Imported occupational lead poisoning: report of four cases

BACKGROUND

In most industrialized countries, occupational lead poisoning has become increasingly rare, however this metal remains a serious health hazard in the rest of the world.

REPORT OF CASES

We observedfour male patients (aged 35 / 54 years) who had suffered recurrent abdominal pain due to recent lead exposure (for 7 to 13 months) in two Chinese battery recycling plants. On their return to Italy, three of them presented normocytic, normochromic anaemia. The diagnosis was confirmed by high lead levels in the blood and urine, decreased erythrocyte delta-aminolevulinic acid dehydratase (ALA-D), raised erythrocyte zinc protoporphyrin (ZP), and elevated urinary excretion of b-aminolevulinic acid (ALA-U) and porphyrins. Chelation with EDTA resulted in increased urinary lead excretion, improvement of the clinical picture, decreased ZP, and progressive normalization of the other lead biomarkers (Pb-B, ALA-D, ALA-U, urinary porphyrins).

CONCLUSIONS

Temporary work in developing countries may result in imported lead poisoning. Differential diagnosis of this unusual condition requires careful medical history collection and specific toxicological analysis. Preventive measures for workers going abroad are needed.

[Multidisciplinary protocol for work resumption after occupational osteoarticular injury: case record]

The results obtained with a protocol aimed at work resumption after occupational osteoarticular injury and subsequent rehabilitation are presented: 159 patients (102 males and 57 females: mean age 43.7 years) were evaluated by the physiatrist and the occupational physician, providing indications based on their functional capabilities and task features. After 6 months, 105 out of 130 subjects available for telephonic follow-up (80.7%) had returned to work (8 after changing tasks, 7 part-time). The mean time for work resumption was 9.4 days for those who resumed working completely, 31.4 days for the others. After 12 months, the percentage of working patients (76 out of 93: 81.7%) was superimposable, indicating that the rehabilitation beneficial effect is maximal in the short-medium period. On the whole, the data prove the efficacy of the multidisciplinary rehabilitative approach.

[Malignant mesothelioma: analysis of a hospital case series]

The 2000-2010 case record of our Institute includes 77 cases of malignant mesothelioma (MM) [67 pleural (40 males, 27 females; mean age 63.9 years), 9 peritoneal (7 males, 2 females; 67.9 years) and one testicular (38 year-old man)], often associated, with various degree of probability, to previous asbestos exposure (occupational or environmental). Twenty-four patients with pleural MM had undergone surgery (12 pleural decortication and 12 pneumonectomy), with median survival, respectively, of 14 +/- 4.33 (standard error) and 38 +/- 4.27 months, longer than that recorded without surgery (8 +/- 0.94 months). Four peritoneal cases underwent peritonectomy with hyperthermic intraoperative chemotherapy: one is still alive 20 months after diagnosis, the others died at 8, 18 and 36 months. The testicular case is still living 6 years after radical orchidectomy. In conclusion, due to past asbestos use, MM is often observed in the current clinical practice. Patients treated surgically present longer survivals.

[Return to work after occupational osteoarticular injury: presentation of a multidisciplinary protocol and preliminary data]

A protocol for work resumption after occupational osteoarticular injury and subsequent rehabilitation is presented: 97 patients (68 males and 29 females; mean age 42 years) were evaluated by the physiatrist and the occupational physician, providing indications based on their functional capabilities and task features. Up to date, 38 underwent follow-up at 6 months: 30 had returned to work (3 after changing tasks, 4 part-time). The mean time for work resumption was 15 days for the 26 subjects who resumed working completely, 1 month for the 4 who resumed partially. These data are encouraging, and highlight the importance of a multidisciplinary rehabilitative approach to facilitate return to work after occupational injuries.

