Toxic reaction to white spirit fumes

A 60 year old man was admitted to hospital confused and pyrexial. Thirty hours prior to admission he had spent approximately one hour painting large surfaces with a polyurethane paint in a small non-ventilated room. Prior to this he had been well, with no history of recent drug or alcohol consumption, nor any other chemical exposure. He drank 30 units of alcohol weekly. Immediately after painting he appeared pale and unwell and complained of malaise and anorexia. He went to bed but spent a very restless night and was noted to be coughing. He got up for a short while 19 hours later but returned to bed because he was unsteady on his feet. His cough continued and he was still restless, often shouting in his sleep. After a further six hours he got up again, but was very uncoordinated and complained of a headache. He subsequently fell down stairs and was unrousable for about five minutes, then became aggressive and confused.

On admission he had a temperature of 40°C, and a left periorbital haematoma. He was drowsy with no memory of recent events, but was well orientated and cardiovascular and neurological examinations were unremarkable. There were no signs of chronic liver disease or jaundice, but the liver and spleen were palpable and there were a few course crepitations in the right lung mid-zone. At this stage haematological investigations, urea, creatinine and electrolytes, chest X-ray and ECG were normal. Blood, urine and sputum cultures were negative. Three days after admission aspartate aminotransferase (AST) was raised, but bilirubin, alkaline phosphatase and gamma glutamyl transferase were normal. Viral titres and cultures, hepatitis B surface antigen, hepatitis B specific immunoglobulin and autoantibodies including antinuclear factor and smooth muscle antibody, were negative. The patient improved without any specific treatment, becoming lucid and apyrexial over the next three days. At this stage the spleen was barely palpable and by the next day could not be felt. The liver remained palpable. An ultrasound scan at this time showed normal appearances of liver and spleen. A blood count four days after admission showed thrombocytopenia; AST had risen further. Histological examination of a percutaneous needle biopsy of the liver showed changes of mitotic activity and thickening of liver cell plates. Necrosis and steatosis were not observed. There was no evidence of any chronic liver disease. The appearances were consistent with the sequelae of exposure to a toxic organic solvent. On discharge five days after admission the patient was well. At follow up one month later he had normal liver function tests, biochemical profile and haematological indices. The authors concluded that the patient had a reaction to white spirit fumes that caused reversible hepatic, bone marrow and nervous system toxicity. In response to the case study publication, however, the manufacturer's medical advisor expressed doubt as to whether the patient's symptoms were solely due to the paint exposure and suggested that other factors were involved (Atkinson et al., 1989).

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