Occupational acute argon gas poisoning: A case report

RATIONALE

Intentional or unintentional exposure to asphyxiating gases is a significant public health concern worldwide. Argon poisoning is fatal, and its onset is primarily due to neurological damage.

PATIENT CONCERNS

A 22-year-old man was admitted to the hospital for argon gas poisoning. While working in a plant containing argon gas, he suddenly lost consciousness, recovered consciousness slightly after on-site treatment, answered questions, and had impaired memory, sensory dullness, normal cognition, and symptoms of dizziness and headache.

DIAGNOSIS

Asphyxiating gas poisoning (argon gas poisoning), metabolic encephalopathy, and hepatic insufficiency.

INTERVENTIONS

Immediately after admission, the patient was treated with nasal cannula oxygen 3 L/min and hyperbaric oxygen therapy once a day. Mecobalamin tablets 500 μg were given orally 3 times a day. Oral Ginkgo biloba extract tablets 40 mg 3 times a day.

OUTCOME

The patient was discharged after treatment with hyperbaric oxygen therapy and nerve-nourishing drugs, with no discomfort, clear consciousness, and good memory, and was followed up by telephone for 2 consecutive months, and the patient is now in good condition with no discomfort.

LESSON

This case describes the pathogenesis, neurological damage, and rescue process of argon gas poisoning. Argon poisoning was found to damage bilateral cerebellar hemispheres and bilateral hippocampal regions, affecting the patient's consciousness and memory, and was found to cause abnormal liver function and heart rate disorders.

Sudden Deaths Among Oil and Gas Extraction Workers Resulting from Oxygen Deficiency and Inhalation of Hydrocarbon Gases and Vapors - United States, January 2010-March 2015

In 2013, an occupational medicine physician from the University of California, San Francisco, contacted CDC's National Institute for Occupational Safety and Health (NIOSH), and the Occupational Safety and Health Administration (OSHA) about two oil and gas extraction worker deaths in the western United States. The suspected cause of these deaths was exposure to hydrocarbon gases and vapors (HGVs) and oxygen (O2)-deficient atmospheres after opening the hatches of hydrocarbon storage tanks. The physician and experts from NIOSH and OSHA reviewed available fatality reports from January 2010 to March 2015, and identified seven additional deaths with similar characteristics (nine total deaths). Recommendations were made to industry and regulators regarding the hazards associated with opening hatches of tanks, and controls to reduce or eliminate the potential for HGV exposure were proposed. Health care professionals who treat or evaluate oil and gas workers need to be aware that workers might report symptoms of exposure to high concentrations of HGVs and possible O2 deficiency; employers and workers need to be aware of this hazard and know how to limit exposure. Medical examiners investigating the death of oil and gas workers who open tank hatches should consider the contribution of O2 deficiency and HGV exposure.

Fatal pulmonary arterial thrombosis associated with chlorine gas poisoning

We present a patient with accidental chlorine gas poisoning who died from pulmonary thrombosis due to a marked increase in hemostatic factors such as von Willebrand factor after recovering from the acute poisoning.

[Chemical obliterans bronchiolitis after azotic acid exposure]

The authors present the case of a 48 years old man having an exposure to irritant gases (azotic and lactic acids) in a closed space, inhaling them for 5 minutes. Shortly after the accident the patient displayed the signs of corneal and conjunctival burn; several days afterwards respiratory symptoms appeared: shortness of breath, dyspnea to minor efforts, then nocturnal dyspnea and orthopnea. Chest X-ray, CT scan, complex lung function tests and bronchoalveolar lavaje, together with the history of recent exposure to irritant gases led to the diagnosis of hypersensitivity obliterant bronchiolitis. Oral corticoids in dose of 60 mg/day determined a substantial clinical, radiological and functional improvement. The authors make some comments on the need of early diagnosis and efficient treatment.

Neurobehavioral deficits in Persian Gulf veterans: evidence from a population-based study. Portland Environmental Hazards Research Center

Reports of low-concentration nerve gas exposures during the Persian Gulf War have spurred concern about possible health consequences and refocused interest on the symptoms reported by many returning military veterans. The Portland Environmental Hazards Research Center is studying veterans from the Northwest USA who report persistent, unexplained "Persian Gulf" symptoms (cases) or who do not report those symptoms (controls). Of the first 101 veterans studied, cases differed substantially from controls on a broad range of psychological tests indicative of increased distress. A subgroup of cases was identified with objective deficits on neurobehavioral tests of memory, attention, and response speed.

