Cases of Poisoning - Reported by Physicians 2007 · Poison Control Centres ChemG § 16e para 3 Case data bank Product data bank Assessment of individual case Analysis Risk identification

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Cases of PoisoningReported by Physicians

aerztl_mitteilungen_07_engl.qxd 24.11.2008 13:57 Uhr Seite u1

Cases of Poisoning Reported by Physicians in 2007Published by: BfR Press and Public Relations OfficeEditors: Centre for Documentation and Assessment of Poisonings at the BfRTranslation from German by Andrea Bartel, BerlinNo of copies printed: 1.000Typesetting and printing: Werbedruck SchreckhasePrinted on chlorine-free paper

ISBN 3-938163-41-0ISSN 1435-4047


Cases of Poisoning Reported by Physicians2007

Centre for Documentation and Assessment of Poisonings at the Federal Institute for Risk Assess-ment – 14th Report (2007)

A. Hahn, K. Begemann, R. Burger, J. Hillebrand, H. Meyer, K. Preußner, M. Gessner

aerztl_mitteilungen_07_engl.qxd 24.11.2008 13:57 Uhr Seite 1

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Table of Contents

1 Introduction 51.1 Legal basis and activities of the Centre 51.2 Processing of reports received 51.3 Product data bank (poison information data bank) 71.3.1 Figures 71.3.2 Collaboration between the BfR, industry and Poison Control Centres 71.3.3 The new Detergents and Cleaning Agents Act 81.4 Standardization on the European level (CEN) for unequivocal product

identification on labels (PI element) 9

2 Case reports by physicians 112.1 Evaluation of reports 112.2 Reports on cases of poisoning in 2007 122.2.1 Origin 122.2.2 Spectrum of cases reported 122.2.3 Circumstances of poisoning 132.2.4 Age structure and sex distribution 132.2.5 Degree of severity of health impairment 132.2.6 Outcome of cases 162.3 The product information system, PRINS 162.3.1 Rapid communications 172.3.2 Summary reports 18

3 Selected toxicological problems 223.1 Container fumigation using methyl bromide 223.2 Selected cases by route of exposure 263.2.1 Dermal exposure 263.2.1.1 Allergic contact eczema 273.2.1.2 Non-allergic contact eczema 283.2.1.3 Non-classifiable contact eczema 303.2.1.4 Special forms 303.2.2 Oral exposure 333.2.2.1 Water intoxication 333.2.2.2 Accidental intake of cleaning agent 353.2.2.3 Carbon grease remover 363.2.3 Inhalation exposure 413.2.3.1 Impregnation spray for tents 413.2.3.2 Glyphosate 433.2.3.3 Bromine 46

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3.2.3.4 Cannabis and lead 483.2.3.5 Rust remover spray 51

4 Annex 544.1 Spectrum of cases reported during the period 1 January – 31 December 2007 544.2 Notification form for cases of poisoning 594.3 Notification form for industrial accidents 604.4 List of Poison Control Centres in Germany 614.5 Press releases on toxicological problems issued by the BfR in 2007 624.6 Abbreviations 64

Cases of Poisoning Reported by Physicians

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1 Introduction

Within the meaning of the Chemicals Act, theterm of poisoning designates all cases in whichhealth impairment has occurred, including sus-pected cases of poisoning. Under the Act, alsothe poison information and treatment centres(Poison Control Centres, PCCs) were subjectedto compulsory reporting of their knowledge (ofgeneral importance) gained in the context oftheir activities.

1.2 Processing of reports receivedReports received on health impairment associ-ated with chemicals are subjected to an assess-ment procedure resulting in the rating of a pos-sible causal relationship between the toxicantand the manifestations observed, as well as other conclusions. Such relationship may beclassified as “possible”, “probable”, “con-firmed”, “absent” or “cannot be assessed”. Therules applied in the assessment of individualcases have been described in detail in earlierannual reports.

The estimation of toxic risks in humans is basedon differentiated analyses and evaluation of thedata on cases. For these purposes, the data oncases in humans are continuously documentedin the form of case data sets and case reports.Information on identified risks is passed on tothe responsible ministries, manufacturers andindustrial associations in the form of rapid com-munications or to the manufacturers in the formof annual summarizing reports by means of theproduct information system, PRINS (see Section2.3). At the same time, the responsible manu-facturers or distributors are requested to submitinformation on the measures envisaged by themto improve product safety.

The knowledge gained during this process ispublished by the BfR in its annual reports, Cas-es of Poisoning Reported by Physicians. Thesepublications are available on request by writing

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1.1 Legal basis and activities of the CentreWith the Chemicals Act (ChemG), legislation inthe Federal Republic of Germany has provideda basis “to protect humans and the environmentfrom harmful effects of dangerous substancesand preparations, particularly to make them rec-ognizable, to avert and to prevent the develop-ment of such effects” (according to § 1).

For a realistic assessment of risks for humanhealth, importance has been increasingly givento the knowledge of data on human toxicologythat can be obtained from the evaluation of cas-es of poisoning in humans. This is why legis-lation has introduced compulsory notification of poisonings by attending physicians from 1 August 1990, by the first amendment to theChemG (§ 16e).

A physician who is consulted for treatment orevaluation of sequelae of diseases caused bychemical substances or products is obliged tosubmit essential data on poisonings to the Cen-tre for Documentation and Assessment of Poi-sonings at the Federal Institute for Risk Assess-ment (BfR).

