Current diagnostic methods for diisocyanate induced occupational asthma

New Method to Biomonitor Workers Exposed to 1,6-Hexamethylene Diisocyanate

Isocyanates such as 1,6-hexamethylene diisocyanate (HDI), 4,4'-methylenediphenyl diisocyanate, and toluene diisocyanate are highly reactive compounds that have a variety of commercial applications, including manufacturing polyurethane foam, elastomers, paints, adhesives, coatings, insecticides, and many other products. Their primary route of occupational exposure is through inhalation. Due to their high chemical reactivity, they are toxic and have adverse effects at the cellular and subcellular levels, leading to irritative and immunological reactions associated with lung disease. High concentrations of isocyanates are strong respiratory irritants. Bronchial sensitization and asthma are among the major adverse clinical reactions associated with low-level chronic exposure to isocyanates. Albumin adducts have been linked to the mechanism of occupational asthma caused by isocyanates. Isocyanates react in vivo with albumin, which is recognized by the immune system. Albumin adducts of isocyanates trigger immune responses and are probably the antigenic basis for isocyanate asthma. Sensitization to isocyanates is the main pathway for adverse health effects. Therefore, markers for the biologically effective dose such as albumin adducts of HDI are needed. A new isocyanate adduct of HDI with lysine─N^ε-[(6-amino-hexyl-amino)carbonyl]-lysine (HDI-Lys)─was synthesized and characterized by ¹H-NMR, ¹³C-NMR, and mass spectrometry (MS). Appropriate internal standards─HDI-Lys-4,4'-5,5'-d₄ (HDI-d₄-Lys) and N^ε-[(7-amino-heptyl-amino)carbonyl]-lysine (Hep-Lys)─were synthesized to establish a LC-MS/MS method for the analysis of HDI adducts in in vitro modified albumin and in workers. The presence of HDI-Lys was found after pronase digestion of albumin and confirmed by two independent chromatographic approaches: with a C8 reversed-phase column and with a hydrophilic interaction liquid chromatography column. Quantification was performed with positive electrospray ionization (ESI)-MS. The adduct peak found in vivo was confirmed with the less sensitive negative ESI-MS. In summary, these are new compounds and methods to determine isocyanate-specific adducts with albumin in workers exposed to HDI.

Medical Monitoring for Occupational Asthma Among Toluene Diisocyanate Production Workers in the United States

OBJECTIVE

The aim of this study was to describe a study of medical monitoring methods and lessons learned in detecting health outcomes in U.S. plants producing toluene diisocyanate (TDI).

METHODS

A multidisciplinary team implemented a medical and environmental monitoring program in three TDI plants.

RESULTS

Of 269 eligible workers, 197 (73%) participated and 42 (21%) met symptom and/or lung function criteria that would trigger evaluation for possible asthma over 5 years of data collection. Subsequent evaluation was delayed for most, and a web-based data collection system improved timeliness.

CONCLUSION

Medical monitoring of TDI workers identified workers triggering further assessment per study protocol. Systems and/or personnel to ensure rapid follow-up are needed to highlight when triggering events represent potential cases of asthma needing further evaluation. Implementation of a research protocol requires resources and oversight beyond an occupational health program.

Genetic variants with gene regulatory effects are associated with diisocyanate-induced asthma

BACKGROUND

Isocyanates are major causes of occupational asthma, but susceptibility and mechanisms of diisocyanate-induced asthma (DA) remain uncertain.

OBJECTIVE

The aim of this study was to identify DA-associated functional genetic variants through next-generation sequencing (NGS), bioinformatics, and functional assays.

METHODS

NGS was performed in 91 workers with DA. Fourteen loci with known DA-associated single nucleotide polymorphisms (SNPs) were sequenced and compared with data from 238 unexposed subjects. Ranking of DA-associated SNPs based on their likelihood to affect gene regulatory mechanisms in the lung yielded 21 prioritized SNPs. Risk and nonrisk oligonucleotides were tested for binding of nuclear extracts from A549, BEAS-2B, and IMR-90 lung cell lines by using electrophoretic mobility shift assays. DNA constructs were cloned into a pGL3 promoter vector for luciferase gene reporter assays.

