Agency for Toxic Substances and Disease Registry
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Learning Objectives |
Upon completion of this section, you will be able to
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Purpose |
Most environmental and occupational diseases either manifest as common medical problems or have nonspecific symptoms. Yet environmental factors rarely enter into the clinician’s differential diagnosis. As a result, clinicians miss the opportunity to make correct diagnoses that might influence the course of disease in some afflicted individuals (by stopping exposure) and that might prevent disease in others (by avoiding exposure) (Goldman and Peters 1981). What can a clinician do to improve recognition of disease related to current or past exposures? First, one must be suspicious and think about the possibility of environmental factors of disease. Next, one needs to incorporate an exposure history questionnaire into the practice. The purpose of this case study is not to demonstrate all exposure possibilities but rather to illustrate the principles and process of investigating the etiology. |
Exposure Factors vs. Etiology |
The preceding case study describes a patient with angina. He has new, nonspecific symptoms of headache and nausea. Suppose this patient lived near a hazardous waste site.
Each of these factors could play a role in the etiology of this patient’s illness; each exposure could cause disease. |
Three Scenarios |
The patient described in the case study—a 52-year-old male with angina—is portrayed in three scenarios throughout this document. An exposure history provides clues that prompt the clinician to investigate the possibility of toxic exposure.
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Etiologic Diagnosis |
Most environmental and occupational diseases either manifest as common medical problems or have nonspecific symptoms (e.g., headache, difficulty concentrating, behavioral problems, rashes, asthma, angina, myalgia, difficulty conceiving, spontaneous abortion) (Amdur MO 1991; Wigle D 2000; Marshall, Weir et al. 2002). Etiology distinguishes a disorder as an environmental illness. Unless an exposure history is pursued by the clinician, the etiologic diagnosis might be missed, treatment may be inappropriate, and exposure can continue. |
Table 1. Examples of Environmental Causes of Medical Problems (Goldman and Peters 1981) | ||
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Symptoms and Diseases | Agent | Potential Exposures |
Immediate or Short-term Effects | ||
dermatoses (allergic or irritant) |
metals (chromium, nickel), fibrous glass, solvents, caustic alkali, soaps |
electroplating, metal cleaning, plastics, machining, leather tanning, housekeeping |
headache |
carbon monoxide, solvents |
firefighting, automobile exhaust, wood finishing, dry cleaning |
acute psychoses |
lead, mercury, carbon disulfide |
removing paint from old houses, fungicide, wood preserving, viscose rayon industry |
asthma or dry cough |
formaldehyde, toluene diisocyanate, animal dander |
textiles, plastics, polyurethane kits, lacquer, animal handler |
pulmonary edema, pneumonitis |
nitrogen oxides, phosgene, halogen gases, cadmium |
welding, farming, chemical operations, smelting |
cardiac arrhythmias |
solvents, fluorocarbons |
metal cleaning, solvents use, refrigerator maintenance |
angina |
carbon monoxide, methylene chloride |
car repair, traffic exhaust, foundry, wood finishing |
abdominal pain |
lead |
battery making, enameling, smelting, painting, welding, ceramics, plumbing |
hepatitis (may become a long-term effect) |
halogenated hydrocarbons (e.g., carbon tetrachloride) |
solvents use, lacquer use, hospital workers |
Latent or Long-Term Effects | ||
chronic dyspnea, pulmonary fibrosis |
asbestos, silica, beryllium, coal, aluminum |
mining, insulation, pipefitting, sandblasting, quarrying, metal alloy work, aircraft or electrical parts |
chronic bronchitis, emphysema |
cotton dust, cadmium, coal dust, organic solvents, cigarettes |
textile industry, battery production, soldering, mining, solvent use |
lung cancer |
asbestos, arsenic, nickel, uranium, coke-oven emissions |
insulation, pipefitting, smelting, coke-ovens, shipyard workers, nickel refining, uranium mining |
bladder cancer |
β-naphthylamine, benzidine dyes |
dye industry, leather, rubber-workers, chemists |
peripheral neuropathy |
lead, arsenic, hexane, methyl butyl ketone, acrylamide |
battery production, plumbing, smelting, painting, shoemaking, solvent use, insecticides |
behavioral changes |
lead, carbon disulfide, solvents, mercury, manganese |
battery makers, smelting, viscose rayon industry, degreasing, manufacture/repair of scientific instruments, dental amalgam workers |
extrapyramidal syndrome |
carbon disulfide, manganese |
viscose rayon industry, steel production, battery production, foundry |
aplastic anemia, leukemia |
benzene, ionizing radiation |
chemists, furniture refinishing, cleaning, degreasing, radiation workers |
Key Points |
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Progress Check |