Clinical Analysis And Prognosis Study On Occupational Medicamentosa-like Dermatitis Induced By Trichloroethylene

Objects To describe the occupational epidemiological and clinical characteristics of the cases who were diagnosed as Occupational Dermatitis Medicamentosa-like of Trichloroethylene (OMDT). We tried to shed light on the pathogenic research of OMDT as well as to better the treatment. Meanwhile we carried out prognosis study to investigate the late effect related to OMDT or Glucocorticoid treatment.Methods The cases who were hospitalized in the Hospital of Occupational Diseases Control of Guangdong Province from 1997 to 2008 were collected according to our inclusion and exclusion criteria, and analyzed by focusing on the general personal information, occupational history, workplace investigation as well as clinical manifestation and laboratory results. All the data were recorded through Epidata3.1, managed and analyzed by Excel and SPSS13.0. We compared clinical manifestation and laboratory results based on related factors, by Pearsonχ2 test for categorical variables, and by Student's t test or ANOVA and Wilcoxon test or Kruskal-Wallis test for the continuous variables depending on their distribution. We also did the prognosis study to explore possible late effect probably related to OMDT or Glucocorticoid treatment, which includes immune, cutaneous, liver and renal impairment as well as carcinogenicity and reproductive toxicity.Results1. Occupational epidemiological characteristicsWe included 200 cases of OMDT for our study. Based on the results, we couldn't find evident differences about gender ratio and provinces distribution, but the workers from the south were more than that from the north.86.5% of the cases were young workers, and the M was 22 years old. The cases concentrated between 1999 and 2006. And the cases started decreasing from 2005. There were significant high incidence in March to April, August and October, yet low incidence in February, July and November to December. Most of the cases were happened in electroplating-hardware plants, followed by electronics plants in Pearl River Delta region, Guangdong province.All the OMDT exposed to TCE definitely, and onset around 30 days after commencement of occupational TCE exposure. Workfellows almost didn't suffer from OMDT, and just limited to a small amount of workers who could be rapid recurrence of rash when re-exposed to TCE. The exposing concentrations of TCE of 49 cases were tremendously different. The maximum was 13072.8 mg/m3 and the minimum was 0.60 mg/m3 as well as the M was 46.90mg/m3.44.9% of them were under the Occupational Exposure Limits(OELs,60mg/m3). The incubation periods of the cases whose TCE exposure concentrations were less than OELs were longer than the others. After stopping TCE exposure about 1 to 58 days, the M of TCA concentration in urine was 28.10 mg/L.26.8% of the cases' TCA concentrations in urine exceeded 50mg/L(OELs) and 55.1% were under the OELs. About job categories,68.5% of the cases were soaking and scrubbing materials with TCE, yet 31.5% of the cases who didn't use TCE but exposed to TCE since they worked in the same workplaces with TCE job categories.88.0% of the cases didn't have any individual protective equipment.2. Clinical manifestation and impairment characteristicsClinical Manifestations Characteristics The main clinical manifestations of OMDT were erythra, fever, lymphadenopathy and liver disorder. We grouped OMDT into four clinical types, Exfoliative dermatitis (75.1%), Polymorphic erythema (15.9%),Stevens-Johnson Syndrome (5.5%) and Epidermolysis Bullosa (3.5%). And we couldn't find any difference about the gender ratio, TCE exposure concentrations and NAT2 genotypes among the clinical types. For blood routine examinations at the time of hospitalization, Esoinophilia of 82(43.2%) were higher than reference values. B ultrasonic suggested that 107 cases of OMDT were hepatomegaly, splenomegaly, or hepatosplenomegaly. Electrocardiogram showed 94 cases with abnormal ECG, including frequent sinus irregularity.Laboratory Results Comparing the laboratory results between at the time of hospitalization(TH) and the convalescence period(CP,30～60 days after treatment), the ALT, AST, D-BIL, TBA, AKP, GGT in TH were significantly higher than the latter, but ChE was lower, while the TP, ALB, GLB were not statistically significant. The GGT of Juveniles were higher than adults'and ChE of fast NAT2 genotypes were higher than slow NAT2 genotypes (P <0.05). We couldn't find any significant differences about liver function laboratory results in different TCE exposure concentrations groups and clinical types groups.The IgG, IgA and CRP in TH were higher than that in AP, while C3 was lower than the latter significantly. And the differences about IgM and C4 level were not statistically significant. The liver disorder degree of the cases whose C3 levels were less than reference values were