RESULTS

NGS detected 130 risk variants associated with DA (3.1 × 10^-6 to 6.21 × 10^-4), 129 of which were located in noncoding regions. The 21 SNPs prioritized by using functional genomic data sets were in or proximal to 5 genes: cadherin 17 (CDH17; n = 10), activating transcription factor 3 (ATF3; n = 7), family with sequence similarity, member A (FAM71A; n = 2), tachykinin receptor 1 (TACR1; n = 1), and zinc finger and BTB domain-containing protein 16 (ZBTB16; n = 1). Electrophoretic mobility shift assays detected allele-dependent nuclear protein binding in A549 cells for 8 of 21 variants. In the luciferase assay 4 of the 21 SNPs exhibited allele-dependent changes in gene expression. DNA affinity precipitation and mass spectroscopy of rs147978008 revealed allele-dependent binding of H1 histones, which was confirmed by using Western blotting.

CONCLUSIONS

We identified 5 DA-associated potential regulatory SNPs. Four variants exhibited effects on gene regulation (ATF rs11571537, CDH17 rs2446824 and rs2513789, and TACR1 rs2287231). A fifth variant (FAM71A rs147978008) showed nonrisk allele preferential binding to H1 histones. These results demonstrate that many DA-associated genetic variants likely act by modulating gene regulation.

Comparison of biological effects with albumin adducts of 4,4'-methylenediphenyl diisocyanate in workers

Lung sensitization and asthma are the main health effects of 4,4'-methylenediphenyl diisocyanate (MDI). Albumin adducts (isocyanate-specific adducts) of MDI might be involved in the etiology of sensitization reactions. Albumin adducts of MDI were analyzed in sera of diisocyanate-exposed worker with and without diisocyanate occupational asthma (DA), as well as in exposed workers with and without diisocyanate-specific IgG antibodies. In DA-positive workers and IgG-positive workers, albumin adducts were significantly higher versus workers without DA and those who were specific IgG negative. The odds ratio to be DA-positive was 57 times larger for workers with adduct levels above 230 fmol/mg. The odds ratio to be IgG-positive was 10 times larger for workers with adduct levels above 113 fmol/mg. Therefore, albumin adducts appear to be a good predictor of the biological effects. The albumin-adduct levels in workers without biological effects were in the range of the adduct levels found in previous studies of healthy MDI-factory and construction site workers.

Is the analysis of histamine and/or interleukin-4 release after isocyanate challenge useful in the identification of patients with IgE-mediated isocyanate asthma?

Isocyanates are a well-known and frequent cause of occupational asthma. The implementation of specific inhalation challenges (SICs) is the gold standard in asthma diagnosis supporting occupational case history, lung function testing, specific skin prick tests and the detection of specific IgE. However, the diagnosis is not always definitive. An interesting new approach, analyses of individual genetic susceptibilities, requires discrimination between a positive SIC reaction arising from IgE-mediated immune responses and one from other pathophysiological mechanisms. Hence, additional refinement tools would be helpful in defining sub-classes of occupational asthma and diagnosis. We used total IgE levels, specific IgE and SIC results for sub-classification of 27 symptomatic isocyanate workers studied. Some mutations in glutathione S-transferases (GSTs) are suspected either to enhance or to decrease the individual risk in the development of isocyanate asthma. Our patient groups were assessed for the point mutations GSTP1*I105V and GSTP1*A114V as well as deletions (null mutations) of GSTM1 and GSTT1. There seems to be a higher risk in developing IgE-mediated reactions when GSTM1 is deleted, while GSTT1 deletions were found more frequently in the SIC positive group. Blood samples taken before SIC, 30-60 min and 24h after SIC, were analyzed for histamine and IL-4, classical markers for the IgE-mediated antigen-specific activation of basophils or mast cells. We suggest that the utility of histamine measurements might provide an additional useful marker reflecting isocyanate-induced cellular reactions (although the sampling times require optimization). The promising measurement of IL-4 is not feasible at present due to the lack of a reliable, validated assay.

Exposure to airborne particles and volatile organic compounds from polyurethane molding, spray painting, lacquering, and gluing in a workshop

Due to the health risk related to occupational air pollution exposure, we assessed concentrations and identified sources of particles and volatile organic compounds (VOCs) in a handcraft workshop producing fishing lures. The work processes in the site included polyurethane molding, spray painting, lacquering, and gluing. We measured total VOC (TVOC) concentrations and particle size distributions at three locations representing the various phases of the manufacturing and assembly process. The mean working-hour TVOC concentrations in three locations studied were 41, 37, and 24 ppm according to photo-ionization detector measurements. The mean working-hour particle number concentration varied between locations from 3000 to 36,000 cm⁻³. Analysis of temporal and spatial variations of TVOC concentrations revealed that there were at least four substantial VOC sources: spray gluing, mold-release agent spraying, continuous evaporation from various lacquer and paint containers, and either spray painting or lacquering (probably both). The mold-release agent spray was indirectly also a major source of ultrafine particles. The workers’ exposure can be reduced by improving the local exhaust ventilation at the known sources and by increasing the ventilation rate in the area with the continuous source.

