Nasal pathology and ultrastructure in patients with chronic airway inflammation (RADS and RUDS) following an irritant exposure

BACKGROUND

Reactive airways dysfunction syndrome is a chronic asthma-like condition developing after an acute irritant exposure, and chronic inflammation has been seen on endobronchial biopsy. Reactive upper-airways dysfunction syndrome is chronic rhinitis developing in temporal association with a toxic inhalation exposure, but the pathophysiology is unknown.

OBJECTIVES

To study biopsies of the nasal mucosa in patients with reactive upper-airways dysfunction syndrome and in some cases reactive airways dysfunction syndrome developing in temporal association with a chlorine dioxide exposure, to see if a histologic basis for the persistent rhinitis and sensitivity to chemical irritants could be determined.

METHODS

Specimens were stained with hematoxylin-eosin and immunoperoxidase stains for substance P, vasointestinal peptide, and S-100 (nerve fibers), and fixed in glutaraldehyde for electron microscopy. Biopsies of three nonexposed subjects were performed for comparison. A pathologist blinded to clinical data interpreted the specimens.

RESULTS

Inflammation ratings of exposed individuals were higher than for the nonexposed individuals. The number of nerve fibers stained was greater for patients vs controls. Substance P and vasointestinal peptide staining was nonspecific. Electron microscopy showed desquamation of the epithelium and permeability of epithelial cell junctions.

CONCLUSION

This study suggests a mechanism by which ongoing low level exposures perpetuate airway inflammation after an inducing toxic inhalation. A possible overlap between reactive airways dysfunction syndrome, reactive upper-airway dysfunction syndrome and the multiple chemical sensitivity syndrome is suggested.

The risk of aspiration in Dettol poisoning: a retrospective cohort study

1. To determine if the risk of aspiration is increased in 'Dettol' (4.8% chloroxylenol, pine oil and isopropyl alcohol) poisoning and the factors that may be responsible, a study was made of 89 patients and 89 matched control subjects with other forms of poisoning admitted to the Prince of Wales Hospital, Hong Kong. 2. Aspiration was more common in patients with Dettol poisoning (8% vs 3%, P = 0.16). There were more control subjects with drowsiness at presentation (54% vs 24%, P < 0.0001), but the use of gastric lavage (88% vs 64%, P < 0.001) and the occurrence of vomiting (62% vs 17%, P < 0.0001) were more common in patients with Dettol poisoning. 3. Our findings suggest that Dettol poisoning may be associated with an increased risk of aspiration. This increase in risk may be related to the use of gastric lavage and the common occurrence of vomiting in patients with Dettol poisoning.

Poisoning due to Savlon (cetrimide) liquid

1. Seven adult cases of deliberate oral exposure to 'Savlon' liquid (chlorhexidine gluconate 0.3%, cetrimide 3%) are presented. 2. In six patients, the symptoms were relatively mild including nausea, vomiting, sore throat and abdominal pain. 3. One patient who had concomitantly taken 'Dettol' liquid was comatose and hypotensive at presentation and was complicated by aspiration pneumonia and adult respiratory distress syndrome (ARDS). She was ventilated for a total of 10 days and was hospitalised for 5 weeks. 4. The data from this study suggest that symptoms associated with Savlon poisoning are usually mild. When aspirated, Savlon together with 'Dettol' liquid can cause ARDS.

Is chloroxylenol nephrotoxic like phenol? A study of patients with DETTOL poisoning

Chloroxylenol, a phenolic derivative commonly used as a household disinfectant, has similar, although lesser, toxic manifestations in comparison to phenol when ingested. The main objective of this study was to determine if chloroxylenol is nephrotoxic like phenol by studying 121 patients with DETTOL (4.8% chloroxylenol, pine oil, isopropyl alcohol) poisoning. Three patients (2.5%) developed renal impairment as evidenced by raised plasma urea and creatinine concentrations following ingestion of 200 to 500 ml of DETTOL. Two of these patients also had serious complications, including aspiration leading to pneumonia and adult respiratory distress syndrome, from which 1 died. The etiology of the renal impairment is likely a direct toxic effect of chloroxylenol on the kidneys and associated transient hypotension. Fortunately, renal impairment only appears to be a problem when relatively large amounts of DETTOL are ingested.

Serious complications associated with Dettol poisoning

Dettol is involved in 10% of self-poisoning-related hospital admissions in Hong Kong. Although serious poisonings and even deaths after ingesting this common household disinfectant have been reported, the frequency with which these complications may occur is not known. In a retrospective study of 67 cases of Dettol poisoning, we found that serious complications were relatively common (8%) and these included aspiration of Dettol with gastric contents resulting in pneumonia, cardiopulmonary arrest, bronchospasm, adult respiratory distress syndrome, and severe laryngeal oedema with upper airways obstruction. It is particularly important that the airways are adequately protected before the patient is lavaged following Dettol poisoning, and the immediate recognition of any upper airway obstruction requiring intubation will then be life-saving.

A five year evaluation of acute exposures to phenol disinfectant (26%)

A five year retrospective review of all exposures to a high concentration phenol disinfectant (Creolin Disinfectant 26% phenol) reported to a regional poison center located 96 cases, with 16 cases lost to follow up. There were 60 oral-only exposures, 7 dermal-only exposures and 12 oral/dermal exposure. One patient was an inhalation exposure. Fifty-two cases (65%) were evaluated in a hospital. Eleven patients with oral exposures (14%) experienced rapid CNS depression, but no seizures occurred. Vomiting, coughing, and stridor was noted in 14, 7 and 4 patients respectively. Burns were noted in 17 of 72 (24%) patients with oral exposure and 5 of 19 (26%) with dermal exposure. Seventeen patients underwent endoscopy. Tissue sloughing was noted in one case. All other burns were first degree. No cardiovascular complications occurred. Twenty-eight patients (35%) were followed at home via telephone with one episode of vomiting and one episode of dermal irritation occurring. CNS toxicity from exposure to a high concentration phenol containing cleaning product appears to be rapid in onset. The absence of serious toxicity and major chemical burns in this series does not eliminate concern with the corrosive and systemic risks of phenol poisoning.

