) . nisone . One week later, the patient complained only of Oiled Nubuck Leather Protector (Panita Entreprises, mild shortness of breath on exercise . His physical exami- Vancouver, British Columbia) was a new formulation first nation was normal . Four weeks later, he was asytnptom- distributed in Canada in late 1993 and sold primarily in atic and his medication was discontinued . Pulmonary Quebec. This leather protector also was manufactured in function tests obtained at I week were normal (Table 1) . the United States by Vanguard Chemical Corporation (S t Patient 2 The patient's wife also had a medical history Louis, Missouri) . The product was sold in Quebec in 237- negative for respiratory disorders . She reported acute res- mL pump spray containers under different store brand piratory symptoms--severe shortness of breath at rest, names (Simard et Voyer, Transit, Pegabo, Aldo, an d dry cough, palpitations, and diaphoresis--that began a Panita) . According to the Canadian distributor, the for- few minutes after her husband used the leather protector. mulation of the leather protector was 95% Soltrol-10 iso- Table 1 . Pultimmary function tests . Parameter Measured Patient I Patient 2 Admission I Week After Exposure 4 Weeks After Exposure X Predicted Measured % Predicted Measured x Pnd'Nd,d Vital capacity IL) 4.18 67 4 .90 84 Forced vital capacity IL) 3.85 62 5.02 86 Forced expiratory volume in 1 second (U 2 .96 57 3.94 79 Forced eKpiratayvalume in 1 second (L)/ 77 ~ 77 _) forced vital capacity IL 1 Peak expiratory flow rate (Usec) 396 63 548 gp 3 .11 76 3 .32 81 2 .92 84 80 r4 349 84 24 2 ANNALS Of EMERGENCY MEDICINE 25:6 JUNE 1SlS tULMONA N Y TOXICITY 1aG6crte. Sanfcon & Ifluis p. 3 for their illness is direct pulmonary toxicity of one or more S . Pwrooa N. Passem MA Hydrocat4on aerosal pnetmonitss in an aduR . Amh fine, Alpd of the ingredients . Hydrocarbons, namely trimethylpetuane 19113 :1 43 lfiai- 1611 6 . or C7 and C8 isoparaffins, or the fluoropolymer resin 6- Wi '0nn* T0100DI M 0taO1I'"npl"I1dSfla 'e vapors . J 01ccupm&0 e7 6: 1e921, might have played a role in the pulmonary toxicity. Other commercially available leather protectors are made of various concentrations of trichlotroethane as well Reprint no . 47/1164104 Address for re~rittts : as other hydrocarbons and chemical substances . Inhalation Martin tat'eert~ MO. ~RCP(c) of trichloroethane is known to cause central nervous sys- ~"t E"le'ge"~' Medicine tern symptoms, but there is little evidence of pulmonary A~ Mcutria Hospita l toxicity. Woo et al* described acute respiratory symptoms 687 West Pine Ave1K,e and hypoxemia in a 25-year-old man after the use of a M ontreai, ouaec waterproofing aerosol product containing trichlotoethane Canada and a fluorocarbon resin' The authors attributed these 1-13p tA 1 effects to the trichloroethane portion of the formulation . 514.842-1231 ext azn Other descriptions of pulmonary toxicity secondary to Fax 514-B43-1638 inhalational exposure to hydrocarbons can be found ; some occurred in the context of professional exposures to kero- senes 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 obtained primarily by telephone . Other unknown environ- mental factors may have played a role in the acute pulmonary toxicity reported . 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 by the hydrocarbon ingredients or the fluoropolymer resin- Both cases responded rapidly to supportive treatment with bronchodilators and corticosteroids . More cases involving similar formulations of leather pmtectors have been reported. Emergency physicians should be aware of the potential acute pulmonary toxicity of leather protectors . REFERENCES 1 . Srttilatein MJ.lirton 8t . Keene W. Acute respiatury illness linked to use of aero,d Wall= condtiaer. AIAH4'R 3923,41 .965-967 2. Kuliy K Bmrt J . Philips S : Serve acute respiratory itlnoss tested m use of shoe spay MAlIN9! 13'D:42J1B5-B87 . 7_AlbredA WN. Bryant CJ: Polyim tunic to" associated wrlh snmting and use of a Niot7naleasu tpray corraumg potyretra&nmetlrylene. J QrruP MpJ 1987_23817-819 4. Woo OF. Nealy IN. Sheppard D: Chest pain and hYpoxmia from inhalation of a tKirikmetliane aerosol product- J Imriml LYIa laoiol 1993:20 :333 341 844 ANNALS OF EMER6ENCY MEDICINf 75 'n JUNE 1995