Diffused systemic sclerosis due to occupational solvent exposure

Abstract

To the Editors,Systemic sclerosis (SSc) is an uncommon autoimmunedisorder of the connective tissue, discriminated by skinfibrosis, vascular dysfunction and gastrointestinal tract,lungs, and kidneys involvement [1]. The prevalence rang isestimated between 50 and 300 cases per 1 million persons[2]. Its pathogenesis is apparently multi-factorial such asintrinsic and extrinsic factors. Similar to other autoimmunedisorder, in SSc also some biologic (such as cytomegalo-virus (CMV)) and non-biologic agents (such as specificchemical toxins) can trigger the immunologic cascade insusceptible hosts. Environmental and occupational agentsone of the extrinsic triggering factors that may playessential and developing role in SSc. Several case reportsand series informed that various solvents (organic or non-organic) are associated with limited form of SSc butits diffused form was very rare [3–9]. Benzene, toluene,xylene, trichloroethane, trichloroethylene, perchloroethy-lene, VM & P naphtha, and mineral spirits are some of themost famous solvents that were identified in relation toSSc [3].WereportacaseofSScinapatientworkinginthechemical manufacture industry where he was exposed todifferent solvents. A 49-year-old male patient was refer-redtoBaqiyatallahHospital(Tehran, Iran) complainingof hands’ skin discoloration, thickness, and hardeningsand arthralgia in whole of PIP and MCP joints which havebeen progressed since 5 months ago. Recently, tiny ulceron hand fingers’ tip was emerged. Also, he was affectedby exertional dyspnea, gastro-esophageal reflux (GER),and morning stiffness with 45 min duration. Physicalexamination revealed Reynolds phenomenon in wholehand fingers, especially bilateral third and fourth finger.Laboratory findings showed elevated ESR level andwhite blood cell count, while rheumatoid factor (RF),anti-nuclear antibody (ANA), plasma creatinine level,and other findings were not remarkable. Lung computedtomography (CT scan) showed subpleural fibrotic changesin both lungs. He had worked in chemical manufactoryappointed to a duty where he was to deal with severalorganic solvents derived from benzene since 2 years ago.An environmental chemical mixtures investigation wasperformed within the factory, supplemented by a quanti-tative meteorological assessment to estimate the averagelevel of exposure to different solvents. The levels ofdimethylbenzene, xylene, trimethylbenzene, and naph-thalene were found to be several times higher than thestandard at the place. Demographic, clinical, and labora-tory findings were compatible with diffused form of SScdue to occupational exposure to benzene derivate sol-vents. The patient exposure was cut off and treatment wasstarted with methyl prednisolone, pentoxifylline, aspirin,methotrexate, and supportive medication. The therapeuticresponse after 6 months was favorable. GER and Skinulcers healed, and skin thickening and pulmonary changesdid not progress.