Document o6GB3JzbYMzqZ1yxLg81z077

II fk JAMA. Nov 5. 1973 Vol 226. No 6 Meat-Wrapper's Asthma A New Syndrome? William N. Sokol, MD; Yosscf Aelony, MD; Gilt on N. Ba!L MD Three patients employed as meat wrappers developed respiratory symptoms when exposed to the fumes of a polyvinyl chloride iiim cu` *th a hot wire. The patients were middle-aged women who smoked etcarises and demonstrated reversible airway obstruction on pulmonary tunc: zr. testing. The cause of their symptoms is not known, but some mgred iit of the polyvinyl chloride film is suspected. TTTTo have recently li'eattni V/t/ three patients who arc em > ployed as meal wrappers and who had severe respiratory proV lenis. In all three, the onset of res piratory difliculty followed cxjxisurc to fumes produced by cutting with a hot wire a plastic film made of the common polymet, polyvinyl chloride. Wc arc reporting these cases because wc suspect the phenomenon is not un common, yet it has not been re]virtcd previously in the medical literature. Report of Cases Case 1.--a 40-ycar-old woman who had worked ax a supermarket meat wrapper for ten ycirx without respiratory diflieully was first xcco in 1972. Following t!ic introduction of a new plastic film tu wrap the moat, she began tu cxiioricnce dys|>nea, coughing, and wheeling after lour to fra. the Dvp,rtfnrr.t of M.dicme (Hr- Sclnl. Aeleay. awl rvilll, I'srtor (ictu-rj' l|v.f.[t-.i. Torrance. CaM; and l:CLA Sch,l of Mnlttinc, lan Angrlrs (llr. U.-rll) Or. Mil fe> a r.** in Alters and tnnuuhok'gy and Ur. Artav a a fl*v in Itwpiraivry IWw at tiarlur (ill*, oral llwaiiuL Kririni rv,(Ut-ti* to Harbor Cmrral l(...|.ital, lonn W Chimhi At, Tonamr, CA So>H (or, (be tall. five hours uf work. She alt-ii-uivil l_!? re action to the fumes prn,*. seed ~-,h-* plastic film was cut wi:h a hoi i."? Her symptoms were most se.tr.* nr. .rays when the breathlessness r.'tci: [.*; -..ited her from completing the J.iy* *r A# the week progressed, her sympr. still occurred after four to i:v* .-.ours .: * rap ping. hut each day they St- T.etl to *.! -vast- in intensity. She had jr ,k] a .. s vi cigarettes each day fer It t but stnpiwd when her sympt- -~j K*g-iv There wax no iieriumal or foc*.-y h>-*.r-*y ,;* e.- tcnia. hay fever, or astign. T;*.t ;_i i-.nt wax first examined when r sever- - ; >s.e of wheeling forced her *.* Ivjv, At that time, rcsutix of phys* ji war. atlon were normal, except for a :'-** on-:- ;*.ra* lory whceicx and modcr-ie c\pirv.,.-y J-- by. Complete blood cell trrr.t. cr..**r.r*-*yic sedimentation rate, rnutir.t *'!.>-: :*-;--.tea! assays, urinalysis. VDI1L *.i-st .*...i.. and chest x-ray Sim wr; a::::1.-. *,.rs:ai limits. Skin u-su for a .-.'sins were all negative. Te;*-1 of i- - -ary function showed a mild*:. with a decreased vital .-er.ity .*_t in creased residual lung * ;s*. I**.-*;- i* e to hmnchudilator thcsaiy Treatment with uri'.y adr. " .-mil hrmichli|atr* rvlic<-r r.tr r *;: a;* She has been able to jrt*...i,: -.* *.- i ami continue working ! > * u.:aj * * -. Mcat-Wiapper's Aitnmi-i.-.j. ei - O .V '^ R&S 157039 ( V dilators orally each workday. Disrontinua- On returning to work, she developed trodaction of polyvinyl chloride and lion of thcrjpy u followed by recurrence wheezing and breathlessness, requiring had experienced no symptoms. . of wheezing and dyspnea at work, No med iation u requiroj in the evening or on '-- -reckcmU. Case 2--A 45-year-old >wiua experi enced dyspnea while working a* a super market meat w rapper. She had worked at this market for ten yean without respira tory difficulty until soon after a process rradmi--mn to huspilaL Her symptoms eventually developed after working hours and on weekends. Believing that her res piratory problem was related to the plastic fumes, she quit her job. In the ensuing two years, she has developed uonseasonal wheezing, shortness of breath, and cough ing. punctuated by upper respiratory in The time required fur development of symptoms was brief (30 minutes) in patients 2 and 3 and was delayed (five hours) in patient 1. In patient 3, symptoms eventually occurred inde pendently of fume exposure, and she now has chronic dyspnea and pro was introduced to wrap the meat in a plas fections. She currently develops one-flight duces sputum. Patients 1 and 2 have tic Aim cut with a hot wire. While wrap dyspnea and pruduecs one quarter of * cup symptoms only on exposure to the ping, the patient noted the gradual onset of sputum daily for approximately four plastic fumes. All three patients of breatldessness and wheeling, and she was forced to leave work. She felt well but did not work for the next six months. On returning to meat wrapping, she developed shortness of breath and wheezing within 30 minutes. The dyspnea became so dis turbing that she came to hospital emer gency room. months nf the year. The patient