According to the Chemicals Act, reportingrefers to illnesses or suspected poisonings thatare associated with the following substances:� Chemical substances and products used in

the household, e.g. detergents and cleaningagents, hobby and DIY articles;

� Cosmetics;� Pest control products;� Plant protection products;� Wood preservatives;� Chemicals and products used at the work-

place;� Harmful chemical substances found in the

environment, also after industrial accidents;and

� Plants/animals.


to Pressestelle, Bundesinstitut für Risikobewer-tung, Thielallee 88-92, 14195 Berlin, Germany,and they have also been published as electron-ic documents on the internet (www.bfr.bund.de).

In Fig. 1, these tasks and procedures are shownin graphical form.


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Notificationsphysicians

ChemG § 16e para 2

Human data

InformationPoison Control Centres

ChemG § 16e para 3

Case data bank

Product data bank

Assessment of individual case

AnalysisRisk identification

aimed at scientific

information

Statistical analysesCase reports

Press releases

Rapid communications

to manufacturers/distributors,

ministeries, industrial associations

Criterionsevere

health impairment(see Section 2.3)

Summarizing reports

annually to manufacturers

Criterionnon-severe

health impairment(see Section 2.3)

Measures for risk minimization

Risk communication

aimed atrisk management

Notificationsindustry

ChemG § 16e para 1Dangerous

products / biocides

WRMG § 10Detergents and cleaning

agents

Cosmetics Regulations § 5dCosmetics (through BVL*)

Voluntary notifications

Fig. 1: Terms of reference of the Centre for Documentation and Assessment of Poisonings

*BVL: Bundesamt für Verbraucherschutz und Lebensmittelsicherheit – Federal Office for Consumer Protection and FoodSafety


1.3 Product data bank (poison informationdata bank)

1.3.1 FiguresUntil late December 2007, documents on264 149 products were recorded in the poisoninformation data bank maintained by the BfR,which can be accessed by the Poison controlCentres (PCCs) in Germany, thus supportingtheir activities in providing consultation andtreatment in cases of poisoning. Consequently,the number of notifications on products submit-ted to the Centre for Documentation and As-sessment of Poisonings at the BfR increased by35 731 in 2007. The structure of the data bankand the different types of product data setshave been described in detail in earlier reports.

1.3.2 Collaboration between the BfR, indu-stry and Poison Control CentresThe major part of product data on dangerouspreparations and biocidal products as well as ofthe voluntary reports by manufacturers, distribu-tors and importers received by the BfR is still

submitted on paper forms. The recording of cos-metics, which until June 2005 had been enteredinto the poison information data bank at the BfRpredominantly directly in electronic form, is nowcarried out at the Federal Office for ConsumerProtection and Food Safety (BVL), as a conse-quence of the subdivision of the former FederalInstitute for Health Protection of Consumers andVeterinary Medicine (BgVV) into the two succes-sor institutes, BfR and BVL. From the BVL, the data were returned to the BfR at monthly intervalsand from there, transmitted to the PCCs togetherwith the other product data in the well-estab-lished way. From 2008, the cosmetics data setsare directly distributed to the PCCs by the BVL.

Altogether, i.e. including the dangerous prepa-rations and biocidal products notifiable under § 16e para 1 of the Chemicals Act as well asdetergents and cleaning agents, 26 773 notifi-able product data sets have been transmitted to the PCCs. Of these, 7 918 refer to dangerouspreparations, 10 449, to biocides and 8 406,to detergents and cleaning agents.

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Fig. 2: Development of notifications legally required under § 16e para 1 of the Chemicals Act: Dangerous preparations,biocidal products (2002: entry into force of the regulations on biocides), as well as detergents and cleaning agents underthe Detergents and Cleaning Agents Act (notifications since 5 May 2007)

0

2.000

4.000

6.000

8.000

10.000

12.000

1998 2000 2002 2004 2006

Year

No

tifi

cati

on

s

Dangerous preparations

7 918

Notifications

Biocides

10 449

Notifications

Detergents and cleaning agents

8 406

Notifications



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Fig. 3: Notifications on products received since 1996 and transmission of information to the German Poison Control Centres

0

50.000

100.000

150.000

200.000

250.000

300.000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Total Cosmetics Products, voluntary Dangerous preparations, biocides,

detergents and cleaning

agents

Pro

du

cts

1.3.3 The new Detergents and CleaningAgents Act On 5 May 2007, the new German Detergentsand Cleaning Agents Act (Wasch- und Reini-gungsmittelgesetz – WRMG) came into force. Ithas been harmonized with Regulation (EC) No.648/2004 on detergents having been in effectsince 8 October 2005, and replaces the oldWRMG of 5 March 1987. As a consequence,the BfR has been assigned new tasks. In § 10,in conjunction with Annex VII C to the EU Deter-gents Regulation, the WRMG stipulates thatmanufacturers of detergents shall make avail-able a data sheet to the BfR listing the name ofthe detergent, of the manufacturer and of theingredients together with their correspondingweight percentage ranges. The data sheet shallbe submitted in electronic form as determinedby the BfR. For this purpose, a corresponding

format has been defined in XML by the respon-sible unit. Among other tools, a ZIP file archivehas been made available for product notifica-tions under the WRMG. This archive also in-cludes an Excel file allowing to record data andcheck them for plausibility to some extent. Final-ly, the WRMG notification is generated as anXML file and submitted to the BfR. For corre-sponding instructions, see the BfR website.