Diagnosis and prevention of diseases induced by isocyanate

Isocyanates are among the most frequent causes of occupational asthma in industrialized countries. Early diagnosis of diisocyanate asthma followed by prompt termination of chemical exposure can prevent chronic morbidity due to persistent asthma. Chronic exposure to isocyanates also induces hypersensitivity pneumonitis (HP). The accurate diagnosis of diisocynate asthma requires a systematic approach that combines information obtained from the occupational history, immunologic tests and physiologic studies. The prevention of health problems from toluene diisocyanate (TDI), 4,4'-methylenediphenyl diisocyanate (MDI) and 1,6'-hexamethylene diisocyanate (HDI) is essential for all those handling the chemicals. Regulatory exposure limits should be observed. However, wheezing, coughing or even asthmatic attacks may occur after exposure much below the regulatory exposure limits especially in sensitive individuals. Preventing or minimizing exposure is of prime importance and should be supported by the installation of engineering controls, by education of the workforce, by regular monitoring of the workplace exposure and by medical surveillance. To prevent such asthma it is suggested that workers should be tested airway sensitivity and should avoid working in areas that have dust containing specific-IgE. Such tests must be periodically performed after working. Symptoms induced by isocyanate need earlier discover and early isolation of the associated individuals.

PTEN as a unique promising therapeutic target for occupational asthma

The tumor suppressor phosphatase and tensin homologue deleted on chromosome ten (PTEN) dephophorylates phosphatidylinositol 3,4,5-triphosphate (PIP3) and is a key negative regulator of phosphoinositide kinase-3 (PI3K) signaling pathway. PTEN also suppresses cellular motility through mechanisms that may be partially independent of phosphatase activity. PTEN is one of the most commonly lost tumor suppressors in human cancers, and its down-regulation is also implicated in several other diseases including airway inflammatory diseases. There is increasing evidence regarding the protective effects of PTEN on the bronchial asthma which is induced by complex signaling networks. Very recently, as for the occupational asthma (OA) with considerable controversy for its pathobiologic mechanisms, PTEN has been considered as a key molecule which is capable of protecting toluene diisocyanate (TDI)-induced asthma, suggesting that PTEN is located at switching point of various molecular signals in OA. Knowledge of the mechanisms of PTEN regulation/function could direct to the pharmacological manipulation of PTEN. This article reviews the latest knowledge and studies on the roles and mechanisms of PTEN in OA.

Occupational asthma caused by sculptured nails containing methacrylates

BACKGROUND

In recent decades, the use of artificial nails including methacrylates (MAs) has increased. This study presents the first two clinical cases of occupational asthma (OA) caused by sculptured nails containing MAs.

METHODS

In both cases, OA was diagnosed on the basis of a work simulation test combined with the patient's history of occupational exposure and respiratory symptoms.

RESULTS

Both patients developed work-related respiratory symptoms 4-5 years before the current examinations. Previously, the first patient (a 30-year-old female) was diagnosed as having allergic contact dermatitis (ACD) to MAs; the second patient (a 27-year-old female) had no skin symptoms. In both cases, a dual asthmatic reaction was observed in the bronchial provocation test, in which the patients simulated their work using their own products including MAs.

CONCLUSIONS

Sculptured nails containing MAs can induce OA in nail technicians. Products not containing MAs should be used to prevent OA and ACD. If MAs are used, they should be handled with appropriate safety measures.