Effects of a hydrochloric acid spill on neurobehavioral and pulmonary function

A container truck leaked 800 L (200 gallons) of hydrochloric acid (HCl) near a mobile home park in Louisiana in August 1993. The investigating officer and residents became acutely ill with burning and tearing eyes, burning throats, headache, chest pain, shortness of breath, and flu-like complaints. Twenty months later, 45 exposed adult subjects and 56 age-matched referents underwent neurobehavioral testing, including balance, reaction time, blink-reflex latency, and spirometry. They also completed health questionnaires and a profile of mood states. The exposed subjects differed significantly from referents by t test and by covariance analysis for balance, simple and two-choice visual reaction time, digit symbol, and for placing pegs in a pegboard. Proximity to the HCl spill increased sway speeds and impaired pulmonary midflow rates. Chronic neurobehavioral dysfunction and airways obstruction were found after environmental HCl exposure.

Long term morbidity in survivors of the 1984 Bhopal gas leak

BACKGROUND

The extent and nature of long term health sequelae among survivors of the Bhopal gas disaster are not known. In 1994 an International Medical Commission was set up with the aim of assessing respiratory, neurological and other health effects attributable to gas exposure.

METHODS

An epidemiological survey of a representative sample of gas-exposed inhabitants of Bhopal was conducted in January 1994; for reference, a group of unexposed persons in the same city were surveyed. Questionnaires regarding health and exposure were administered to 474 persons, and a random sample (n=76) were subjected to respiratory and neurological testing. Responses to the questionnaire and the results of clinical testing were analysed according to a measure of individual gas exposure.

RESULTS

A large number of subjects reported general health problems (exposed v. unexposed; 94% v. 52%) and episodes of fever (7.5/year v. 2.5/year); adverse outcome of pregnancy (e.g. still-births, 9% v. 4%) and respiratory symptoms (81% v. 38%), with a strong gradient by exposure category. This was not accounted for by differences in smoking, and was consistent with the results of spirometric testing. Neurological and psychiatric symptoms were reported more frequently by subjects in high exposure categories and the results of neurological examination and testing tended to confirm this finding. Ophthalmic symptoms demonstrated a similar pattern. Although a number of other symptoms were reported (with the possible exception of gastrointestinal disease), there was no clear evidence of other organ system damage attributable to gas exposure.

CONCLUSION

The gradient of reported symptoms and clinical test results with estimates of exposure among these survivors of the gas leak suggests that a proportion of their current respiratory and neurological disease was due to gas exposure.

Fetal methemoglobinemia: a cause of nonimmune hydrops fetalis

A case of nonimmune hydrops fetalis resulting from fetal methemoglobinemia is presented. A woman with a pregnancy at 17 weeks' gestation was admitted after combustion gas intoxication. Although the mother totally recovered, the fetus showed signs of nonimmune hydrops fetalis at follow-up. Fetal methemoglobin levels were very high.

[Hypothermia: a non renal indication for peritoneal dialysis]

Accidental hypothermia, a condition seldomly seen in Chile, is defined as a spontaneous core temperature reduction to less than 35 degrees C and is associated with great morbidity and mortality. We report a 16 years old female intoxicated with liquefied petroleum gas that was admitted in coma, hypothermic, with severe hemodynamic derangement, lactic acidosis, rhabdomyolysis and iliofemoral phlebothrombosis. Peritoneal dialysis with solutions at 27 degrees C was used as a quick and safe means to revert hypothermia and avoid its complications.