Two cases of asbestosis and one case of rounded atelectasis due to non-occupational asbestos exposure

Asbestos is a well-known cause of several neoplastic (malignant mesothelioma, lung cancer) and non-neoplastic (asbestosis, pleuropathies) occupational diseases. Lower-level exposure in the general environment may induce pleural plaques and thickenings, and is associated with an increased mesothelioma risk. We present two patients (a 68-year-old man and a 72-year-old woman) who developed asbestosis (in association with pleural plaques and calcifications), and a 78-year-old man who developed rounded atelectasis (with pleural plaques and benign effusion), after living for several decades in the proximity of large Italian asbestos-cement plant. None of them had been exposed to asbestos occupationally. Besides living in a contaminated area, the woman used to clean the work clothes of her brother, who was employed in the local asbestos factory. The three cases indicate that non-neoplastic, long-latency asbestos-related diseases which are usually observed as a consequence of occupational exposures, may rarely develop in subjects living in contaminated geographical sites and buildings. These unusual environmental diseases raise the diagnostic problem of differentiating them from other, more common respiratory illnesses, and impose the duties of patient notification, assessment and follow-up, to assess the possibility of progression of disease and increased neoplastic risk.

[Exercise electrocardiography in the sanitary surveillance of workers with physical strain]

To evaluate the opportunity of exercise electrocardiography (ECG) in the sanitary surveillance of workers with physical strain, we estimated the energy consumption of the duties of 22 electrical workers (males; age: 35-56 years). They subsequently underwent Treadmill exercise ECG, determining for each worker the maximal METs (multiples of basal metabolism) and the critical potency (P(CRIT)). In one subject, myocardial ischemia arose 9 minutes after the beginning of the test. The others interrupted the test after 7-13 minutes for tiring; 5 of them showed ventricular extra systoles, paired or isolated. Twelve subjects presented arterial hypertension, at rest and/or during exercise. Ergonomic analysis revealed that the occupational duties were between 1.5 and 8.0 METs. The energy consumption of the job on the whole was 4-6 METs (medium intensity). The maximal METs reached by the examined subjects were between 8.8 and 15.6; however, only 11 workers went reassuringly over the 4 METs required by duty analysis at P(CRIT). One subject was declared unfit for the job, and a judgement of partial idoneity was expressed for 3 workers. Preventive and therapeutic indications were given to 12 subjects. Aerobic training was suggested to 10 workers. The study indicates that an ergonomic evaluation is advisable for the most energy consuming occupational duties. In such cases, the sanitary surveillance should include a cardiologic assessment with exercise ECG, reproducing the physical strain of the specific job.

[Analysis of a case series of workers with mobbing syndrome]

Mobbing represents nowadays a major challenge for Occupational Medicine. We examined, during the last seven years, 253 patients who asked medical assistance for psychopathological problems by them ascribed to mobbing in the working environment. All patients underwent occupational health visit, psychological counselling (including personality tests administration), and psychiatric evaluation. A clinical picture probably due to mobbing was diagnosed in 37 workers: 2 cases of Post-Traumatic Stress Disorder (PTSD), 33 of Adjustment Disorder (AD), and 2 of anxiety disorder. Regarding mobbing typology, we found 19 cases of vertical mobbing (by an employer/manager to employees), 14 cases of strategic mobbing, 3 cases of horizontal mobbing (among colleagues), and one non intentional mobbing. In conclusion, a pure mobbing syndrome was diagnosed in a lower proportion than that reported by other investigators. The described interdisciplinary approach appears useful for the diagnostic assessment of suspect mobbing cases, that in turn is crucial for prognosis and treatment, as well as in relation to medico-legal issues and work-related compensation claims.