Issues in diisocyanate antibody testing

Diisocyanates are used to produce a wide variety of polyurethane products; they are also recognized as an important cause of occupational asthma. Their chemical reactivity presents challenges to toxicologists and clinicians alike seeking to understand the mechanisms underlying diisocyanate asthma. In this article, we review the literature on immunoassay detection of IgE and IgG binding to diisocyanate-protein conjugates and assess the utility of such testing as a diagnostic tool and exposure indicator. Data from 29 studies of occupational exposure to diisocyanates revealed considerable variability in assay methodology and heterogeneity in the prevalence of positive antibody responses across laboratories. In studies that included both confirmed diisocyanate asthma subjects and exposed nonasthmatics, positive IgE responses identified cases with low sensitivity (18-27%), but high specificity (96-98%). Detection of IgG binding to diisocyanate conjugates is an indirect, qualitative indicator of disease status and past diisocyanate exposure. The utility of these assays is limited, however, due to a lack of (1) method standardization, (2) population norms to guide interpretation of results, and (3) demonstration that the assays improve either on disease prediction or on exposure confirmation beyond that of other indicators. Sources of assay heterogeneity are discussed and suggestions are offered for improving test performance and interpretability.

Diisocyanate asthma and gene-environment interactions with IL4RA, CD-14, and IL-13 genes

BACKGROUND

Diisocyanate asthma (DA) affects 2% to 10% of exposed workers, yet the pathogenetic mechanisms underlying this disorder remain ill defined.

OBJECTIVE

To determine if specific single nucleotide polymorphisms (SNPs) of interleukin 4 receptor alpha (IL4RA), IL-13, and CD14 promoter genes are associated with DA.

METHODS

Sixty-two workers with DA confirmed by specific inhalation challenge (SIC) and 75 diisocyanate-exposed, SIC-negative workers were analyzed for SNPs associated with IL4RA, IL-13, and CD14 promoter genes.

RESULTS

No associations were found with individual SNPs and DA. When stratified according to specific diisocyanate exposure, a significant association was found between IL4RA (I50V) II and DA among individuals exposed to hexamethylene diisocyanate (HDI) (odds ratio [OR], 3.29; 95% confidence interval [CI], 1.33-8.14; P = .01) only. Similarly, the IL4RA (I50V) II and IL-13 (R110Q) RR combination was significantly associated with DA in HDI-exposed workers (OR, 4.13; 95% CI, 1.35-12.68; P = .01), as was the IL4RA (I50V) II and CD14 (C159T) CT genotype combination (OR, 5.2; 95% CI, 1.82-14.88; P = .002) and the triple genotype combination IL4RA (I50V) II, IL-13 (R110Q) RR, and CD14 (C159T) CT (OR, 6.4; 95% CI, 1.57-26.12; P = .01).

CONCLUSIONS

Gene-environmental interactions may contribute to the pathogenesis of DA, and gene-gene interactions may modulate this relationship.

Host factors in occupational diisocyanate asthma: a Swiss longitudinal study

OBJECTIVE

To investigate the usefulness of surrogates for individual susceptibility to organic diisocyanates in occupational asthma.

SUBJECTS

All new cases declared to the Swiss National Accident Insurance Company (SUVA) for establishment of a case for compensable occupational disease during 1993. Sixty-nine persons, of whom three were women, were suspected of having occupational asthma due to isocyanates. Of these, 47 subjects fulfilled the criteria to be accepted as an occupational disease case.

METHODS

All subjects were studied clinically and gave a blood sample for the phenotyping of their alpha-antitrypsin status and for immunological studies. The subjects were also given a peroral dose of caffeine for the determination of their N-acetylation capacity. Finally, those with an occupational disease were subjected to the methacholine provocation test.

RESULTS

Forty-four persons with occupational disease, out of 47, were heterozygous antitrypsin carriers and/or slow acetylators of primary amines. In the bronchial provocation with methacholine, 12 of these subjects had an unaltered response and seven had a mild reaction, 13 a moderate one and 15 a severe reaction.

INTERPRETATION

The study confirms the finding that slow N-acetylators are susceptible to asthma from exposure to common diisocyanate monomers at work. The same applies to heterozygous antitrypsin-phenotype carriers. Thus, the use of these markers may reinforce the diagnostic procedure, but they cannot completely replace the immunological tests.