[Follow-up studies on chronic obstructive pulmonary disease among Ookunojima poison gas workers]

A high prevalence of chronic bronchitis has been reported among former employees of a poison gas factory in Ookunojima. The author has studied changes in clinical features by analyzing chest X-ray, sputa and respiratory function in 72 cases whose clinical courses could be observed for the 10 year period from 1981 to 1991. FEV1.0 in the patients with emphysematous change on chest X-ray was significantly decreased as compared to that of patients with inflammatory change and those with normal findings. FEV1.0 in the obstructive and infectious-obstructive type groups, in terms of clinical classification of chronic bronchitis, was significantly decreased as compared to that of simple and inflammatory types. These results show that the obstructive ventilation disorder in these two groups is progressive. Next, the author analyzed CT findings of the whole lung in 93 cases, including the former 72 cases. %(I-E) represents the alteration ratio of whole lung field CT numbers during full inspiration and full expiration. %(I-E) in the emphysematous group was significantly decreased as compared to the other two groups. %(I-E) showed a good correlation with FEV1.0 (r = 0.645), FEV1.0% (r = 0.500) and V50/V25(r = 0.523). This parameter was considered to be useful for evaluation of the obstructive ventilation disorder in these cases. The chronic bronchitis in these poison gas workers has been reported to be predominantly inflammatory and to have a variable clinical course. However, our results show that progression of the obstructive ventilation disorder caused by emphysematous change produces long term deterioration of pulmonary function in poison gas workers.

[Monitoring of an acute compartment syndrome of unusual etiology using MRI (magnetic resonance tomography) and MRS (magnetic resonance spectroscopy)]

The authors report on an acute compartment syndrome occurring symmetrically in the extensors of both forearms. The etiology of this unique compartment syndrome, not previously described, could be attributed to the inhalation of a propane-butane gas mixture, low in oxygen, while sleeping, in combination with external compression of both forearms, due to the patient's head lying on both forearms while sleeping. Ischemic damage to muscles was precisely located using non-invasive MRI (Magnetic Resonance Imaging). The extent of cellular damage due to ischemia after fasciotomy and healing by secondary intention was quantitatively assessed using non-invasive 31P-MRS (Phosphorus Magnetic Resonance Spectroscopy). The results correlate with the clinical and histological findings and indicate a bioenergetic regeneration of the ischemic skeletal muscle's cells.

Bronchoalveolar lavage study in victims of toxic gas leak at Bhopal

Bronchoalveolar lavage using flexible fibreoptic bronchoscope was carried out in 50 patients 1-2 1/2 yr after exposure to the 'toxic gas' at Bhopal. Thirty six patients in the analysis were categorised into 3 groups (viz., mild, moderate and severe), depending upon the severity of exposure. There was an increase in cellularity in the lower respiratory tract (alveolitis) of the severely exposed patients (in both smokers and non-smokers), compared to normals (P less than 0.05). The increase in cellularity in severely exposed non-smokers was due to abnormal accumulation of macrophages (P less than 0.01), and in severely exposed smokers, to macrophages (P less than 0.01) and neutrophils (P less than 0.05). Mild and moderately exposed patients did not show significant change in cellularity in lower respiratory tract, compared to normal individuals (P greater than 0.2). There was a trend towards increasing cellularity, as the severity increased (P less than 0.0001) and higher numbers of total cells were seen in severely exposed smokers, suggesting that smoking is a risk factor. It appears, therefore, that subjects severely exposed to the toxic gas at Bhopal may have a subclinical alveolitis characterised by accumulation and possibly activation of macrophages in the lower respiratory tract. Smokers, who were exposed to the gas had in addition, accumulation of neutrophils.

Pulmonary barotrauma including orbital emphysema following inhalation of toxic gas

Severe pulmonary barotrauma occurred following smoke and toxic gas inhalation in a 20-year-old male. He developed pneumothorax, pneumomediastinum, and extensive facial subcutaneous emphysema which intensified during treatment with positive pressure ventilation. Following the appearance of diplopia and exotropia, orbital emphysema was demonstrated radiologically. The diplopia and exotropia were manifestations of mechanical interference in extra-ocular muscle function by the intra-orbital air, an unusual expression of pulmonary barotrauma.

