Question

Toxicology Course

Analyze this case, what is the possible toxicant exposure? There maybe more than one!

A 48 year old man that you are treating for acne returns to your clinic for a follow up appointment. You first saw this patient about 3 weeks ago. At that time, he had multiple acne-like lesions on his face and eyelids. (See picture below). The patient noted that he was surprised about the development of acne at his age; he never suffered from this condition during adolescence. He had used over-the-counter astringents and anti-acne medications, but they did not affect the lesions.

A review of the patient’s medical history indicates that he has:

• No history of hepatitis
• No recollection of contact with hepatitis patients
• No prior evidence of liver difficulties
• No record of blood transfusion.

The patient is married and has three teenaged children. His wife and children are in good health. They live in an older high rise apartment building where the patient has been a handyman, electrician and part-time building manager for the past year. He spends a lot of time in the basement area, which includes:

• Heating facilities
• A laundry,
• A recreation room with pool table, and
• A workshop.

The patient is an avid fisherman who spends most weekends fishing and eating his catch with his two sons. His biochemical panel reveals the following:

ALT    74 IU/L          Normal 0 – 50 IU/L

Glutamyl transpeptidase (GGTP or GGT) 190 IU/L (normal 15–85)

Total bilirubin 2.8 mg/dL (normal 0–1.5)

BUN and Creatinine: Normal

ALP Normal

1. What toxicants might you suspect given the presentation above?
2. Why would the toxicant cause the symptoms enumerated?
3. What lab tests could you order to confirm your diagnosis?
4. How might you treat this patient

Answer 1

Based on the lab result which shows liver being affected and the symptoms of acne is very similar to the skin problems due to chlorinated hydrocarbons.

Chlorinated solvents are used in dry cleaning facilities and since the patient spends most of the time in the basement where there is laundry he is exposed to  the chemical.

While consuming sea food he is again exposed to dioxins (Polychlorinated dibenzodioxins (PCDDs)) which too could give rise to the above problems. Since the children were not affected this shows that there was additional exposure to cause this reaction in the patient, that is over-exposure to halogenated aromatic compounds including chlorinated dioxins and dibenzofurans.

Since he was a handyman he could have maintained the various equipments for which he could have used the chlorinated solvent, also the heat exchange medium in certain facilities uses chlorinated solvents.

The toxicant causes the skin oil to be removed and causes skin irritation leading to acne like lesions in the face. This affliction is called as Chloracne. Oedema of skin and straw coloured cysts accompanied by pustules are the first symptoms of the onset of chloracne.

Later it can affect other organs especially liver dysfunction as it is toxic to the system.

The history of the patient, physical examination and examination of tissue - histopathology, and high serum concentration of chloracnegens through lab tests can confirm the diagnosis. Immunohistochemical tests can be performed on the skin lesions to support the diagnosis.

Treatment option would be to prevent exposure to these toxic substances, as it is highly resitant to any treatment. Symptoms of the disease can be treated with appropriate treatment like cauterisations for lesions and antibiotics for secondary infections.