These data as well as those submitted under § 16e para 1 ChemG and those submitted on avoluntary basis are edited by the BfR for trans-mission to the PCCs to provide emergency ad-vice on poisoning management. In addition, theBfR is obliged to submit to the Federal Environ-ment Agency, also in electronic form, the nameof the manufacturer and the trade name of thedetergent and/or cleaning agent.


1.4 Standardization on the European level(CEN) for unequivocal product identificationon labels (PI element)More than six years after the BfR predecessorinstitute, the Federal Institute for Health Protec-tion of Consumers and Veterinary Medicine –BgVV, had adopted the proposal of a BgVVcommission for product identification by organ-izing an Initial Workshop (PCCs, industry, con-sumers’ associations), a reasonable idea hasbeen translated into a European standard (CENstandard EN 15178:2007). For emergency ad-vice and in cases of adverse product effects,an easy and unmistakable identification of in-gredients will be possible in the future by meansof a product identification field provided inproduct labelling close to the bar code.

Tailor-made emergency advice in cases of poi-soning and health evaluation of adverse prod-uct effects requires a precise knowledge of theformulation of the product involved. Up to thepresent, the formulation traditionally has beenlinked to the trade name and is recorded ac-cordingly in the respective databases. However,

the trade name rarely appears on packages inan unequivocal way. Therefore, both lay personsand specialists often find it difficult to identifythe correct trade name, which in an emergencymay be decisive for being able to provide ad-vice. A targeted search on the package is com-plicated by the presence of company logos,corporate identity measures, certificates, in-structions for use, additional information, warn-ings and advertising texts, references to daugh-ter products, etc. In addition, many consumersbecome confused by a multilingual labelling of packages, which facilitates a cost-effectiveinternational marketing of products.

The original idea to distinguish the trade nameby highlighting it in a contrasting colour or evenby underlining could not be implemented forreasons of product design. Likewise, attemptsto use the bar code (EAN code) for unequivocalproduct identification have remained unsuc-cessful because the bar code does not includea clear reference to the formulation of the prod-uct. It is used for pricing and marketing logisticspurposes.

Beginning with a DIN standardization project onthe national level and subsequently, also undera European CEN standardization project, abody of representatives of industry, govern-ment, politics and Poison Control Centres havedeveloped a standard providing a solution forclear and easy product identification labelling,which came into effect in October 2007.

According to the new CEN standard, a productidentification field has to be reserved on pack-ages next to the bar code providing space forplacing an unequivocal product identification element (PI element). The PI element beginswith a standardized sign (the letter “i” in a cir-cle), followed by a sequence of letters or num-bers providing unequivocal reference to the for-mulation. Whenever possible, the address andcontact data of the company responsibleshould be given below this PI element.

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Fig. 4: Which is the correct product name? Problems toidentify the name of a modern detergent



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Fig. 5: BfR proposal for a uniform identification

The standard covers all consumer products withthe exception of human and veterinary medici-nal products. In the sense of the standard, themanufacturer shall, on his own responsibility,use this field for giving unequivocal informationbased on the product formulation, using anidentification element (I element). In doing so,he is free with regard to using correspondingcodes or the trade name together with addition-al information that cannot be misunderstood.

However, uniform recommendations and re-quirements for all product categories as to thedesign of the identification element have beenconsidered as meaningful and necessary. Aftercareful consideration how to create a simpleand unequivocal procedure, the BfR has pro-posed to maintain the principle of the reliableand well-established UBA numbers, which re-grettably were abandoned due to the implemen-tation of the European Detergents Regulation.The old UBA number consists of eight digits,with the first four digits to indicate the companycode and the last four digits to accommodatethe formulation code to be fixed by the manu-facturer, importer, or distributor on their own responsibility.

Proposal made by the BfR Based on the CEN standard, the BfR has pro-posed a uniform identification element startingwith the i symbol followed by a 5-digit BfR com-pany code, a 5-digit formulation code to befixed by the manufacturer and a hazard symbol.It would be desirable if with the assistance ofBfR recommendations and initiatives, the la-belling of detergents and cleaning agents withthe UBA number could be continued not only for detergents and cleaning agents but also forother consumer products in the interest of animproved product safety.

Therefore, the BfR advocates the implementa-tion of the European standard, which in additionto a precise identification of the formulation incases of emergency enquiries will also enablean exact identification of adverse health effectsof products. The new CEN standard also offersobvious advantages for manufacturers, im-porters and distributors: Unlike the mere tradename, the identification element with its unmis-takable reference to the formulation can mini-mize errors in the ordering system and thus,also save costs.

Gefahrensymbol

C Xn Xi T T+

Firmen-Code

Produkt/RezepturBfR-Firmencode

Gefahrensymbol

nach GHS (codiert)

Firmen-Code

Produkt/RezepturBfR-Firmencode

C9999912345 X9999912345

Gefahrensymbol

C Xn Xi T T+BfR-Firmencode

C9999912345 X9999912345

Company Code

Product/formulation BfR-Company Code

Hazard symbol

GHS coded


2.1 Evaluation of reports

genossenschaften to the BfR. Since 2001, acontinuous decrease has been observed in thenumber of these reports. According to the BG-Institute for Occupational Safety and Health(Berufsgenossenschaftliches Institut für Ar-beitsschutz – BIA), this decrease can be attrib-uted to an actual reduction in the number ofaccidents, and not to changes in the reportingbehaviour. This is caused by prophylactic cam-paigns informing about circumstances and pre-vention of accidents, an improved occupationalsafety and accident prevention due to more ef-fective safety measures and changes in opera-tional processes (in part also automation).

