title: Medical documentation, bioanalytical evidence of an accidental human exposure to sulfur mustard and general therapy recommendations.
abstract: Sulfur mustard (SM) is a chemical warfare agent (CWA) that was first used in World War I and in several military conflicts afterwards. The threat by SM is still present even today due to remaining stockpiles, old and abandoned remainders all over the world as well as to its ease of synthesis. CWA are banned by the Chemical Weapons Convention (CWC) interdicting their development, production, transport, stockpiling and use and are subjected to controlled destruction. The present case report describes an accidental exposure of three workers that occurred during the destruction of SM. All exposed workers presented a characteristic SM-related clinical picture that started about 4h after exposure with erythema and feeling of tension of the skin at the upper part of the body. Later on, superficial blister and a burning phenomenon of the affected skin areas developed. Similar symptoms occurred in all three patients differing severity. One patient presented sustained skin affections at the gluteal region while another patient came up with affections of the axilla and genital region. Fortunately, full recovery was observed on day 56 after exposure except some little pigmentation changes that were evident even on day 154 in two of the patients. SM-exposure was verified for all three patients using bioanalytical GC MS and LC MS/MS based methods applied to urine and plasma. Urinary biotransformation products of the β-lyase pathway were detected until 5 days after poisoning whereas albumin-SM adducts could be found until day 29 underlining the beneficial role of adduct detection for post-exposure verification. In addition, we provide general recommendations for management and therapy in case of SM poisoning.
authors: Bundeswehr Institute of Pharmacology and Toxicology, 80937 Munich, Germany; Walther-Straub-Institute of Pharmacology and Toxicology, Ludwig-Maximilians-University Munich, 80336 Munich, Germany.
authors: Dirk
authors: D
authors: Steinritz
authors: Department of Handsurgery, Plastic and Microsurgery, Burn Center, BG Trauma Hospital Hamburg, 21033 Hamburg, Germany.
authors: Enno
authors: E
authors: Striepling
authors: Department of Handsurgery, Plastic and Microsurgery, Burn Center, BG Trauma Hospital Hamburg, 21033 Hamburg, Germany.
authors: Klaus-Dieter
authors: KD
authors: Rudolf
authors: Institute for Interdisciplinary Dermatologic Prevention and Rehabilitation (iDerm) of the University of Osnabrück and Dermatologic Center, BG Trauma Hospital Hamburg, 21033 Hamburg, Germany.
authors: Claudia
authors: C
authors: Schröder-Kraft
authors: Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany.
authors: Klaus
authors: K
authors: Püschel
authors: RHG Medizinische Dienstleistungen, 29633 Munster, Germany.
authors: Andreas
authors: A
authors: Hullard-Pulstinger
authors: Bundeswehr Institute of Pharmacology and Toxicology, 80937 Munich, Germany.
authors: Marianne
authors: M
authors: Koller
authors: Bundeswehr Institute of Pharmacology and Toxicology, 80937 Munich, Germany.
authors: Horst
authors: H
authors: Thiermann
authors: Department of Chemistry, Humboldt-Universität zu Berlin, 12489 Berlin, Germany.
authors: Felix
authors: F
authors: Gandor
authors: Hamm-Lippstadt University of Applied Sciences, Biomedical Engineering, 59063 Hamm, Germany.
authors: Michael
authors: M
authors: Gawlik
authors: Bundeswehr Institute of Pharmacology and Toxicology, 80937 Munich, Germany. Electronic address: haraldjohn@bundeswehr.org.
authors: Harald
authors: H
authors: John
mesh_terms: D000059:Accidents; D000328:Adult; D001768:Blister / Q000139:chemically induced* / Q000175:diagnosis / Q000628:therapy; D002619:Chemical Warfare Agents / Q000378:metabolism / Q000506:poisoning*; D002853:Chromatography, Liquid; D004282:Documentation; D004890:Erythema / Q000139:chemically induced* / Q000175:diagnosis / Q000628:therapy; D008401:Gas Chromatography-Mass Spectrometry; D006801:Humans; D007509:Irritants / Q000506:poisoning*; D008297:Male; D008875:Middle Aged; D009151:Mustard Gas / Q000378:metabolism / Q000506:poisoning*; D011041:Poisoning / Q000175:diagnosis / Q000628:therapy; D011485:Protein Binding; D012074:Remission Induction; D012709:Serum Albumin / Q000378:metabolism; D000075462:Serum Albumin, Human; D012720:Severity of Illness Index; D012867:Skin / Q000187:drug effects* / Q000473:pathology; D053719:Tandem Mass Spectrometry; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: C422455:ALB protein, human; D002619:Chemical Warfare Agents; D007509:Irritants; D012709:Serum Albumin; D009151:Mustard Gas; D000075462:Serum Albumin, Human
keywords: Albumin adducts; Chemical warfare agents; Sulfur mustard; Vesicant; ß-lyase products