smoked one pack of cigarettes per day for nine years, but she stopped smoking when her present illness began. History showed a contact dermatitis but no previous history of hay fever, rhinitis, or asthma. Her family history is negative for atopy or asthma. smoked cigarettes (10 to 2C years) be fore their illnesses, and all three had reversible airway obstruction on pul monary function testing. None -dem onstrated - peripheral cosinophilia, reactions to common allergens ad ministered by intracutancous skin The `patient had smoked a pack of ciga The remits of physical examination testing, rocntgenographic abnormal rettes a day fur 36 yean. Her family his were within normal limits, except for her ities, or marked personal or family tory and personal history were negative for asthma, hay fever, eczema, or atopy. Results of physical examination (five hours after leaving work) were normal. Complete blood cell count, erythrocyte sedimentation rale, routine blood determi nation, latex fixation, VDltL test for sy phiiis, and chest x-ray film were within nor mal limits or negative. Skin tests with common allergens were negative. Pulmo- chest, which showed scattered wheezes on expiration and persixteni bibasilar crepi tant rales. * Laboratory tests including a complete blood roll count, erythrocyte sedimentation rate, VDRI, test for syphilis, and routine blood chemistries were within normal lim its. An x-ray film of the chest showed mild overinflation, with apical capping of both upper lolics. Histoplasmin and inter- history of atopy. We do not know the frequency of this syndrome, but wc suspect it is not rare. The first patient told us about the second patient. The third patient came independently but has told us about a co-worker (whom wc have not seen) who has suffered sim ilar symptoms apparently from expo xnr function foting showed a de-r-ased mrdia'c-sirengih tubercu'ir. tests were sure to the polyvinyl chloride film. Wc V__ jaxfmal expiratory flow rate that im proved with bronchodilation. The patient was given lironcliodilators orally to take , frophylaeticatly. Using this medication, she has been able to WTap meat inter mittently without any respiratory symp toms. She is asymptomatic after work and on weekends, requiring no medications at those times. Case 3.-A 54-ycar-otd woman had a negative. A eccvidkiidia skin tost gave 10 mm of induration at -IS hours. Intradermal tests to common allergens were negative. Pulmonary function studies showed a de creased vital capacity and an increased functional residual capacity. The forced vi tal capacity responded to bronchodilation. Nitrogen washout was increased to 4.C% retention after seven minutes of oxygen breathing, with a normal of <2%. have learned from local physicians of two other patients with similar his tories. Unfortunately, wc have not been able to study these patients. The manufacturer of the polyvinyl chloride film used by these meat wrappers has informed us that liecause of previous rc|>ortx from several cities of respiratory problems associ three-year history of intermittent wheez ing and coughing. Her illness began six Comment ated with polyvinyl chloride fumes produced in the meat wrapping pro yean after she started working in a super These three case reports strongly cess, an investigation of the matter market as a meat wrapper. A few weeks before her symptoms commenced, the wrapping material was changed to a plas tic film, which she cut with a wire h--ated to 161 C Many people working in the area Complained of the fumes produced when the film was cub One of her co-workers was unable to wear his contact lenses nesr the fumes, and another developed couch suggest that a causal relationship ex ists between the inhalation of plastic fumes and respiratory symptoms. In each instance, the plastic film was polyvinyl chloride made by the same manufacturer. All patients had worked in similar areas and had no respiratory symptoms wrapping meat has already been completed. The in vestigation, in which polyvinyl chlo ride film was pyrolyxed and the resulting gases identified nnd quanti tated, concluded that these fumes did not present any liazard to meat wrap pers. Other investigators, however, have ing when exposed to the fumes. Thirty with other materials for six to ton suggested that polyvinyl chloride minutes a.'lcr first inhaling these fumes, years prior to the use of the polyvinyl does have toxic |olciiliaiitics. (loess the patient noted tightness in her chest, followed by wheezing, shortness of i-rcuth. and coughing. Her symptoms improved af ter moving away from the fumes hut re turned on ree\|n<Mire. She denied having tdarhc, chills, fever, or sore thmab In k -__ c nest nine months, she continued to ex perience dillirully only during working hours. During one severe episode, she was chloride film. In each patient, symp toms occurred only after cxjmxurc to the polyvinyl chloride fumes. The areas where the meat was wrapped were rather crowded, without special ventilation for fume removal, and were chilled to approximately 11 C. The patients had worked in these and Hnlwrmaii' implanted polyvinyl chloride stivers into rahhit muscle, which resulted in an unusual numlier of eosinophils in a forcign-lrody gran uloma with numerous giant cells, while the control |dastie (|m!ycthy|cne) showed only the usual nontoxic, nonvusinophtlic-cottlaining, foreign- hospitalized for pneumonia ami asthma. same areas, however, before the in- IhmIv reaction. In addition, pure poly- <40 JAMA, Nov 5. 