INTRODUCTION: The United States Consumer Product Safety Commission recalled Stand N’ Seal “Spray-On” Grout Sealer after 88 reports of adverse reactions after using the aerosolized sealant. 28 individuals sought medical attention for respiratory symptoms with 13 individuals requiring medical treatment. This case documents the clinical course of a patient from the time of exposure to this aerosolized sealant up to the diagnosis of Reactive Airways Dysfunction Syndrome (RADS).
CASE PRESENTATION: A 43 year old male smoker with no subjective or objective evidence of pulmonary disease or atopy used Stand N’ Seal “Spray-On” Grout Sealer in an enclosed room within his house. Within a few hours of exposure to this aerosolized sealant he developed severe cough and shortness of breath. By the time the patient reached the Emergency Department he was found to be tachypneic, tachycardic, and hypoxic. The patient's initial chest x-ray revealed bilateral perihilar and infrahilar airspace disease. He was treated with albuterol and ipratropium nebulization, intravenous methylprednisolone, and then transferred to the Intensive Care Unit as he was still requiring 100% FiO2 to keep his oxygen saturation barely above 90% on arterial blood gas. While hospitalized, he was treated with oxygen, albuterol nebulization, and oral dexamethasone 10mg every 8 hours. Upon discharge the patient did not require oxygen, he had improvement in his respiratory symptoms, and was instructed to take a 10 day course of oral prednisone. The patient followed in the Pulmonary Clinic one week after discharge. He noted definitive improvement but continued to have intermittent wheezing and chest tightness which improved with the use of his albuterol inhaler. He had no tobacco use since his hospitalization. A repeat chest x-ray was normal. Spirometry done showed a forced vital capacity (FVC) of 3.13 liters (64% of predicted), forced expiratory volume in one second (FEV1) of 2.42 liters (62% of predicted), and a normal ratio of the FEV1/FVC, consistent with restrictive physiology. He subsequently had full pulmonary function tests which, in addition to a restrictive physiology, revealed a significant bronchodilator response (320 ml and 13% improvement in FEV1) and a reduced single-breath diffusion capacity for carbon monoxide of 31.5 ml/mmHg/min (68% of predicted). The patient returned for follow-up one month later with complaints of intermittent cough and shortness of breath in response to strong odors, fumes, cold air, and exertion. He had remained tobacco free. He then underwent cardiopulmonary exercise testing which showed no ventilatory mechanical limitation, gas exchange abnormality, or diffusion impairment. Sixteen weeks after the initial exposure, the patient had a methacholine challenge test and his FEV1 decreased from 2.80 liters to 2.19 liters (22% reduction) following the administration of methacholine at a concentration of 1 mg/ml. Given these findings, the patient was started on inhaled fluticasone/salmeterol 500/50mcg and diagnosed with RADS.
DISCUSSIONS: The risk of developing RADS after an inhalational exposure to a toxic substance has been difficult to quantify. This patient fulfills the seven diagnostic criteria for RADS. To our knowledge, none of the reported patients who were exposed to Stand N’ Seal “Spray-On” Grout Sealer have official documentation of the development of RADS.
CONCLUSION: The case emphasizes the importance that physicians must recognize that inhalation exposures to toxic substances within the home, not just the workplace, can lead to the development of RADS.
DISCLOSURE: Amanda Godfrey, No Financial Disclosure Information; No Product/Research Disclosure Information