SHOE SHINING: HAZARDOUS TO THE HEALTH

Abstract

SESSION TITLE: Occupational and Environmental Lung Diseases SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Hydrocarbons are ubiquitous in society and are found in many common household products, including gasoline, cleaning agents, mineral oil, and industrial solvents. In 2016, the American Association of Poison Control Centers reported 29,796 cases of hydrocarbon exposure, with approximately 20 deaths attributed to this exposure. There are three main types of hydrocarbon exposure: children with unintentional ingestion of household hydrocarbons, workers with dermal or inhalational occupational exposures, and adolescents and young adults with intentional inhalational abuse. CASE PRESENTATION: Our patient is a 40-year-old male sailor who presented to the emergency department with productive cough and dyspnea. Approximately two hours prior to arrival, the patient was waterproofing his boots in an enclosed space. On initial evaluation, his heart rate was in the 100s, respiratory rate in the 30s, and oxygen saturation in the 70s%. His exam was notable for diffusely diminished breath sounds. He was placed on 10 liters via nonrebreather. The Poison Control Center was contacted, and the inhaled toxin was identified as a petroleum-based hydrocarbon. A chest x-ray showed diffuse bilateral hazy opacities. He was admitted to the intensive care unit and placed on high-flow nasal cannula with flow and FiO2 titrated to maintain oxygen saturation greater than 92%. A high resolution CT scan of the chest showed diffuse bilateral upper and central lobe predominant groundglass opacities with subpleural sparing consistent with diffuse alveolar damage. Treatment with high dose steroids and bronchodilators was initiated, and over the next 48 hours the patient had significant improvement. He was discharged on a tapering dose of prednisone and supplemental oxygen at 4 liters per minute for exertion. After discharge, his spirometry showed a mild restrictive pattern with a mild reduction in DLCO; he no longer required supplemental oxygen. Follow up chest imaging is currently pending. DISCUSSION: The mechanisms by which hydrocarbons cause pulmonary toxicity are dose-dependent, and include alveolar and interstitial edema, desquamation of pneumocytes, and disruption of surfactant. Hypoxia results from a combination of ventilation-perfusion mismatch, shunt formation, and bronchospasm. Initial imaging may be normal, with delay of radiographic changes for several hours after the development of pneumonitis. Radiographic findings typically demonstrate bilateral interstitial infiltrates, though may also reveal pneumatocele, pneumothorax, pleural effusions, and lung necrosis; additionally, intra-alveolar oils can coalesce into nodules surrounded by fibrosis called parafinomas. While symptoms usually resolve within a few days, radiographic abnormalities may last months. Most cases of hydrocarbon lung toxicity resolve with supportive care of oxygen and ventilatory support, but there have been case reports of benefit from corticosteroids, whole or segmental lung lavage, and intratracheal surfactant in severe cases, though there is no firm evidence for these treatments. CONCLUSIONS: Hydrocarbons are found in several household products, making exposure to these items not uncommon. While the acute effects of hydrocarbon toxicity are well recognized, the long-term effects of acute and chronic exposure require further research. Reference #1: Connellan SJ. Lung diseases associated with hydrocarbon exposure. Resp Med 2017; 126:46-51. Reference #2: Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report, Clin Toxicol 2017;55:(10)1072-1254. Reference #3: Tormoehlen LM, Tekulve KJ, Nanagas KA. Hydrocarbon toxicity: A review. Clin Toxicol 2014; 52:479-489. DISCLOSURES: No relevant relationships by Jeannette Collins, source=Web Response No relevant relationships by Angeline Lazarus, source=Web Response