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2 Case reports by physicians

During the period from 1 August 1990, i.e. thebeginning of the compulsory notification, to 31December 2007, altogether 52 798 reports oncases of health impairment, poisoning or sus-pected cases of poisoning were received bythe BfR. In 2007, i.e. the reporting year consid-ered, 4 093 notifications were received (Fig. 6).

The increase in the number of notifications re-ceived in 2000 was due to an agreement withthe Berufsgenossenschaften. According to thisagreement, all cases of acute health impair-ment after contact with chemicals or chemicalproducts are directly reported by the Berufs-

Fig. 6: Cases reported (BG reports 100 % = 3 895; non-BG reports 100 % = 198) BG: Berufsgenossenschaften – Institu-tions for statutory accident insurance and prevention for trade and industry in Germany

0

1.000

2.000

3.000

4.000

5.000

6.000

7.000

8.000

9.000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Non-BG reports BG reports

Number

Year


Also the share of reports received from hospi-tals and medical practitioners has decreasedconsiderably. However, evaluations by the PCCshave shown that the share of health impair-ments after intake of or contact with chemicalproducts, household chemicals, plant protectionand pest control products and all other notifi-able product groups has remained high anddoes not correspond to the number of notifica-tions received by the BfR.

2.2 Reports on cases of poisoning in 2007

2.2.1 OriginIn 2007, 3 895 cases, i.e. 95.2 % of all casesnotified, were reported by the Berufsgenossen-schaften. The remaining 198 notifications (4.8 %)were essentially submitted by hospitals, medicalpractitioners and PCCs.

2.2.2 Spectrum of cases reportedFig. 7 provides a synoptic view of the spectrumof product groups involved in the cases report-ed. Among the total of cases reported by the

Berufsgenossenschaften, those of poisoning by chemical products and primary substanceshave remained in top position. All other productgroups played a minor role, with shares of4.3 % each, or less.

As expected, the spectrum of substances andproducts involved in cases of poisoning is dif-ferent in the reports received from the Berufs-genossenschaften and in those received fromhospitals and medical practitioners. Also among the latter, notifications related to chemi-cal products ranked first in the reporting year.They are followed, at a clear distance, by thegroup of primary substances, similar to the BG reports. Next in the ranking are health com-plaints caused by foods and beverages, pesti-cides and medicinal products that were report-ed although these are not subject to compulso-ry notification.

For a detailed list of toxicants in tabular formsee Annex. In this table, the cases reported in2007 have been classified by product applica-


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*Others: Plants,fungi, animals, vet-erinary medicines,agrochemicals,narcotic drugs,warfare/anti-riotagents, industrialaccidents, miscel-laneous

Fig. 7: Spectrum of cases reported (BG reports 100 % = 3 895 reports;non-BG reports 100 % = 198 reports)

0

10

20

30

40

50

60

70%

Chem

. Pro

ducts

Primar

y su

bstan

ces

Pestic

ides

Med

icin

al p

roduct

s

Cosmet

ics

Other

s*

Foods/bev

erag

es


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Table 1: Spectrum of reports – synoptic view (repeat listing of toxicants per case possible)

BG reports(100 % = 3 895 reports)

Non-BG reports(100 % = 198 reports)

Chemical products 60.6 % (2 359 Cases) 42.4 % (84 Cases)

Primary substances 28.5 % (1 110 Cases) 21.2 % (42 Cases)

Medicinal products 4.3 % (166 Cases) 8.1 % (16 Cases)

Pesticides 2.4 % (92 Cases) 7.6 % (15 Cases)

Cosmetics/personal hygiene products

1.6 % (64 Cases) 4.0 % (8 Cases)

Foods and beverages 0.7 % (27 Cases) 11.1 % (22 Cases)

Agrochemicals 0.3 % (10 Cases) 0 % (0 Cases)

Industrial accidents 0.2 % (6 Cases) 0 % (0 Cases)

Veterinary medicinal products 0.1 % (3 Cases) 0 % (0 Cases)

Warfare/anti-riot agents 0.1 % (2 Cases) 0 % (0 Cases)

Plants 0.1 % (3 Cases) 3.0 % (6 Cases)

Animals 0 % (1 Case) 0.5 % (1 Case)

Narcotic drugs 0 % (0 Cases) 1.0 % (2 Cases)

Fungi 0 % (1 Case) 6.1 % (12 Cases)Others 2.8 % (111 Cases) 0.5 % (1 Case)

tion groups (assignment of toxicants accordingto their intended use).

2.2.3 Circumstances of poisoningThe Berufsgenossenschaften almost exclusivelyreported cases of exposure to poisons in thecontext of occupational accidents (ca. 97 % ofcases). The remaining 3 % of cases referred toaccidents that had occurred during the com-mon use of a product or because a chemicalhad been mistaken for another substance, orthe circumstances of the accident were un-known.

Among the reports submitted by hospitals andmedical practitioners, cases of accidental poi-soning predominated (49.5 %), followed by ex-posure during common use (28.3 %). Exposuredue to mistaking chemicals for other sub-stances was the cause in 8.6 % of cases, suici-dal actions were reported in 1.5 % of cases.Only 1 % of cases were associated with theabuse of substances. In the remaining cases,causes remained unknown.