Airborne concentrations of methylene diphenyl diisocyanate (MDI) in North American wood mills during the manufacturing of oriented strand board (OSB)

Air monitoring data were collected from industrial hygiene surveys over an 8-year period in oriented strand board (OSB) mills. Personal samples were taken to evaluate potential employee exposures to MDI. Area samples were taken to determine the effectiveness of control measures used in the mills to prevent fugitive emissions of wood dust, MDI, and MDI-coated wood dust from the OSB manufacturing process. Personal sampling results (578 samples covering 11 different job categories) ranged from 0.0002-0.524 mg/m3, with a GM = 0.001 and GSD = 3.71. Area sampling results (1657 samples covering 14 stationary locations in the mills) ranged from 0.0002-2.5 mg/m3, with a GM = 0.004 and GSD = 5.52. The statistical range of the data suggests high variability. While exposures to MDI above the established limits (0.051 mg/m3, 8-hour time-weighted average, 0.2 mg/m3, ceiling) can and do occur when engineering controls are not maintained and/or proper work practices and personal protective equipment are not followed/used for certain high exposure potential tasks, the data indicate that over 97% of the personal and 92% of the area sampling results are less than 0.051 mg/m3. Wipe testing was performed to determine the presence of removable, unreacted diisocyanates (NCO functional groups)from various surfaces. Positive results were found in about 13% of the wipe tests on surfaces confined to the blender, forming line, and hopper deck process areas.

Animal models for diisocyanate asthma: answers for lingering questions

PURPOSE OF REVIEW

Diisocyanates are the leading cause of occupational asthma, the most commonly reported lung disease associated with the workplace. Clinical studies have implicated the immune system in the pathogenesis of occupational asthma, but ethical and moral issues prevent mechanistic investigations in humans. For this reason, the development and characterization of animal models are germane to further understanding of diisocyanate occupational asthma and to identify avenues for therapeutic intervention. This review will highlight important features of existing experimental animal models with emphasis on new developments.

RECENT FINDINGS

Experimental animal models of diisocyanate occupational asthma have demonstrated an immunological basis for the disease. Mice can be sensitized by dermal or respiratory exposure, suggesting that either exposure route may be important in the workplace. Recent findings show that sensitized mice develop airway hyperreactivity and inflammation, reflective of human disease. The transfer of lymphocytes or serum from sensitized mice can cause clinical disease in naive mice. Transgenic animals have identified a role for specific immunity, including the involvement of T-helper type 1/2 responses as well as CD4 and CD8 T cells in diisocyanate occupational asthma. Recent animal models have shown that sensitization can occur through subchronic inhalation of vapor-phase diisocyanate at levels as low as 20 ppb.

SUMMARY

Recent progress using animal models has been instrumental in furthering current understanding of the involvement of the immune system in disease pathogenesis. The demonstration of diisocyanate occupational asthma in a murine model after sub-chronic inhalation exposure at relevant exposure levels should provide opportunities for more accurate risk assessment data.

Symptom onset in the first 2 years of employment at a wood products plant using diisocyanates: some observations relevant to occupational medical screening

BACKGROUND

Questionnaires are essential tools for medical screening, but their role in monitoring workers at increased risk of occupational asthma (OA) remains indeterminate.

METHODS

Employees who were at a newly established wood products plant without previous exposure to methylene diphenyl diisocyanate (MDI) completed an initial questionnaire and from one to four follow-up questionnaires during a 2-year period. Onset of symptoms in 132 workers was assessed by exposure groups and modeled using generalized estimating equations.

RESULTS

Onset of attacks of dyspnea with wheeze, attacks of dyspnea or cough at rest, and chest tightness were significantly associated with MDI exposure after controlling for age, smoking, and wood dust exposure. Onset of cough on most days was significantly related to smoking and dust. Onset of phlegm production was significantly related to both MDI and dust exposure.

CONCLUSIONS

Onset of certain symptoms is significantly associated with MDI exposure. Early detection of MDI-associated health effects using a short screening questionnaire appears feasible.

[Dermatologic occupationally relevant type I allergies]

In Germany the most frequent initial report of occupational disease is due to occupational skin diseases ("Berufskrankheitenanzeige nach Nr. 5101 der Berufskrankheitenverordnung") defined as "severe or recurrent skin diseases that force the discontinuation of any activity that causes or that could be causing the development, the worsening, or the recurrence of the skin disease". The majority of these occupational skin diseases consists of irritant and allergic contact dermatitis. In contrast, work place- related Type I allergy (contact urticaria syndrome) is less frequent, but carries the risk of systemic reactions. The clinical manifestations and pattern of exposure to Type I allergens in the work place are described.

What can we learn about asthma from studying occupational asthma?

OBJECTIVE

To review the clinical features and underlying mechanisms of occupational asthma in an attempt to glean insights into various other forms of asthma.

