The differential diagnosis for this patient might include coronary artery disease, acute bronchospasm, musculoskeletal injury, narcosis, anxiety, hyperventilation syndrome, solvent inhalation exposure, carbon monoxide poisoning, pulmonary embolus, and esophagitis.
Although the patient's work is mainly supervisory, he may do other work intermittently (e.g., as a replacement mechanic). It is important to know not only his job classification, but also his specific duties and what occurs in his immediate work environment. Occupational exposures might include solvents, motor fuels, antifreezes, hazardous noise, paints, welding fumes, freon, carbon monoxide, and ultraviolet exposure from arc welding. Suboptimal ergonomic work stations with heavy lifting or repetitive work could contribute to symptoms. Environmental exposures of concern might include solvents, paints, welding fumes, and carbon monoxide from auto repair and inadequately vented heating units. Living near industries or hazardous waste sites that release these materials into the environment may also result in exposure.
The temporal association of symptoms and use of the degreasing solution suggests a causal relationship. More information about the degreaser is needed, including its identity, ingredients, and potential health effects. The identity could be obtained from the patient or by checking with the bioenvironmental engineering officer responsible for the auto repair shop. The health effects can be determined by talking with the manufacturer, talking with a toxicologist at a regional poison control center, or by consulting printed or electronic information sources. If the degreaser is not the most likely cause of the patient's symptoms, other etiologies must be considered. The patient should be evaluated to exclude each of the diagnoses in answer (a).
Educating the patient about engineering controls, personal protective measures, and the health effects of Stoddard solvent should help prevent future problems. Although the chest tightness may have been triggered by exposure to Stoddard or another solvent, the presence of an underlying condition requires further evaluation. Because of the patient's family history, he should be evaluated for etiologies of chest pain, including coronary artery disease or a dysrhythmia.
It is important to assess whether the children come in contact with the material and, if so, what approximate doses they receive. If the material is applied in a well-ventilated area (e.g., outdoors) and in small quantities for a limited time, most people would not suffer significant health effects. However, the younger son, who is
asthmatic, could be at increased risk because the solvent may act as a nonspecific stimulus to provoke bronchoconstriction.
Flammable organic solvents such as Stoddard solvent should be used only by adults, with appropriate ventilation and skin protection. All potentially toxic substances should be kept in nonbreakable, clearly labeled containers, which should be tightly covered when not in use, and kept out of children's reach.
- Eye and throat irritation suggest that the patient may have been exposed to moderately high levels of Stoddard solvent, which could have also caused his CNS complaints (e.g., dizziness and euphoria) and respiratory complaints (e.g., burning sensation in the nose and throat). The overexposure could have occurred from widely applying the degreaser and heating it in an enclosed space with no ventilation.
Exposure to Stoddard solvent does not result in cardiovascular effects and is unlikely to be the cause of the patient's chest discomfort. The chest discomfort and dizziness are consistent with angina due to underlying cardiac disease or a transient dysrhythmia.
- The patient most likely has eczematous irritant contact dermatitis (see Case Studies in Environmental Medicine: Skin Lesions and Environmental Exposures). Exposure to Stoddard solvent, oils, other irritants, or allergens such as metal contaminants should be assessed, and cessation of exposure is recommended. The patient should be encouraged to use appropriate skin protection and to avoid contact when possible.
- There is no specific laboratory test that would prove the neighbor's complaints are due to Stoddard solvent. An industrial hygiene assessment using personal sampling could be carried out to determine whether the neighbor is exposed to Stoddard solvent. Neurobehavioral tests, which are functional tests of the CNS, could indicate whether impairment of function has occurred, but they would not indicate etiology.
- Advise against further unprotected exposure to known CNS toxicants such as ethanol, solvents, and certain gases (e.g., carbon monoxide).
- See Pretest answer (c).