2.2.4 Age structure and sex distributionIn 2007, the share of cases referring to adultsamong the total of cases reported was 98.4 %.The three accidents involving children occurredin schools and kindergartens, respectively.

The share of cases in adults predominated alsoamong the reports received from hospitals andmedical practitioners. However, the share ofchildren in these cases was as high as 33 %(Table 3).

2.2.5 Degree of severity of health impairmentAlso in 2007, the majority of cases reported referred to minor health impairment only, bothamong the cases reported by the Berufs-genossenschaften and among those reportedby hospitals and medical practitioners. Moder-ate and severe health impairments were mostlyreported by medical practitioners or physiciansworking in hospitals (Table 5).

The product groups involved most frequently withregard to the degree of severity of health effects


have been listed in Table 6 for the cases reportedby the Berufsgenossenschaften, and in Table 7,for the cases reported by hospitals and medicalpractitioners. Of course, the toxicants reportedfrom occupational environments were differentfrom those reported to have been involved in theprivate sphere, on account of e.g. the differencesin the availability of certain product groups.

Exposure to substances from the group of build-ing materials referred almost exclusively to lime,mortar, concrete and similar products formingcalcium hydroxide under humid conditions,

which may cause irritation or chemical burns.The group of “accumulators” summarizes re-ports on incidents such as the release of sulfu-ric acid from motor vehicle batteries due to anexplosion.

Health impairment or cases of poisoning due tomedicinal products are not subject to compul-sory notification under the Chemicals Act. Nev-ertheless, cases of accidental contact, mostlyreferring to splashes of skin disinfectants affect-ing the eye, have been reported by the Berufs-genossenschaften.


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Table 5: Degree of severity of health impairment – synoptic view



None 3.6 % (139 Cases) 13.6 % (27 Cases)

Minor 85.6 % (3 334 Cases) 56.6 % (112 Cases)

Moderate 6.6 % (259 Cases) 13.6 % (27 Cases)

Severe 0.2 % (6 Cases) 10.1 % (20 Cases)Cannot be assessed 4.0 % (157 Cases) 6.1 % (12 Cases)



Male 59.2 % (2 304 Cases) 51.0 % (101 Cases)

Female 27.7 % (1 079 Cases) 41.4 % (82 Cases)Unknown 13.1 % (512 Cases) 7.6 % (15 Cases)

Table 4: Sex distribution – synoptic view

Table 2: Duration of exposure – synoptic view



Acute 99.9 % (3 892 Cases) 83.8 % (167 Cases)

Chronic 0.1 % (2 Cases) 7.6 % (15 Cases)Unknown 0 % (1 Case) 8.1 % (16 Cases)



Children 0.1 % (3 Cases) 32.8 % (65 Cases)Adults 99.9 % (3 892 Cases) 67.2 % (133 Cases)

Table 3: Age groups – synoptic view


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Health impairmentProduct group Minor (3 334 Cases) Moderate (259 Cases) Severe (6 Cases)

Primary substances 907 101 3

Cleaning agents, total 636 63 1

Drain cleaners 11 2 1All-purpose cleaners 39 2

Oven and grill cleaners 23

Descaling products 13Industrial cleaners 56 11Milking machine cleaners 57 8Metal cleaners 20 1Lavatory cleansers 24 2

Disinfectants/sterilizers 332 13

Medicinal products 149

Waste gases 137 7 1

Paints and related materials 128 7

Accumulators 76 4

Building materials 99 19Pesticides 81 7

Table 6: Product groups involved most frequently, by degree of severity of health impairment (BG reports)

Health impairmentProduct group Minor (112 Cases) Moderate (27 Cases) Severe (20 Cases)

Cleaning agents, total 15 4 4

Descaling products 1Glass cleaners 1Oven and grill cleansers 2Lavatory cleansers 4 1 1

Shoe and leather cleansers

1 2 1

Primary substances 28 5 4

Waste gases 1

Primers 1

Offi ce materials, chemical 10 1

Luminophors 6

Lamp oil 3 1

Pesticides, total 10 3 1

Insecticides 3 2Wood preservatives 6

Foods and beverages 9 2 5

Alcoholic beverages 1Fungi 5 2 3


2.2.6 Outcome of casesFor the notifications submitted by the Berufs-genossenschaften, the outcome has remainedunknown in ca. 41 % of cases. The reason forthis is that in the majority of cases, the reportsubmitted corresponds to that by the “Durch-gangsarzt” (“transition doctor” appointed by theBerufsgenossenschaft). As a rule, the reportingform is completed after the patient’s first pres-entation. Therefore, such report does not con-tain any information on the course of the pa-tient’s illness. In selected cases, enquiries weremade to obtain information on the course of ill-ness. In the majority of cases on which informa-tion was available, patients had recovered com-pletely.

Of the notifications submitted by hospitals andmedical practitioners, patients recovered com-pletely in 147 cases (74.2 %). In 32 cases16.2 %), the outcome was unknown; in elevencases (5.5 %), late sequelae could not be exclud-ed or partial recovery was reported. The remain-ing eight cases (4.1 %) had lethal outcomes.

