Severe acute hepatitis in a printing company worker: a case study

Acute 1,2-Dichloropropane Poisoning due to Ingestion of Rubber Cement: An Autopsy Case Report and Review

ABSTRACT

1,2-Dichloropropane (1,2-DCP) is a common industrial solvent and chemical intermediate that can cause acute poisoning to humans through exposure during its production and industrial use. The target organs of 1,2-DCP include the eyes, respiratory system, liver, kidney, central nervous system, and skin. Forensic identification of 1,2-DCP poisoning is difficult because of the lack of characteristic pathological changes. This article reports an autopsy case of acute 1,2-DCP poisoning caused by self-ingestion of rubber cement. A woman developed seizures and coagulation dysfunction after ingesting approximately 10 mL of rubber cement and died 43 hours later. Autopsy revealed generalized subcutaneous hemorrhage, cardiopulmonary multifocal hemorrhage, bronchopneumonia, severe cerebral edema, focal hepatic necrosis, granular deposition in the glomerular capsule and renal tubules, and delipidation of the adrenal cortex. These findings indicate that 1,2-DCP poisoning can induce central nervous system dysfunction, respiratory system damage, liver and kidney function damage, hemolytic anemia, disseminated intravascular coagulation, and adrenal damage. This case may provide useful perspectives for forensic identification of 1,2-DCP poisoning in the future.

EASL clinical practice guidelines for the management of occupational liver diseases

The Clinical Practice Guidelines (CPG) on Occupational Liver Diseases (OLD) of the European Association for the Study of the Liver (EASL) have been developed to increase awareness, recognition and improve management of patients with OLD. Indeed, although workplace exposure has been associated with virtually the entire spectrum of acute and chronic liver diseases, data on the epidemiology of OLD are scarce. These diseases may be a result of high-level accidental exposure or prolonged lower level exposure to a variety of chemicals including solvents, pesticides, metals and other agents. While acute liver diseases related to OLD are uncommon and easily recognized, chronic liver diseases are relatively more frequent but often overlooked because of their asymptomatic course and an insidious onset which is often accompanied by comorbidities. Because of the absence of data in observational studies and meta-analyses or systematic reviews, the evidence and recommendations in these guidelines have been graded according to the Oxford Centre for Evidence-based Medicine, which assesses evidence according to diagnostic, prevalence, aetiological, prognostic or preventive categories. They can still generate grades of recommendation even when the evidence is inconclusive.

EASL Clinical Practice Guideline: Occupational liver diseases

A variety of chemicals have been linked to occupational liver diseases, including several solvents and mixtures thereof, pesticides, and metals. Workplace exposures have been associated with virtually the entire spectrum of acute and chronic liver diseases. However, their prevalence is inadequately quantified and their epidemiology limited. Occupational liver diseases may result from high accidental or from prolonged lower level exposures. Whereas the former is uncommon and easily recognised, the latter are relatively more frequent but often overlooked because they may display normal values of conventional markers, have an insidious onset and be asymptomatic or be obfuscated and confounded by concurrent conditions. In addition, specific tests of toxicity are not available, histopathology may not be revealing and the assessment of internal dose of chemicals is usually not decisive. Given these circumstances, the diagnosis of these liver disorders is challenging, one of exclusion and often requires an interdisciplinary approach. These recommendations offer a classification of the type of liver injuries associated with occupational exposures - based in part on the criteria for drug-induced liver injury - a grading of their severity, and the diagnostic and preventive criteria for chemically induced occupational liver disease.

Acute toxic encephalopathy induced by occupational exposure to 1,2-dichloropropane

1,2-Dichloropropane (1,2-DCP) is used widely in Korea as a substitute for trichloroethylene or methylene chloride. Some companies mistakenly consider that 1,2-DCP is an eco-friendly detergent because its use is not regulated, but 1,2-DCP is known to inhibit the central nervous system in animals; a few cases of accidental exposure have been reported in humans. We present a case of acute encephalopathy caused by exposure to 1,2-DCP. A 41 yr-old male presented with dizziness, headache, and diplopia after exposure to the detergent without protective equipment. Brain magnetic resonance imaging suggested metabolic encephalopathy, but the patient had no thiamine deficiency and no other metabolic disorder. As the symptoms had commenced after exposure to a large amount of solvent while skimming rust from the surface, and as the symptoms were more severe during the work week, improved on weekends, and disappeared after solvent exposure ceased, the toxic encephalopathy was likely induced by inhalation of the detergent.