[Management of occupational stress among patients with cardiac diseases]

The object of our study was the evaluation of psycophysic condition, stress perception and coping in a sample of subject in cardiac rehabilitation. Our study recruited 48 worker patients (44 male, M = 50.5 +/- 8.8; 4 female, M = 50.8 +/- 8.7). They were submitted to: 1) cardiac evaluation and rehabilitation in DH regimen; 2) psychological assessment; 3) work's characteristic evaluation. The evaluation were made at the moment of recruitment and six month later 42 subjects went back to work after 81.8 +/- 49 days; 2 subjects had a worsening of their clinic conditions not consistent with an occupational resumption; 4 subjects didn't go back to work. In the 42 worker subjects we have find a significant decrease of anxiety (p < 0.019) and depression levels (p < 0.004); a significant improvement of Quality of Life perception in its physical (p < 0.000) and psychic aspects (p < 0.021) and an improvement about the ability to reorganize the work to better ménage stress (p < 0.012).

[Rhabdomyolysis in a worker exposed to paraffinic mineral oils. Unusual association with bronchiolitis obliterans and organizing pneumonia (BOOP)]

We describe a 29-year-old worker; exposed to metal dust, sawdust and paraffinic mineral oils in a factory producing accessories for leather articles and clothing, who came to observation with fever (39 degrees C), chest pain and marked increase of muscular enzymes. Chest computed tomography showed two areas of lung consolidation, that subsequently appeared enlarged with central escavation. Lung biopsy lead to the diagnosis of BOOP. The case has been reported to the judicial and workers' compensation authorities as probable occupational toxic myopathy. Indeed, exposure to paraffinic mineral oils is a known, though unusual, cause of rhabdomyolysis. The association with BOOP has never been previously described.

[Noise-induced hypoacusia in maintenance workers of high voltage electric lines]

Noise-induced hypoacusia continues to represent an important issue in Occupational Medicine in relation to epidemiology, diagnostics, medicolegal issues and occupation related compensation claims. We present the clinical and audiometric findings of 45 maintenance workers of high tension electric lines, undergoing medical surveillance. Noise-induced hearing loss was diagnosed in 49% of cases ("pure" in 27% and mixed--with the concurrence of other causes--in 22% of cases). These unexpected data indicate that electric lines maintenance should be considered a high risk occupation for noise-induced damage, and confirm the need of enforcing current protective laws.

Silicotuberculosis in the elderly: report of two cases

Silicotuberculosis is observed rarely in the current clinical practice. We present two patients (a 72-year-old man and a 84-year-old woman) who developed silicosis after having worked for several decades in the ceramics industry. In both, pulmonary tuberculosis complicated the clinical picture several years after retirement. The first subject presented a multicavitary lesion in the apex of the right lung, which subsequently evolved with fibrosis. The other developed bilateral tubercular bronchopneumonia and right tubercular pleurisy, that improved after prolonged antimycobacterial polychemotherapy. The two cases confirm that patients with silicosis are at an increased risk of developing tuberculosis, and show that, nowadays, silicotuberculosis may represent a geriatric problem. In the elderly, recognition of tuberculosis associated with silicosis is often difficult. Occupational history, radiology (conventional chest radiography and computed tomography) and microbiology (identification of Mycobacterium tuberculosis in sputum and pleural exudate) are helpful for the correct diagnosis, which, in turn, is important for prognosis and treatment, as well as in relation to medico-legal issues and occupational-related compensation claims.

[Proposal for an outline to be used in the assessment of chemical risk according to the legislative decree 25/20002]

We present an operative outline for the evaluation of chemical risk in the work environment, according to the legislative decree 25/2002. It includes the following points: identificative data of the company, scope and field of application, description of the working activities, preventive and protective measures, medical report (including biological monitoring), environmental monitoring, conclusive evaluation. The scheme is a quali-quantitative instrument for the employer and his collaborators to establish whether the chemical risk present in the single productive sites can be considered "moderate" or "not moderate".

