INTRODUCTION:Exposure to fumes from heated fluorine-containing polymers (fluoropolymers) is known to cause polymer fume fever and chemical pneumonitis. However, the diagnosis can easily be missed. This case report outlines the importance of a detailed occupational history in the presentation of sudden shortness of breath and flu-like symptoms.
CASE PRESENTATION:A 29 year old previously healthy man presented with sudden onset of dyspnea, chest pain, dizziness, rigors and dry cough. His symptoms began shortly after smoking a cigarette at work, which he did regularly. His work involved waterproofing boat covers with a spray gun. He regularly wore a cartridge respirator while spraying, and denied any symptoms related to work. A co-worker also presented on the same day with similar symptoms. Past medical history included occasional sinusitis and seasonal allergies. He was on no medications. He had a 10 pack-year smoking history. There was no recent travel. Physical exam: Temperature 37.8oC; pulse 120 beats/minute; blood pressure 138/77 mmHg, RR 28 breaths/minute; SaO2(RA) 77% with subsequent SaO2(4L) 95%. He was alert but in respiratory distress using accessory muscles. Lung exam demonstrated bibasilar inspiratory crackles, without stridor. The remainder of the exam was unremarkable.Laboratory: WBC 18.7 (66% segs, 14% bands, 2% eosinophils, 8% monocytes, 10% lymphocytes); Creatinine 1.3; CK 873; troponin < 0.04; ABG(4L) 7.56/23/58/21.ECG: sinus rhythm, 120 beats/minute.CXR: bilateral lower lung field consolidation.Chest CT: Diffuse ground glass infiltrates, predominantly in the middle and lower lobes.Hospital course: The patient was admitted to the Intensive Care Unit and treated with supplemental oxygen, ceftriaxone and doxycycline, and intravenous corticosteroids. Further evaluation included blood cultures and nasal viral swab that were negative. He was unable to expectorate a sputum sample. Additional occupational history revealed that he had worked as a boat cover repairer for the past 7 years without incident. Due to cold weather on the day of admission, the windows and doors that normally served as ventilation in the factory had been shut. The material data safety sheet (MSDS) for the waterproofing product was reviewed; it listed only non-toxic mineral spirits. The manufacturer of the product was contacted, who revealed that the product also contained a fluoropolymer. No other chemical products were present. The patient improved, and after four days no longer required oxygen supplementation. Follow up chest radiograph showed resolution of infiltrates.
DISCUSSIONS:Inhalation of heated fluoropolymers, such as polytetrafluoroethylene (PTFE or Teflon), can cause a clinical syndrome called polymer fume fever. Such polymers are used in various manufacturing processes, including production of “non-stick” cooking utensils, upholstery production, and ski waxing. When heated, the combustion products can cause a flu-like illness with fever and chills. Less commonly, a more severe chemical pneumonitis occurs, with dyspnea, hypoxia, and, pulmonary interstitial edema. Typical radiographic findings include bilateral alveolar infiltrates.Symptoms and radiographic findings typically resolve within days without sequelae. Limited case reports suggest that repeated or more severe exposures may cause chronic obstructive or restrictive changes. Workers who smoke are at greater risk, resulting from combustion of fluoropolymercontaminated cigarettes. Workplace precautions include use of a respirator when working with heated fluorocarbons, adequate ventilation, and avoidance of cigarettes at work which could get contaminated. In this case it is likely that polymer combustion products from the patient’s fluoropolymer-contaminated cigarette were the primary cause of lung injury. Decreased ventilation at the workplace may have led to fluorocarbon deposition on the cigarettes in the vicinity of the sprayed product.
CONCLUSION:Inhalation of combusted fluoropolymers can cause a clinical spectrum including flu-like illness and pneumonitis. Diagnosis requires a thorough occupational history. Increased recognition of this disease will more clearly elucidate pathophysiologic mechanisms and treatment options.
DISCLOSURE:Negin Hajizadeh, No Financial Disclosure Information; No Product/Research Disclosure Information