DATA SOURCES

Published literature, including consensus guidelines on diagnosis and management of occupational asthma.

STUDY SELECTION

This article represents a synthesis of these data sources and the opinion of the author.

RESULTS

Occupational asthma may be caused by a variety of mechanisms, including both IgE-dependent and non-IgE-dependent immunological processes. IgE-dependent mechanisms are responsible for reactions to all high-molecular-weight occupational antigens and to some but not all low-molecular-weight antigens. Factors in sensitization and onset include the general genetic predisposition to make IgE and the specific responsiveness of the individual to particular allergens. Once sensitized, the main factor that influences the onset of symptoms is the degree of exposure. In general, the higher the level of exposure, the more likely the sensitized person is to develop asthma.

CONCLUSIONS

Occupational asthma can be induced by a variety of agents that appear to use different mechanisms to affect the airway. Studies of the remission of occupational asthma indicate that resolution is a slow process. However, the study of occupational asthma may eventually allow us to identify treatments that will accelerate remission or induce remission in other forms of asthma.

Differential roles for CD4 and CD8 T cells after diisocyanate sensitization: genetic control of TH2-induced lung inflammation

BACKGROUND

Exposure to diisocyanates is a major cause of occupational asthma. We previously developed a novel mouse model of diisocyanate-induced asthma involving epicutaneous sensitization to hexamethylene diisocyanate (HDI) that demonstrates many features of the human disease, including airway eosinophilia and mucus hypersecretion.

OBJECTIVE

To determine what factors are critical for the development of HDI-induced airway inflammation, we investigated the strain distribution of this response and the roles of CD4(+) and CD8(+) T cells.

METHODS

Mice were epicutaneously exposed to HDI and then challenged with HDI, either by means of inhalation to induce airway inflammation or on the ear to induce contact hypersensitivity (CHS). Lymph node cytokine production and serum antibodies were also measured.

RESULTS

Induction of airway eosinophilia was highly dependent on the mouse strain used, with C57BL/6, A/J, CBA, C3H, and C57BL/10 mice all having significantly fewer eosinophils than BALB/c mice. HDI-specific antibodies and lymph node IL-5 and IL-13 production were also diminished in non-BALB/c strains. In contrast, CHS to HDI developed in all strains tested. Studies in mice deficient in either CD4(+) or CD8(+) T cells revealed that CD4(+) T cells were critical for HDI-induced airway eosinophilia, whereas CD8(+) T cells were the major effector cells in CHS.

CONCLUSION

The data suggest that, in contrast to CHS, induction of T(H)2 responses after epicutaneous exposure to diisocyanates is strongly genetically influenced. Furthermore, the lung inflammatory response to inhaled HDI appears to depend primarily on effective generation of these CD4(+) T(H)2 responses, as is the case in atopic asthma.

Occupational asthma caused by exposure to low-molecular-weight chemicals

Chemical agents cause approximately 40% of cases of occupational asthma (OA). Diagnosis of OA caused by chemicals relies on the demonstration of decrements in lung function at the workplace or during a controlled specific inhalation challenge to the suspect chemical agent. Evaluation of workers is accomplished best with a stepwise algorithmic approach and while the worker is symptomatic and still exposed at work. An early diagnosis followed by cessation of exposure can result in asthma remission and is likely to prevent progression to chronic disabling obstructive disease.

Recent developments in diisocyanate asthma

OBJECTIVE

To summarize the latest experimental findings on diisocyanate asthma and discuss the impact of these data on our understanding of disease pathogenesis and diagnosis.

DATA SOURCES

The literature reviewed includes articles from PubMed (National Library of Medicine) published within the last 3 years (1999-2001). In addition, pertinent older references are discussed to provide a historical perspective and background.

STUDY SELECTION

The data discussed were chosen to highlight key concepts relevant to diisocyanate asthma pathogenesis and are grouped accordingly.

RESULTS

In many ways, diisocyanate-induced asthma mirrors allergic asthma caused by other stimuli; however, the immune-mediated pathways believed to be central to the disease have been difficult to define. Recent studies on the human immune response to diisocyanates provide additional evidence supportive of an immune basis for pathogenesis but also highlight well-recognized differences between diisocyanate asthma and common atopic asthma. Studies on the antigenic form of diisocyanates and their interaction with epithelial tissues provide new insights that may help explain these apparent immunologic differences. Genetic factors that influence disease have begun to be identified but remain poorly characterized. Associations of particular major histocompatibility complex class II alleles with diisocyanate asthma further fuel the hypothesis that immune-dependent mechanisms underlie pathogenesis, whereas associations of glutathione S-transferase polymorphisms (in conjunction with recent studies defining the effects of diisocyanates on thiol-redox homeostasis) may implicate additional antigen-independent mechanisms. Long-term follow-up studies of diisocyanate asthma patients have confirmed the prognostic value of early removal of symptomatic patients from exposure and highlight the need for effective diagnostic tests of sensitivity and susceptibility.

