Mustard gas (sulfur mustard-SM) is an alkylating chemical warfare agent widely used in previous conflicts and most recently in the Iran-Iraq war. Stockpiles of SM exist in several countries and represent a continued threat as a potential terrorist weapon. Exposure can result in cutaneous, ophthalmic, and pulmonary toxicity along with systemic effects to include bone marrow toxicity.
We present a case series of three US soldiers who were inadvertently exposed to SM vapor and liquid after detonating a cache of Iraqi munitions. These soldiers were exposed for approximately 5 minutes and noted cutaneous burns/blisters, conjunctival irritation, and dyspnea within 8 hours of exposure. All had detectable levels of SM exposure by biomarker levels. Pulmonary function tests were normal with a mildly depressed DLCO and negative methacholine challenge. Plain radiographs, laryngoscopy, and oxygen saturation were all normal. Subjective dyspnea on exertion out of proportion to objective findings has persisted for 10 months post-exposure. Empiric treatment with inhaled corticosteroids and bronchodilators for airway reactivity failed to provide benefit.
Our case series outlines the evaluation and management of 3 soldiers exposed to mustard gas during Operation Iraqi Freedom, and reviews the long-term complications of SM exposure. Previous literature has reported delayed pulmonary effects to include COPD, bronchiectasis, asthma, airway narrowing, and pulmonary fibrosis. Delayed pulmonary complications are typically exacerbated over time in regards to both severity and frequency.
In most cases of mild sulfur mustard pulmonary toxicity, much of the patients’ evaluation is unrevealing with regards to a pathophysiologic explanation for persistent respiratory complaints. Often, imaging with high-resolution CT offers the best objective data for long-term follow-up of pulmonary complications. We present the evaluation and management of 3 cases of mild pulmonary SM toxicity from Operation Iraqi Freedom and review the literature on delayed pulmonary effects of SM.
Jacob Collen, No Financial Disclosure Information; No Product/Research Disclosure Information