more critical than those whose C3 levels were normal. The IgG of slow NAT2 genotypes were higher than the fast one, while we couldn't find any significant differences about immune function laboratory results in different age, TCE exposure concentrations and clinical types groups. The peripheral mature lymphocytes of CD3+, CD8+levels of 32 cases were higher than reference values significantly, while the total lymphocytes, CD4+, NK, B lymphocytes CD19+and CD4/CD8 were lower than reference values significantly. The CK, CK-MB, LDH as well as HBDH levels in TH were higher than those in CP significantly. The CK-MB of Stevens-Johnson Syndrome types was higher than other clinical types.8 cases of BUN test were abnormally higher than reference values,7 cases of CREA, and 14 cases of UA. Yet only 3 cases of the BUN, CREA and UA were higher than reference values at the same time. However, the BUN level in TH were lower than that in CP (P<0.001).The CREA of the cases whose TCE exposure concentration exceeded OELs were higher than the other.3. Treatment and OutcomesTreating with appropriated dosage of glucocorticoid was critical for the recovery of OMDT. The M of initial dose (in the term of a-methyl-prednisolone) was 100 mg. The initial dose lasted 5 days and then began to extenuate, and the extenuation dosage was 10.0 mg (M).The course of treatment was 62 days (M), and total dosage of glucocorticoid was 2910.2mg(M). The course of treatment and total dosages among the cases whose TCE exposure concentration exceeded OELs were larger than the other. The incidence rate of complications was 59.5%. The common complications of OMDT were cholecystitis, lung infections, keratitis and conjunctivitis.92.9% of OMDT could recover and discharged after treatment, while the mortality was 7.1%. The leading causes of mortality were liver failure combined with MODS and infectious diseases such as severe pneumonia and sepsis.4. Prognosis study71 cases of OMDT have been found by now, the others couldn't be found because of the contact information were invalid.46 cases had the various healthy problems while the others were not. The main healthy problems included skin itching, allergy to medicines and materials, frequent fever and cold, et al. The serious problems were Xerophthalmus and ONFH. When separated into two groups, we could not find significant differences among the TCE exposure concentrations, NAT2 genotypes, and clinical types. The cases with various healthy problems had the larger total dosage of glucocorticoid than those without any healthy problems. We could figure out that the incident rate of healthy problems increased progressively with the increasing dosage of glucocorticoid. We were grabbed by a female OMDT who had baby once but the infant died after parturitions because of congenital malformation. Although the couple had the similar family medical history, we still have to investigate this later. About the psychosocial influences,95.8% of the OMDT claimed that the disease experiences influenced their daily life and handicapped their job-finding. All the cases felt frightened about TCE and other organic solvents as well as recurrence of OMDT. ConclusionYoung workers were the main source of the cases probably since they were also the main exposure population. And the cases were idiosyncrasy as the workfellows almost didn't suffer from OMDT. All the cases exposed to TCE definitely and initially but varied from the exposing time and concentrations which suggests OMDT doesn't have the dose-response relationship. All the cases were the very first time exposure to TCE around 30 days before diseases onset. We suggest that it's essential to draft protective and preventive criteria for the chemicals such as TCE that can cause immune impairment.OMDT was obviously rapid-onset and caused massive healthy impairments, including skin disorder, immune-mediated liver injury as well as cardiac involvement. But only about 8.0% cases had renal involvement and half of them resulted from MODS. Appropriate glucocorticoids treatment was the key to OMDT whose mortality was 7.1%. And the mortality was lower than before based on our study.The pathogenesis of OMDT was proved to be the immunoenhancement, probably caused by the hypersensitivity via the cell-mediated immunity and humoral immunity. And the immunoenhancement was supposed to cause the massive healthy impairment. However, C3 might not take part in this hypersensitivity.After discharge, we were unexpected to find 64.8% of the OMDT could have had varying healthy problems which are probably related to OMDT or total dosage of glucocorticoid according to our research.Yet the relationship between OMDT or glucocorticoid treatment and the healthy problems including ONFH by now remains to question. However, OMDT could affect the cases' life quality. Taking all into consideration, it's necessary to carry on the prognosis study. Meanwhile, they should be paid more attention.