1973 Voi 226. No 6 Meal-Wrapper's Asthma--Sokol et *1 R&S157040 vinyl chloride resin destroyed cells in in vitro cultures. The rell culture inhibilion experiments have been inde pendently confirmed.-' There is some evidence that the eusinophil-rieh for* eign-body reaction noted by Guess and Haberman may be seen in hu mans. Stcnilc et al` desrrihed a 31year-old factory employee who shov eled polyvinyl chloride dust. His chest roentgenogram showed many minute nodulcvalong with an inter stitial Fibrotie pattern. Lung biopsy specimens showed a foreign body sur rounded by a granuloma, with strik ing cosinophilia. The foreign body eould be dissolved with a polyvinyl chloride solvent, eyclohexanol. Jhc problem posed by our patients is whether fumes generated from healed polyvinyl chloride arc toxic. Cornish and Abar* pyrolized polyvinyl chloride polymers in a stream of air by gradually raising the temperature from ambient to fiOO C. Exposure to this air stream supplemented with oxygen produced pulmonary edema and interstitial edema in rats. Some animals also showed focal bronchial and intra-alveolar hemorrhage. It is doubtful, however, if this level of ex posure was ever experienced by our patients. Our patients resemble somewhat those individuals, first descriltcd by Harris,1 who experienced respiratory difficulty when cxjioscd to heated Tef lon. This syndrome has been called polymer fume fever. The symptoms include attacks of tightness of the chest, difficulty in breathing, some times with a dry. irritating cough, and fever licginning several hours af ter e\|isurc to the hral-degradation products of pnlytetraffuurocthylcnc (Teflon). Recovery is rapid and usu ally cimplclc. The patients who de velop this syndrome work in plants where jmlytctralluoroelhylenc is pro cessed, and smoke cigarettes. The plastic adheres to the cigarclt" and is given oir when heated to > 300 C as a very fine particulate sublimate. The syndrome is thought to lie due to the inhalation of this sublimate.*"* Our patients differed from those with polymer fume fever by not expe riencing chills, fever, or sore throat. This example of a polymer-fume-relatcd syndrome, coupled with the evi dence that polyvinyl chloride may have some toxic potential strengthen our suspicion that the patients' symp toms are caused by exposure to the polyvinyl chloride fumes. Cornish and Abar' have reported that carbon monoxide and hydrochlo ric acid are the products of major tox icologic importance from the combus tion of vinyl chloride polymer. O'Mara et at* in describing the combustion profile of vinyl chloride monomer, noted phosgene as well as hydrochlo ric acid and carbon monoxide. Hydro chloric acid and phosgene are both bronchial irritants that could conceiv ably cause the patients' symptoms. Conclusion Although the cause of the syn drome is unclear and we have on1} tie-. scrilml three eases. it seem.- advi-aldc to call this matter In general atten tion to gain some idea of its preva lence and to inform physician- and their patients of the potential hazard of fumes from ixdyvinyl chloride Reference* l- Cm W, llittmu & et vinyl *nd |Wi|yJt:iDir |itatir ;nJ th**:r aJli* lives. J BmmmJ Mi1* t fit* WlJuist, & Diaman osteolyb. Afik et *1. O.v:^:iof.k. wvro- //.miu. 1/71. & &x*odc F. et ai: wj -ro br ike inhalation of ptlyvinvkilx-ndv dti?- M\U Lnrtl.i&XW,, l*7</. 4, Cornish 11. A^r & TpUlHiv of product* of vind piauin. An* Lm*. iron 19:15*21.IMS. i Htniv Uls; Fdyiwofvsw fever. L*wrf Ini!. ft. Wilbomu K. >miih KK: r^ymer-fc^r fercr.JAMA 219:1 U7-15KL U72. 7. Lewis CL. Kerby CR: A* vjvdt*nic mer-fumc fever JAMA IfrltfTV?;*, ls**i* ft. I'otymer fume fever, cdi'.tTial, Ldr<- *2% 2ft. 1972. 9. O'Mora AID. Crider LR. Daniel KL vVm* bullion product* from vinyl fV.^ride r. :r.:mer. Am fitdJigg A*** J 3\b3r\>'\ W71. CORRECTION Wrong Pollution.--T*'.' crjv.r* uurrud in kvuUu .Uin v --.r amachams juge of the 17 (225:1435. 1973). The title of the booLUn on p-.-llj- tion should have been p:wn ns "Tr.e Pbytteian'* Guide to Ouor JY..l> lion," not air pollution r^ragRicr. Ii or water pollution tpar^^rnph 3 . JAMA. Nov S. 1973 Vol 226. No 6 Meat-Wrapper's Ailhmj-Sw^Ol et jt 641 noto