CONCLUSIONS

Diisocyanate-induced asthma appears to be a multifactorial disease involving the immune system, airway epithelium, and genetic factors. The potential long-term adverse effects of diisocyanate exposure in sensitized patients underscore the need for further studies to elucidate the pathogenesis of this disease and identify biomarkers for sensitization and susceptibility.

Experience with early detection of toluene diisocyanate-associated occupational asthma

There is good reason to expect that regular respiratory surveillance and early removal of workers who develop toluene diisocyanate (TDI)-associated occupational asthma can effectively protect these workers from accelerated pulmonary function decline. Application of this simple principle in operating industrial workplaces presents numerous challenges. The experience of one corporation is presented. One approach is to remove from future diisocyanate work, all workers who develop symptoms consistent with occupational asthma. However, the experience within this one corporation concurs with earlier, more carefully controlled investigations that such a strategy would be unduly restrictive of workers' occupational options. Fewer than half of the workers, who might have triggered such a practice, have required removal after more thorough occupational medical evaluation. Diisocyanates are such well known occupational asthmagens that other exposures tend to be ignored when considering respiratory health problems in a workplace. A small series of workers with work-related respiratory symptoms will be discussed. The usual industrial hygiene air monitoring demonstrated excellent control of the polyisocyanate hazard. Further investigation demonstrated poor control of a mold-release solution. Control of that exposure has allowed previously restricted workers to return to their former work making polyurethane parts. The number of cases available for analysis and discussion from this single, albeit large, corporation is small. Significant advances in understanding whether time-weighted average (TWA), task-specific, or dermal exposures to TDI and other polyisocyanates are most hazardous will require either many more years of experience within one corporation, or pooling of experience across the industry.

Role of tumor necrosis factor in toluene diisocyanate asthma

Nearly 9 million workers are exposed to chemical agents associated with occupational asthma, with isocyanates representing the chemical class most responsible. Isocyanate-induced asthma has been difficult to diagnose and control, in part because the biologic mechanisms responsible for the disease and the determinants of exposure have not been well defined. Isocyanate-induced asthma is characterized by airway inflammation, and we hypothesized that inflammation is a prerequisite of isocyanate-induced asthma, with tumor necrosis factor (TNF)-alpha being critical to this process. To explore this hypothesis, wild-type mice, athymic mice, TNF-alpha receptor knockout (TNFR), and anti-TNF-alpha antibody-treated mice were sensitized by subcutaneous injection (20 micro l on Day 1; 5 micro l, Days 4 and 11), and challenged 7 d later by inhalation (100 ppb; Days 20, 22, and 24) with toluene diisocyanate (TDI). Airway inflammation, goblet cell metaplasia, epithelial cell damage, and nonspecific airway reactivity to methacholine challenge, measured 24 h following the last challenge, were reduced to baseline levels in TNF-alpha null mice and athymic mice. TNF-alpha deficiency also markedly abrogated TDI-induced Th2 cytokines in airway tissues, indicating a role in the development of Th2 responses. Despite abrogation of all indicators of asthma pathology, TNF-alpha neutralization had no effect on serum IgE levels or IgG-specific TDI antibodies, suggesting the lack of importance of a humoral response in the manifestation of TDI-induced asthma. Instillation studies with fluorescein-conjugated isothiocyanate and TDI suggested that TNF-alpha deficiency also resulted in a significant reduction in the migration of airway dendritic cells to the draining lymph nodes. Taken together, these results suggest that, unlike protein antigens, TNF-alpha has multiple and central roles in TDI-induced asthma, influencing both nonspecific inflammatory processes and specific immune events.