Disaster at Bhopal: the accident, early findings and respiratory health outlook in those injured

In December, 1984, in Bhopal, India, a massive leak of methyl isocyanate (MIC) resulted from operational and equipment malfunctions in a pesticide plant. Many thousands of residents of the city, most in proximity to the plant, suffered sublethal and lethal respiratory injuries, the expected consequences of high-level exposure to this type of potent irritant chemical vapour. Animal toxicologic information was limited prior to the accident, but has since confirmed that the lung is the major target of these lethal injuries, invariably with pulmonary oedema. Early concerns regarding acute cyanide intoxication were not supported by subsequent scientific inquiry. Superficial corneal erosions did not result in permanent eye injury. The primary medical (and, presumably, legal) issue which is unresolved, and perhaps unresolvable, is the incidence and determinants of long-term respiratory injury in the survivors. Available evidence, which is limited, suggests that chronic damage, when present, is, or resembles, fibrosing bronchiolitis obliterans, the expected consequence when permanent injury results from acute, high-level irritant gas exposure. Definition of the follow-up population is uncertain, and exposure information is lacking. Dose-response relationships are not likely to emerge from follow-up studies.

Chlorine inhalation toxicity from vapors generated by swimming pool chlorinator tablets

We have presented two cases of serious respiratory injury after brief exposure to vapors from solid chlorine compounds. We could find no previous reports of such accidents and, therefore, have related these cases to alert the medical community. We would recommend that physicians caring for children include warnings about these preparations in their routine counseling of parents.

Effects of Nocardia rubra cell wall skeleton on interleukin 2 production and lymphocyte proliferation in former poison gas factory workers

Phytohemagglutinin (PHA)-induced interleukin 2 (IL-2) production and lymphocyte proliferation were measured in former workers of the Okunojima Poison Gas Factory (poison gas workers), who have a high incidence of lung cancer, and the efficacy of administration of Nocardia rubra cell wall skeleton (N-CWS) was studied. In comparison with normal controls and poison gas workers receiving N-CWS, lymphocyte proliferation in poison gas workers not receiving N-CWS showed a significant decrease, while IL-2 production showed a slight though not statistically significant decrease. When N-CWS was administered to poison gas workers, IL-2 production and lymphocyte proliferation were significantly elevated, with a peak two weeks after administration. N-CWS, by elevating IL-2 production of lymphocytes, is considered to have improved the depression of lymphocyte proliferation.

[Radiological changes of the lungs induced by inhalation of irritating gases (author's transl)]

The radiological changes and clinical symptoms induced by in 109 persons by inhalation of irritant gases are described. Seven persons developed pulmonary oedema, abnormal radiological manifestations were observed in 19 while 81 persons there were no detectable radiological changes. Toxic pulmonary oedema is frequently detected earlier by roentgenologic means than clinically. The length of the radiological latent period depends not only on the concentration of the irritant but also on the type of the gaseous substance. The first roentgenologic signs of toxic pulmonary oedema are broadening and blurring of the outline of the hilar vessels. The pulmonary changes are characterized initially by disseminated small to medium sized shadows in the central portion and base of the lungs; later they tend to spread and merge.

[Roussy-Levy's syndrome: clinical aspects (author's transl)]

A case of non familial Roussy-Lévy syndrome is presented: optic atrophy, gait ataxia, bilateral hypotrophy of thenar and hypothenar muscles, weak deep tendon reflexes of the upper limbs, weak knee jerks, absent ankle jerks, bilateral Babinski, anapallaesthesia from the bisiliac spine distally, bilateral pes cavus. The literature on Roussy-Lévy syndrome is discussed and whether this syndrome should be considered as a precise entity among heredo-degenerative diseases. The overlapping of differing clinical features may suggest an intermediate form between Friedreich's and Charcot-Marie-Tooth's diseases.

Arsine toxicity aboard the Asiafreighter

Eight sailors on board the Asiafreighter were exposed to arsine that had escaped from a cylinder in the cargo hold. Four suffered severe toxicity and within a few hours had developed fever, weakness, nausea, vomiting, diarrhoea, abdominal pain, and haemoglobinuria. These patients had pronounced intravascular haemolysis, which in one patient was complete. This patient was also stuporose and anoxic, a condition attributed to failure of oxygen transport and sludging of red cell debris in the cerebral and pulmonary circulations, but he regained a normal level of consciousness after exchange transfusion. Evidence of marrow depression was present: the reticulocyte response to the haemolysis was poor and there was a thrombocytopenia. All four patients developed renal failure, one being totally anuric for five weeks. Two patients developed peripheral neuropathy, and one was still severely disabled six months after the incident. The other four patients had a similar, though less severe, illness.