title: Epidemic parenteral exposure to volatile sulfur-containing compounds at a hemodialysis center.
abstract: OBJECTIVE
  To determine the cause of acute illness on August 30, 2000, among patients at an outpatient dialysis center (center A).
  
  
  METHODS
  We performed a cohort study of all patients receiving dialysis on August 30, 2000; reviewed dialysis procedures; and analyzed dialysis water samples using microbiologic and chemical assays.
  
  
  METHODS
  Dialysis center (center A).
  
  
  METHODS
  A case-patient was defined as a patient who developed chills within 5 hours after starting hemodialysis at center A on August 30, 2000.
  
  
  RESULTS
  Sixteen (36%) of 44 patients at center A met the case definition. All case-patients were hospitalized; 2 died. Besides chills, 15 (94%) of the case-patients experienced nausea; 12 (75%), vomiting; and 4 (25%), fever. Illness was more frequent on the second than the first dialysis shift (16 of 20 vs 0 of 24, P < .001); no other risk factors were identified. The center's water treatment system had received inadequate maintenance and disinfection and a sulfurous odor was noted during sampling of the water from the reverse osmosis (RO) unit. The water had elevated bacterial counts. Volatile sulfur-containing compounds (ie, methanethiol, carbon disulfide, dimethyldisulfide, and sulfur dioxide) were detected by gas chromatography and mass spectrometry in 8 of 12 water samples from the RO unit and in 0 of 28 samples from other areas (P < .001). Results of tests for heavy metals and chloramines were within normal limits.
  
  
  CONCLUSIONS
  Parenteral exposure to volatile sulfur-containing compounds, produced under anaerobic conditions in the RO unit, could have caused the outbreak. This investigation demonstrates the importance of appropriate disinfection and maintenance of water treatment systems in hemodialysis centers.
authors.affiliation: Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
authors.forename: Dejana
authors.initials: D
authors.lastname: Selenic
authors.forename: Francisco
authors.initials: F
authors.lastname: Alvarado-Ramy
authors.forename: Mathew
authors.initials: M
authors.lastname: Arduino
authors.forename: Stacey
authors.initials: S
authors.lastname: Holt
authors.forename: Fred
authors.initials: F
authors.lastname: Cardinali
authors.forename: Benjamin
authors.initials: B
authors.lastname: Blount
authors.forename: Jeff
authors.initials: J
authors.lastname: Jarrett
authors.forename: Forrest
authors.initials: F
authors.lastname: Smith
authors.forename: Neil
authors.initials: N
authors.lastname: Altman
authors.forename: Charlotte
authors.initials: C
authors.lastname: Stahl
authors.forename: Adelisa
authors.initials: A
authors.lastname: Panlilio
authors.forename: Michele
authors.initials: M
authors.lastname: Pearson
authors.forename: Jerome
authors.initials: J
authors.lastname: Tokars
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D002954:Citrobacter / Q000302:isolation & purification; D015331:Cohort Studies; D015169:Colony Count, Microbial; D003428:Cross Infection / Q000453:epidemiology / Q000209:etiology / Q000382:microbiology; D004196:Disease Outbreaks; D004220:Disulfides / Q000633:toxicity*; D004866:Equipment Contamination; D005260:Female; D017583:Hemodiafiltration / Q000009:adverse effects* / Q000295:instrumentation*; D015312:Hemodialysis Solutions / Q000633:toxicity; D006801:Humans; D008297:Male; D008875:Middle Aged; D009995:Osmosis; D006435:Renal Dialysis / Q000009:adverse effects* / Q000295:instrumentation; D013212:Staphylococcus epidermidis / Q000302:isolation & purification; D014877:Water Pollution, Chemical / Q000009:adverse effects* / Q000032:analysis
chemical_list: D004220:Disulfides; D015312:Hemodialysis Solutions