Altogether, nine deaths were reported to the BfR(by BGs, hospitals and medical practitioners) in2007. Below, some of these lethal cases havebeen listed in a summarizing view:� For unknown reasons, a 31-year-old patient

had ingested 400 mL of a 25 % vinegar con-centrate. In the course of this case, the pa-tient developed haemolysis and massive re-nal damage. He eventually died from cardio-vascular failure.

� Four cases were reported to the BfR by fo-rensic institutes. The causes of these deathshave remained unclear. In one of these ca-

ses, several food supplements were found inthe immediate vicinity of the corpse. In theother three cases, carbon monoxide and hy-drocyanic acid, respectively, were detectedat post-mortem examinations.

� A lethal case due to rust remover spray hasbeen described in detail in the correspon-ding case report (Section 3.2.3.5).

� One patient had taken metformin, an antidia-betic, together with an unknown quantity ofalcohol and ramipril as a continuous medica-tion. He developed a severe health disturban-ce and eventually died from multiple organfailure.

� A particularly tragic case was the death of achild after ingestion of a lethal dose of com-mon salt.

� The last death that occurred in 2007 was dueto an occupational accident that took a tragiccourse. The patient had inhaled chlorine gasand as a consequence, developed pulmona-ry oedema. In spite of intensive therapy hedied from multiple organ failure.

2.3 The product information system, PRINSThe notifications by physicians in cases of poi-soning legally required under the Chemicals Act(§ 16e para 2) are regularly evaluated to protectconsumers from health risks posed by chemi-cals and chemical products. Since 1994, the re-porting physicians, the responsible ministriesand the scientific community have been in-formed by annual reports on analyses of thesenotifications and the corresponding results. Inthe context of these notifications, the term, poi-soning, is used to designate any health impair-ment associated with chemicals, including forexample also allergies.


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Health impairmentProduct group Minor (112 Cases) Moderate (27 Cases) Severe (20 Cases)Medicinal products 3 2 3Textile, auxiliary products 2

Table 7: Product groups involved most frequently, by degree of severity of health impairment (non-BG reports)


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Since 1998, manufacturers and distributors ofchemical products such as household chemi-cals and DIY products, cosmetics, plant protec-tion and pest control products and correspon-ding products for commercial use have been in-formed about selected cases of health impair-ment associated with their products that havebecome known to the BfR through case reports.For this purpose, a formal procedure (PRINS)was established. In the event of reported healthimpairments, rapid communications are provid-ed for in these cases, depending on the ur-gency of measures to be taken. By such ap-proach, industry is enabled to immediately fulfiltheir obligations with regard to product safety.All other reports are summarized and sent to therecipients at annual intervals.

2.3.1 Rapid communicationsIf reports on severe health risks are received bythe BfR or a preparation is suspected of possi-bly involving a risk, the BfR will provide for im-mediate information of the manufacturer/distrib-utor of the chemical product involved as well asthe competent industrial association/federaltrade association and the Federal Office forConsumer Protection. In addition, an immediatereport is submitted to the three competent min-

istries, i.e. the Federal Ministry of Food, Agricul-ture and Consumer Protection (BMELV), theFederal Ministry for the Environment, NatureConservation and Nuclear Safety (BMU), andthe Federal Ministry of Health (BMG). Suicidesand improper use are excluded from rapid com-munications.

Between 1 January 1998 and 31 December2007, 26 rapid communications were preparedand communicated. A synoptic view of the lastfive years is given in Table 8.

In the reporting year of 2007, one rapid commu-nication was distributed. It referred to a case of poisoning in a 46-year-old female who haddeveloped toxic lung oedema after the use andinhalation of an impregnation spray for tents.Owing to the fact that effective therapeuticmeasures were initiated without delay, manifes-tations receded rapidly, and the patient couldbe discharged after two days. The case hasbeen described in detail in Section 3.2.3.1.

For explanations of individual cases up to 2006,reference is made to the previous annual re-ports.

Year Product Toxicologically relevant substance

Person exposed

Outcome Proposal by BfR (P) and results (R)

2002 Lavatory cleanser Surfactant Elderly male Chemical burns

P: Information

2002 Mild detergent Surfactant Elderly male Death P: Information

2003 Cleanser Surfactant Elderly male Respiratory insuffi ciency

P: Information

2003 Food supplement Proteins Adult male Severe allergy P: Information

2003 Fumigant Sulfuryl difl uoride Adult male Death P: Information

2003 Drain cleaner Potassium hydro-xide solution

Child Severe chemi-cal burns

P: Information

2003 Disinfectant Peracetic acid Adult male Respiratory insuffi ciency

P: Information

2004 Garden torch Paraffi ns, colourless

Infant Respiratory insuffi ciency, death

P: Information R: Accepted



18

2.3.2. Summary reportsInformation on reports referring to cases of non-severe health impairment caused by chemicalproducts in occupational or private environ-ments are transmitted to the responsible manu-facturers/distributors in a summarized form inthe year following the incidents. Since 2003, al-so suicides and attempted suicides have beenincluded in the summary reports, irrespective ofthe degree of severity of poisoning. Rarely, alsoreports of severe cases are submitted to manu-facturers in the form of a summary report if thedata available were insufficient for a rapid com-munication.

Summary reports provide information in tabularform which, depending on the data availablefrom the case reports, includes the following elements:� Product name;� Date of receipt by the BfR of the report on

the case of poisoning;� Case number;� Anonymized patient data such as sex and

age group;

� Aetiology of the poisoning case (e.g. acci-dental or common use, abuse or mistake);

� Site of exposure (workplace or private sphere);

� Duration of exposure (acute or chronic);� Degree of severity of health impairment as

assessed by the BfR.