Biological monitoring of aromatic diisocyanates in workers exposed to thermal degradation products of polyurethanes

Exposure to diisocyanates was assessed by biological monitoring among workers exposed to the thermal degradation products of polyurethanes (PURs) in five PUR-processing environments. The processes included grinding and welding in car repair shops, milling and turning of PUR-coated metal cylinders, injection moulding of thermoplastic PUR, welding and cutting of PUR-insulated district heating pipes during installation and joint welding, and heat-flexing of PUR floor covering. Isocyanate-derived amines in acid-hydrolysed urine samples were analysed as perfluoroacylated derivatives by gas chromatography mass spectrometry in negative chemical ionisation mode. The limits of quantification (LOQs) for the aromatic diamines 2,4- and 2,6-toluenediamine (2,4- and 2,6-TDA) and 4,4'-methylenedianiline (4,4'-MDA) were 0.25 nmol l(-1), 0.25 nmol l(-1) and 0.15 nmol l(-1), respectively. The LOQ for the aliphatic diamines hexamethylenediamine (HDA), isophoronediamine (IpDA) and 4,4'-diaminodicyclohexyl methane (4,4'-DDHM) was 5 nmol l(-1). TDA and MDA were detected in urine samples from workers in car repair shops and MDA in samples from workers welding district heating pipes. The 2,4-TDA isomer accounted for about 80% of the total TDA detected. No 2.6-TDA was found in the urine of non-exposed workers. The highest measured urinary TDA and MDA concentrations were 0.79 nmol mmol(-1) creatinine and 3.1 nmol mmol(-1) creatinine, respectively. The concentrations found among non-exposed workers were 0.08 nmol mmol(-1) creatinine for TDA and 0.05 nmol mmol(-1) creatinine for MDA (arithmetic means). Exposure to diisocyanates originating from the thermal degradation of PURs are often intermittent and of short duration. Nevertheless, exposure to aromatic diisocyanates can be identified by monitoring diisocyanate-derived amines in acid-hydrolysed urine samples.

Clinical findings for residents near a polyurethane foam manufacturing plant

Clinical findings for 38 community residents who complained of symptoms they attributed to exposure to air emissions from nearby fiber processing and polyurethane foam manufacturing facilities are reported. Common complaints included headache, mucosal irritation, shortness of breath, chest tightness, and wheezing. Airway hyperreactivity, measured by methacholine challenge, was observed in 8 individuals (22% of those tested), who also reported temporal relationships between exposure to visible emissions or odors and symptoms consistent with environmentally induced asthma. Six individuals (18.2%) had antibodies to at least 1 of the 3 common industrial diisocyanates. The number of individuals with antibodies to diisocyanates, coupled with the absence of other diisocyanate exposure, was highly suggestive of environmental exposure. The findings raised concern that some residents may have become sensitized to toluene diisocyanate.

Diisocyanate asthma: clinical aspects and immunopathogenesis

Diisocyanates, highly reactive chemicals used in the production of polyurethanes, are currently the most frequently reported cause of chemically induced occupational asthma and their use continues to rise. The prevalence of diisocyanate asthma among exposed workers is estimated to range from 5% to 15%. Routes of exposure include the respiratory tract and skin. Workplace exposures are difficult to quantify and control, and there is no simple diagnostic test for the disease. This review considers recent concepts in exposure. clinical aspects and pathogenesis of the disease. The pathogenesis of diisocyanate asthma remains unclear, with evidence supporting both immunological and nonimmunological mechanisms. Knowledge of the chemical reactivity of diisocyanates, the target biomolecules, and the cellular sites of reaction are fundamental to understanding diisocyanate toxicity and disease. Recent findings of chemical interactions with biological nucleophiles will be described. The importance of diisocyanate-adducted biomolecules will be emphasized and their potential contributions to pathogenesis discussed. It is anticipated that greater understanding of the immunopathogenesis of diisocyanate asthma, including the initial cell/diisocyanate reactions, should lead to clinically useful markers of exposure and early disease.

Pulmonary function tests at work

Occupational exposures remain an important cause of lung disease. A number of PFTs are used in the occupational setting, including spirometry, PEF recordings, methacholine challenge testing, lung volume, and DL(CO). These tests are used in a number of situations, including the clinical evaluation and management of patients with possible occupational lung disorders, preplacement and fitness-for-duty examinations, medical screening of exposed workers, impairment and disability evaluations, and research. The diagnosis of occupational lung disease has serious consequences for a worker and, in addition to a careful occupational history, usually requires objective assessment using PFTs. Serial PFTs are useful in following such patients and screening exposed populations of workers for respiratory conditions.