title: Acute life-threatening extrinsic allergic alveolitis in a paint controller.
abstract: BACKGROUND
  Occupational diisocyanate-induced extrinsic allergic alveolitis (EAA) is a rare and probably underestimated diagnosis. Two acute occupational EAA cases have been described in this context, but neither of them concerned hexamethylene diisocyanate (HDI) exposure.
  
  
  OBJECTIVE
  To investigate the cause of a life-threatening EAA arising at work in a healthy 30-year-old female paint quality controller.
  
  
  METHODS
  Occupational medical assessment, workplace evaluation, airborne and biological monitoring and immunodermatological tests.
  
  
  RESULTS
  Diagnosis of EAA relied on congruent clinical and radiological information, confirmed occupational HDI exposure and positive IgG antibodies and patch tests. The patient worked in a small laboratory for 7 years, only occasionally using HDI-containing hardeners. While working with HDI for 6 h, she developed breathlessness, rapidly progressing to severe respiratory failure. Workplace HDI airborne exposure values ranged from undetectable levels to 4.25 p.p.b. Biological monitoring of urinary hexamethylene diamine in co-workers ranged from <1.0 to 15.4 μg/g creatinine. Patch tests 8 months later showed delayed skin reaction to HDI at 48 h. Subsequent skin biopsy showed spongiotic dermatitis with infiltration of CD4(+) and CD8(+) T cells.
  
  
  CONCLUSIONS
  We believe this is the first reported case of acute life-threatening EAA following exposure to HDI. Low concentrations of airborne HDI and relatively high urinary hexamethylene diamine suggest significant skin absorption of HDI could have significantly contributed to the development of this acute occupational EAA.
authors.affiliation: Institute for Work and Health, 21 Bugnon Street, 1011 Lausanne, Switzerland.
authors.forename: G
authors.initials: G
authors.lastname: Bieler
authors.forename: D
authors.initials: D
authors.lastname: Thorn
authors.forename: C K
authors.initials: CK
authors.lastname: Huynh
authors.forename: C
authors.initials: C
authors.lastname: Tomicic
authors.forename: U-C
authors.initials: UC
authors.lastname: Steiner
authors.forename: N
authors.initials: N
authors.lastname: Yawalkar
authors.forename: B
authors.initials: B
authors.lastname: Danuser
mesh_terms: D000328:Adult; D000395:Air Pollutants, Occupational / Q000633:toxicity*; D000542:Alveolitis, Extrinsic Allergic / Q000139:chemically induced*; D003485:Cyanates / Q000633:toxicity*; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D017953:Isocyanates; D009784:Occupational Diseases / Q000139:chemically induced*; D016273:Occupational Exposure / Q000009:adverse effects*; D010150:Paint / Q000633:toxicity*
chemical_list: D000395:Air Pollutants, Occupational; D003485:Cyanates; D017953:Isocyanates; C015262:1,6-hexamethylene diisocyanate