Cases reported to the BfR will only result in a re-port being sent to the manufacturers if a causalrelationship between the health impairment ex-perienced and the product mentioned is con-sidered at least as possible after evaluation bythe BfR. Information is also submitted on casesreported for which the degree of severity and/orthe causal relationship cannot be assessed.Also in these cases, it is intended to draw themanufacturer’s attention to risks that may arisefrom his product.

By means of the BfR summary reports, manu-facturers and distributors will gain knowledgeon possible risks associated with the handlingof their products. In single cases, they will notbe satisfied by such summarized information

Table 8: Rapid communications 1 January 2002–31 December 2007

Year Product Toxicologically relevant substance

Person exposed

Outcome Proposal by BfR (P) and results (R)

2004

Oil lamp Paraffi ns, colourless

InfantRespiratory insuffi ciency, death

P: Information R: Accepted

2005 Detergents Surfactant Elderly male Death None

2005 Dishwasher cleanser for industrial use

Potassium hydroxide

Elderly female

Severe chemical burns

None

2005 Breadseed poppy

Morphine Infant Respiratory insuffi ciency

P: Guideline values/ maximum levels, control, measures to reduce opiate levels R: Accepted

2006 Detergents Surfactant Elderly female Death None

2007 Impregnation spray for tents

Cannot be assessed

Adult female Lung oedema P: Investigation


19

First level Second level Third levelAgrochemicals 7

Chemical products 269 Paints and related materials

4 Primers 3

Building materials, auxiliary products

5

Offi ce materials, chemical

5

Disinfectants/sterilizers

73

Glues 5

Metallurgy, auxiliary products

3

Lubricants 3

Cleaning products 127 All-purpose cleaners 5

Oven and grill cleaners

4

Descaling products 3

Industrial cleaners 30

Milking machine cleaners

20

Lavatory cleansers 17

Shoe and leather cleaners

4

Water treatment products

7

Primary substances 4

Cosmetics/personal hygiene products

14 Oral care/dental products

4

Skin care products 8 Creams/ointments/lotions

3

Pesticides 31 Herbicides 12

Insecticides 14 Pyrethroids 4Phosphoric esters 7

Fungicides 4

Table 9: Product groups frequently involved in 2007 summary reports

and seek contact with the BfR in writing or bytelephone in order to obtain more detailed infor-mation on a specific case of poisoning.

After evaluation of the total of 4 093 reports oncases of poisoning received by the BfR in 2007,325 of these resulted in summary reports to the

corresponding manufacturers. These cases re-ferred to 301 different products from 140 differ-ent manufacturers.

The table below (Table 9) provides a synopticview of product application groups (minimumthree listings) to which the summary reports on


frequently listed products can be assigned. Asin the previous years, the majority of reports referred to chemical products (altogether 269).Strikingly high numbers have been recorded fordisinfectants (73 cases) and cleaning agents(127 cases). Attention has to be drawn to thehigh number of cases involving milking machinecleaners, which has even increased comparedwith the previous year (from 11 to 20 cases).The 325 cases leading to summary reports to manufacturers referred to health impair-ments characterized by the following degrees of severity:

Table 11 below shows the number of productsin the individual product groups that were involved in moderate health impairments (32products). It may be concluded that an involve-ment in cases of moderate health impairmentwas seen for ca. 10 % of the total of 301 prod-ucts listed in summary reports to manufactur-ers.

In 22 of the total number of 325 cases of poi-soning where summary reports had to be sentto manufacturers, the degree of severity couldnot be assessed despite further investigationsmade.

Five cases were reported to the respective man-ufacturers by way of summary reports althoughthey referred to severe health impairment: In ac-cordance with the decision to include cases ofattempted suicide, one case involving ingestionof a disinfectant was reported. Another case re-ported referred to ingestion of a cleaning agentby mistake. In three cases, there was delayed


20

First level Second level Third levelChemical products 22 Fire lighting products 1


1

Disinfectants/sterilizers

3

Lubricants 1

Cleaning products 13 Dishwasher cleaners 1

Industrial cleaners 3

Milking machine cleaners

1

Soot remover 1

Lavatory cleansers 2

Shoe and leather cleaners

2

Others 3

Others 3

Primary substances 1

Cosmetics / personal hygiene products

4 Skin care products 2 Creams/ointments/lotions

2

Degree of severity of health impairment

No. of cases

Minor 266

Moderate 32

Severe 5Cannot be assessed 22

Table 10: Degrees of severity of cases in summary reports2007


The BfR also performs cumulative data analysesof case reports. If trends become apparent, themanufacturers of the products concerned areinformed. Manufacturers are requested by theBfR to, in turn, communicate comparable dataand trends that may serve to improve productsafety.

21

reporting of accidents to the BfR i.e. in the sub-sequent year only, while the manufacturers hadalready been informed about possible healthrisks involved in the product in the context ofrapid communications, for example in the caseseries in 2006 when health impairments hadbeen caused by “nano sealing sprays”.