[Echocardiographic assessment of alcohol consumers in different clinical stages]

In relation to the importance of cardiac damage in alcohol drinkers this study aims to check the modifications of some cardiac sonographic parameters in drinkers examined at different stages of alcohol intoxication. Seventy-seven male subjects (43 +/- 9 years old) were divided into 3 groups in relation to the biohumoral alterations used for the diagnosis of chronic alcoholism (increase of GGT and MGV). EF, interventricular septum hypertrophy, LVEdD and the presence of left ventricular diastolic failure were considered. All these cardiac sonographic parameters "in toto" were first compared with the same parameters of a group of normal subjects and then the differences of these sonographic parameters between the 3 groups of drinkers were evaluated. These data confirm the early onset of cardiac damage and also that the cardiac alterations may occur before the modifications of the biohumoral parameters considered too. The alterations of the cardiac sonographic parameters considered in this study seem to be a good marker for the identification, quantification and staging of cardiac damage. Interventricular septum hypertrophy, EF and EDV (in this sequence) are to be considered usefull for the diagnosis of cardiac damage in alcohol drinkers. However also LVEdD and the presence of left ventricular diastolic failure are to be evaluated before any therapy.

[The diagnosis of occupational hand-arm syndromes. 2. The quantification of the plethysmographic changes due to the cold test]

The diagnostic utility of digital volumetric pulse plethysmography with the cold test in well known for the study of subjects vibrations exposed and symptomatic for acrosyndrome. In this study the authors show how to perform this test and how to analyse the results quantitatively (in particular the time-course of the vascular modifications during cold test) to improve the clinical interpretation and to allow a comparison during the years. The parameters studied are: the morphologic pattern of each wave; the entity, duration and the regression pattern of the modifications after cold test; the existence of hemorrheologic predisposing conditions to vasospasm. To each of these parameters it has attributed a score and all the scores together represent the sphygmic answer to the cold test.

[The diagnosis of occupational hand-arm syndromes. 1. The state of the art]

Alterations of the microcirculation are, at our latitudes, the most common distal manifestations of the hand-arm syndrome, and of a number of other work-related diseases. Diagnostic investigations aimed at providing documentary evidence for microvascular damage or disfunction are, therefore, of particular importance. This paper discusses the currently available diagnostic approaches for professional acrosyndromes. The biohumoral alterations associated with cold-induced angiospasm are also described, but their diagnostic utilization is not recommended. The technical aspects of the "cold tests", as well as its advantages and drawbacks, are finally presented. On the basis of a personal experience with over 4.500 subjects, the authors conclude that, in the field of prevention, digital volumetric pulse plethysmography in association with the "cold test" should be adopted to evaluate the worker fitness for specific tasks.

Porin content modifies resistance of Salmonella typhimurium to phagocytosis

Mutants of Salmonella typhimurium, which contain different quantities of outer membrane proteins, show different susceptibility to phagocytosis. We correlate susceptibility to phagocytosis with molecular surface characteristics which are responsible for invasiveness and virulence of bacteria.

Comparative study of some biological activities of porins extracted from various microorganisms

The outer membrane of Gram-negative bacteria contains some major proteins, called porins, with particular chemical and physical characteristics which reflect some specialized functions peculiar to the outer membrane. In recent years the biological properties of Salmonella typhimurium SH5014 porins have been the focus of our experimental studies. The aim of the present research was to make a comparative investigation of the biological activities of porins extracted from other microorganisms classified in the Enterobacteriaceae, together with a taxonomically different one, Eikenella corrodens frequently isolated from gum pockets of patients with periodontal disease. Porins from E. coli K12, Proteus mirabilis and Eikenella corrodens were extracted, purified and separated from LPS by means of phenol extraction. The purity of preparation was checked by sodium dodecyl sulphate polyacrylamide gel electrophoresis in slabs. We studied the interactions of these proteins with some cellular and humoral systems within the host. Mouse peritoneal macrophages in the presence of these proteins show morphological and functional modifications, depending upon the type of porins and the concentrations used. The ability of porins to interact with the complement system was investigated in vitro. A pool of sera from 20 blood donors served as a source of human complement. The results obtained with porins of various sources were shown comparatively.