Atopic allergy to chloramine-T and the demonstration of specific IgE antibodies by the radioallergosorbent test

Chloramine-T is a small molecular oxidizing agent that has been widely used as a disinfectant since the beginning of this century. It is generally used in a 5% solution but it is also supplied in powder form. Sporadic case reports of immediate-type sensitization to this agent associated with symptoms of asthma, rhinitis and urticaria have appeared during recent decades. In one of the reports, specific IgE antibodies in sera of four patients who developed asthmatic symptoms after exposure to chloramine-T were demonstrated using a radioimmuno-assay. Three cases of bronchial asthma in workers who had handled chloramine-T powder are described in the present report. Positive skin-prick test reactions to chloramine-T were observed and specific IgE antibodies to human serum albumin treated with chloramine-T were detected using the classic radioallergosorbent (RAST) technique in all three patients.

[Acute accidental poisoning with hospital disinfectant. 45 cases of which 13 with fatal outcome]

Airsane HP 800 is a disinfectant widely used in hospitals as a powder to be diluted in water. It mainly contains a mixture of quaternary ammonium compounds. Forty five cases of acute accidental poisoning with this product have been reported to the Paris Poison Centre. All the victims were mentally disturbed patients: 2 were young adults hospitalized in psychiatric units and the other 43 were old people hospitalized for senile dementia. All ingested the solid preparation which was left in their room by hospital workers who did not know it was dangerous. Corrosive burns of the mouth, pharynx, oesophagus and sometimes of the respiratory tract were produced in most patients. Thirteen of them died. All were old persons. Ten had inhalation pneumonitis and died of acute respiratory distress one hour to twelve days after taking the powder. Progressive deterioration was responsible for the death of the other three between the 19th and 40th days. These severe accidental poisonings could easily be prevented by a better information of hospital workers, and by storing the disinfectant and preparing the solution beyond the reach of patients.

Toxicology of household cleaning products and disinfectants

Hundreds of different household cleaning products are available in homes, presenting potential hazards to pets. These products are complex mixtures of chemicals that vary widely in their toxic potential. Prevention of toxicoses in companion animals follows the same guidelines as those recommended for children: Keep cleaning products out of the reach of pets, do not leave open containers or solutions of cleaning products unattended where animals may get into them, make sure containers of cleaning products are tightly sealed and properly labeled, and dispose of any cleaning solutions promptly after use. If a companion animal has ingested or spilled a cleaning product or disinfectant on itself, it is very important to assess the potential hazard to the animal promptly. Many products contain warnings regarding the corrosive or irritation potential of the product and instructions on the label for preliminary action in the case of accidental oral, dermal, or ocular exposures in humans. These instructions can generally be followed initially until further information on the product can be obtained, although the recommendations on some product labels may be outdated. In general, the clinical management for toxicoses caused by cleaning products and disinfectants involves the prevention of further contact with the concentrated product through either dilution or bathing; emergency stabilization of the patient if clinical signs are present; instituting specific therapies, if available; and use of general supportive care.

The toxicology of detergents, bleaches, antiseptics and disinfectants in small animals

Small animals are exposed to a variety of household products. The most common route of exposure is oral by direct ingestion or from grooming soiled fur and feet. The majority of household products are complex chemical mixtures. The clinician must determine the body burden of toxic or potentially toxic substances and the potential for a combination of chemicals to produce intoxication in a particular species and then plan a course of action. Toxicoses of selected household and commercial products are discussed in detail. Animals are exposed to a variety of antiseptics by numerous routes. Potential for iatrogenic intoxication from antiseptics is also discussed. An abridged version of this article will be published in the 10th edition of CURRENT VETERINARY THERAPY: SMALL ANIMAL PRACTICE, RW Kirk, editor, WB Saunders Co, Philadelphia, PA.

Fatal xylenol self-poisoning

A case of fatal xylenol ingestion by a long-stay mental hospital patient is described. The clinical course was similar to that observed in other phenolic poisonings with active bowel sounds, nausea and vomiting, severe metabolic acidosis, hypotension and cardiac and renal failure. The formulation of xylenol ingested contains alcohol which would facilitate absorption; due to the dangers of such poisonings care must be exercised as to access and exposure to xylenol sterilising agents.

[Poisoning by hypochlorite-containing disinfectants. A retrospective analysis of 594 cases of poisoning]

Hypochlorite-containing disinfectants or bleaching fluids, if inhaled, may lead to life-threatening poisoning (56% of moderately severe cases, 5% of severe cases) through the immediate liberation of chlorine gas, if they are used together with another cleansing fluid which is very acid. A rough estimate suggests that there must be about 700 cases of such poisonings per year in the Federal Republic of Germany. The characteristic symptom is a respiratory distress syndrome when the liberated chlorine gas is inhaled. Toxic pulmonary oedema and cardiovascular failure can occur if the poisoning takes a fulminating course.

Homicidal intoxications by lye- and parachlorcresol-containing disinfectants

In a nursing section for 54 senile, demented inpatients for the period of 3 months, a casual worker committed homicide in 11 cases and attempted homicide in 16 cases by peroral application of lye- and parachlorcresol-containing disinfectants. Autopsies had been performed in nearly all of the fatal cases without detection of the true causes of death. The fatal intoxications could be verified through reexamination of the lung slides and through gas chromatography/mass spectrometry of the formalin-fixed tissue specimens.