Mustard exposure, complications

Table 3.6 Complications 3 Chemical Terrorism of mustard exposure... 

Mustard burns may leave areas of hypopig-mentation or hyperpigmentation, sometimes with scarring. Individuals who survive an acute, single mustard exposure with few or no systemic or infectious complications appear to recover fully. Previous cardiopulmonary disorders, severe or inadequately treated bronchitis or pneumonitis, a prior history of smoking, and advanced age all appear to contribute to long-term chronic bronchitis there is no definitive way to determine whether these conditions are the result of aging,... 

Of the long-term complications of wartime exposure to mustard gas, perhaps the best documented and one of the most serious is recurring corneal ulcers, with eventual opacification and blindness. No exact figures are available for predicting the eventual development of such long-term corneal lesions, but it has been reported that a Ct of 100 mg min/m will cause acute blindness for 24-48 h.20 Permanent blindness typically occurred about 14 yr... 

Acute exposures to sulfur mustard can result in skin and eye damage, gastrointestinal irritation, and depressed myelopoiesis (resulting in leukopenia and anemia) (Vogt et al., 1984). Damage to the respiratory tract, which is the principal cause of mortality in the first few days to weeks after exposure to sulfur mustard, involves acute edema, inflammation, and destruction of the airway epithelial lining (Institute of Medicine, 1993). Infection of the respiratory tract resulting in bronchopneumonia is a common complication of exposure to sulfur mustard. 

Khateri, S., Ghanei, M., Keshavarz, S., Soroush, M., Haines, D. (2003). Incidence of lung, eye, and skin lesions as late complications in 34,000 Iranians with wartime exposure to mustard agent. J. Occup. Environ. Med. 45 1136 3. 

Hefazi, M., Maleki, M., Mahmoudi, M., Tabatabaee, A., Balali-Mood, M. (2006). Delayed complications of sulfur mustard poisoning in the skin and the immune system of Iranian veterans 16-20 years after exposure. Int. J. Dermatol. 45 1025-31. 

Pediatric exposures to vesicants can be quite toxic however, in contrast to nerve agent exposures, HD causes significantly greater morbidity than mortality. While mustard did not cause many deaths in WWI, death from HD exposure is usually due to massive pulmonary damage complicated by infection (bronchopneumonia) and sepsis. Children often show a quicker onset and greater severity of toxicity. Skin and eye toxicity occurs in the form of blisters or irritation that can result in blindness for the most severe cases. Except for lewisite, vesicant exposures must be managed with supportive care and rapid decontamination. 

Although incapacitating airway injury occurs at vapor exposures significantly lower than those that cause severe skin blistering, inhaled sulfur mustard injures respiratory epithelium from the nasopharynx to the bronchioles. Since WWI, the majority of deaths occurring in sulfur mustard casualties have resulted from respiratory complications (Vedder, 1925 Warthin et al., 1918 Willems, 1989). Mild cases are treated to allow maximum comfort, whereas severe cases must attain ade-... 

The reported proportion of casualties who fully recover from sulfur mustard respiratory injury varies from over 90% (Vedder, 1925) to only 20% (Balali-Mood, 1986). Much of this variation can be explained by differences among patients and by attribution of chronic bronchitic symptoms to previous mustard gas exposure in the presence of ongoing causes such as heavy smoking. Major chronic problems such as bronchiectasis and recurrent pneumonia appear confined to casualties who had severe pulmonary infections complicating the acute injury (Urbanetti, 1988). Ocular and skin injuries generally heal completely but with the need for corneal transplantation or for skin grafting to deal with uncommon complications. 

Most casualties die of massive pulmonary damage complicated by infection (bronchopneumonia) and sepsis (resulting from loss of the immune mechanism). When exposure is not by inhalation, the mechanism of death is less clear. In studies with animals in which mustard was administered via routes other than inhalational, the animals died from 3 to 7 days after the exposure they had no signs of pulmonary damage and often had no signs of sepsis. The mechanism of death was not clear, but autopsy findings resembled those seen after radiation.81 (Mustard is considered to be a radio-mimetic because it causes tissue damage similar to that seen after radiation.)... 

Respiratory complications are the greatest cause of long-term disability among people with SM exposure. A pulmonologist who investigated the pulmonary complications in Iranian veterans in 2007 named it mustard lung (Ghanei and Adibi, 2007). 

Several studies have reported chronic bronchitis as the most common late complication of the respiratory system resulting from war exposure to mustard gas (Balali-Mood, 1992 Emad and Rezaian, 1997 Ghanei et al., 2004a-c, 2005,2006a,b Balali-Mood et al., 2005a,b). 

Emadi, S.N., Aslani, J., Poursaleh, Z., et al., 2012. Comparison late cutaneous complications between exposure to sulfur mustard and nerve agents. Cutan Ocul. Toxicol. 31 (3), 214 9. 

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