Role of selective blocking of bradykinin B1 receptor in attenuating immune liver injury in trichloroethylene-sensitized mice

Trichloroethylene (TCE) is able to induce trichloroethylene hypersensitivity syndrome (THS) with multi-system immune injuries. In our previous study, we found kallikrein-kinin system (KKS) activation, including the bradykinin B1 receptor (B1R), which contributed to immune organ injury in TCE sensitized mice. However, the mechanism of B1R mediating immune dysfunction is not clarified. The present study initiates to investigate the potential mechanism of B1R on liver injury. We establish a TCE sensitized BALB/c mouse model to explore the mechanism with or without a B1R inhibitor R715. We found B1R expression was increased in TCE sensitization-positive mice. As expect, hepatocyte intracellular organelles and mitochondria disappeared, glycogen particles reduced significantly as well in TCE sensitization-positive mice via the transmission electron microscopic examination, meanwhile, R715 alleviated the deteriorate above. The blockade of B1R resulted in a significant decreased p-ERK1/2 and increased p-AKT expression. The expression of CD68 kupffer cell and its relative cytokine, including IL-6 and TNF-α, increased in TCE sensitization-positive mice and decreased in R715 pretreatment TCE sensitization-positive mice. Together, the results demonstrate B1R plays a key role in ERK/MAPK and PI3K/AKT signal pathway activation and inflammation cytokine expression in immune liver injury induced by TCE. B1R exerts a pivotal role in the development of TCE induced liver injury.

Occupational cholangiocarcinoma caused by exposure to 1,2-dichloropropane and/or dichloromethane

A cluster of cholangiocarcinoma among printing company workers who were exposed to 1,2-dichloropropane and/or dichloromethane was classified by the Ministry of Health, Labour and Welfare of Japan on 1 October 2013 as "occupational cholangiocarcinoma". At the time of the diagnosis of cholangiocarcinoma, levels of γ-glutamyl transferase, and aspartate and alanine aminotransferases were elevated, and had been elevated in some patients several years prior to the diagnosis. Regional dilatation of intrahepatic bile ducts without tumor-induced obstruction was characteristic in diagnostic imaging. Pathological examination found chronic bile duct injury with DNA damage, precancerous/preinvasive lesions such as biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct in various sites of the large bile ducts, and invasive cholangiocarcinoma such as mass-forming type and intraductal growth-type intrahepatic cholangiocarcinoma and mainly papillary-type extrahepatic cholangiocarcinoma. Whole-exome analysis of the cancerous tissues showed hypermutation, substantial strand bias, and unique trinucleotide mutational changes. Patients seemed to suffer high incidence of postoperative complications including intra-abdominal, which might be related to chronic bile duct injury. Postoperative recurrence from multicentric origins occurred in some patients, as DNA-injured bile ducts have high carcinogenic potential. Aggressive treatment, including second resections for such multicentric recurrences, appeared to be effective. In 2014, the International Agency for Research on Cancer classified 1,2-dichloropropane as Group 1 (carcinogenic to humans) and dichloromethane as Group 2A (probably carcinogenic to humans) carcinogens.

Recurrent Acute Liver Failure Because of Acute Hepatitis Induced by Organic Solvents: A Case Report

The authors present a case of recurrent acute liver failure because of occupational exposure to organic solvents. A 35-year-old man with a 3-week history of worsening jaundice and flu-like symptoms was admitted to our hospital. Viral hepatitis serology and autoimmune factors were negative. The authors considered liver transplantation, but the patient's liver function spontaneously recovered. Liver biopsy revealed massive infiltration of neutrophils, but the cause of the acute hepatitis was not identified. Four months after discharge, the patient's liver function worsened again. The authors considered the possibility of antinuclear antibody-negative autoimmune hepatitis and initiated steroid treatment, which was effective. Four months after discharge, the patient was admitted for repeated liver injury. The authors started him on steroid pulse therapy, but this time it was not effective. Just before the first admission, he had started his own construction company where he was highly exposed to organic solvents, and thus the authors considered organic solvent-induced hepatitis. Although urine test results for organic solvents were negative, a second liver biopsy revealed severe infiltration of neutrophils, compatible with toxic hepatitis. Again, his liver function spontaneously improved. Based on the pathology and detailed clinical course, including the patient's high exposure to organic solvents since just before the first admission, and the spontaneous recovery of his liver damage in the absence of the exposure, he was diagnosed with toxic hepatitis. The authors strongly advised him to avoid organic solvents. Since then, he has been in good health without recurrence. This is the first report of recurrent acute liver failure because of exposure to organic solvents, which was eventually diagnosed through a meticulous medical history and successfully recovered by avoiding the causative agents. In acute liver failure with an undetermined etiology, clinicians should rule out organic solvent-induced hepatitis.