A 26 year old man presented complaining of persistent headaches for one month. He had a history of occasional headaches since adolescence, but, during the past four months, his symptoms had increased in intensity and frequency and were no longer relieved by over-the-counter medication. He had worked as a carpenter in a laminated product manufacturing company for the previous six months, where his duties included working with lacquer thinner to clean cabinet surfaces and spraying laminating materials over cabinet surfaces. Neither he nor any of the other workers used any type of personal protective equipment. The products he used included a spray contact cement which contained 70% methylene chloride, toluene and methyl ethyl ketone and a lacquer thinner which contained toluene, isopropanol, ethyl acetate, isobutyl alcohol and isobutyl acetate. Physical examination was unremarkable apart from his skin on both hands, which showed marked thickening and was very dry with fissures and cracking. Neurological examination was normal, and laboratory investigations including carboxyhaemoglobin concentration (COHb), were normal. Instructions were given to the patient to have his primary care physician check his COHb concentration after a work shift, particularly when he became symptomatic. The next day, although he was working with the doors of the workroom open, he had a mild headache and his COHb was 6.4%. Four days later he was working with the doors of the workroom closed and he reported that the room was poorly ventilated. He became unwell with nausea and vomiting and left work early. He was reported to have a COHb of 21% approximately 35 minutes after leaving his place of work and subsequently received normobaric oxygen therapy. His workplace was subsequently inspected by officials from the local occupational hygiene division, fire and health departments. The major findings were area samples showing methylene chloride concentrations of 300-500 ppm and a carbon monoxide concentration of 28 ppm. Based on this information the company immediately substituted a water based process for the one previously utilising methylene chloride (Mahmud and Kales, 1999).
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