Table 11: Product groups involved in cases of moderate health impairment listed in summary reports in 2007

First level Second level Third levelHair care products 1 Hair dyes/colorants 1

Oral care/dental products

1

Pesticides 5 Insecticides 2 Phosphoric esters 1

Herbicides 2Fungicides 1


3 Selected toxicological problems

branes of the upper respiratory tract and ofthe eyes such as dryness of mouth, ticklingthroat, cough, lachrymation. Also headache,dizziness and malaise as well as skin rashand pruritus were frequently reported.

� Sulfuryl difluoride, a substance recommen-ded as an alternative to methyl bromide, wasinvolved in eight cases reported to the BfR. Inthese cases, health disorders were observedduring fumigation operations, but they werenot associated with fumigation of containers.

In September 2007, the Joint Poison ControlCentre (Gemeinsames Giftinformationszentrum)of the Federal Länder of Mecklenburg-WesternPomerania, Saxony, Saxony-Anhalt andThuringia located in the city of Erfurt informedthe BfR about cases of poisoning with methylbromide and in this context reported two caseswhose details are presented in the following(case reports).

Alerted by this problem, the BfR initiated a sur-vey among PCCs in Germany (nine centres),Switzerland, Austria and France in late Decem-ber 2007. PCCs were asked whether they hadreceived any enquiries regarding the fumigationof containers since the year 2000 and whetheran increasing trend could be seen in the num-bers of such enquiries. The active substancesreferred to in this survey included chloropicrin,1,2-dichloroethane, methyl bromide and sulfuryldifluoride. In addition, information was request-ed with regard to manifestations and degrees ofseverity of corresponding cases of poisoning.Six out of twelve Poison Control Centres ad-dressed responded to the letter sent by the BfR:� The Bonn PCC had not received any enqui-

ries on the substances concerned.� The Berlin PCC had recorded two cases in

2003, one in 2006 and two again in 2007.� The Joint PCC in Erfurt, who had already

submitted reports on two cases to the BfR


22

3.1 Container fumigation using methyl bromideHealth risks associated with the fumigation ofcontainers have been increasingly discussed in previous years. The attention of the public regarding this problem was shown for examplein an article by the German magazine, DerSpiegel. This article named in particular threesubstances being used for container fumiga-tion: Chloropicrin (a type of Green Cross gas),1,2-dichloroethane and methyl bromide.

Evaluation of data has shown that in the contextof physicians’ reports on cases of poisoningunder § 16e Chemicals Act, the BfR receivedreports on 22 cases involving the above sub-stances during the period between 1 August1990, i.e. the beginning of compulsory notifica-tion, and 31 December 2007.

Chloropicrin 0 cases1,2-dichloroethane 8 casesMethyl bromide 14 cases

� Chloropicrin (trichloronitromethane or nitro-chloroform) is a chemical warfare agent causing pulmonary effects. Like phosgene,it became known under the German name ofGrünkreuz (Green Cross) and was one of thecomponents of Green Cross gas shells. Nocases caused by this substance have beenreported.

� Reports on 1,2-dichloroethane (ethylene di-chloride) referred to accidents in the chemi-cal industry or agriculture where patients haddirect contact with low quantities of this sub-stance.

� The highest number of cases reported by theend of 2007 was associated with methyl bro-mide, also referred to as bromomethane. Inall of these cases, health disorders were ra-ted as minor ones. Symptoms reported inclu-ded above all irritations of the mucous mem-


In general, it has to be assumed that the fre-quency of cases of poisoning associated withfumigation of containers is highly underestimat-ed in the corresponding records, for the follow-ing reasons:� Allocation of toxicants is impossible because

many containers are unlabelled. For example,health impairment due to “an unknown gas”is reported without stating the name of thepoison involved. Such reports cannot be as-signed to any defined exposure in follow-upenquiries by the BfR or Poison Control Cen-tres.

� Attending physicians are lacking sufficient information about this problem. Therefore, itmay be missed when establishing the pa-tient’s medical history. Health complaints arenot associated with an exposure to fumigantsand instead, assigned to a different clinicalpicture.

� There is no good reporting behaviour shownby medical practitioners and hospital physici-ans. Reasons for this may be seen in the lackof remuneration of reports, overburdening byacute problems, or ignorance of § 16e of theChemicals Act.

� Employees are not aware of the problem.Since they lack information about fumigationand the risks involved, they would not asso-ciate their health complaints with exposure to fumigants. They would not see a doctor,so that no report will be submitted on thesecases.

23

before (see above), reported another case onthe occasion of the survey.

� The Freiburg PCC submitted information oneight cases of poisoning: two in 2002, one in2005, three in 2006 and two in 2007. Thesecases referred to five poisoning incidentsthat had affected a total of 32 persons.

� The Swiss PCC had recorded eight enquirieson this problem: Six cases had already oc-curred in 1999 (involving methyl bromide and phosphine), one case in 2003 and oneenquiry (no poisoning) had been received in2006.

� The Northern Germany PCC located in Göt-tingen reported 79 exposure incidents and36 precautionary enquiries (share of contai-ner fumigation operations unclear): Phosphi-ne: 40 exposure incidents and ten precautio-nary enquiries; hydrogen cyanide: 20 expo-sure incidents and 17 precautionary enqui-ries; methyl bromide: 13 exposure incidentsand two precautionary enquiries, 1,2-dichlo-roethane: six exposure incidents and no precautionary enquiry, sulfuryl difluoride: noexposure incident and seven precautionaryenquiries, and chloropicrin: neither exposureincidents nor enquiries.

� The poison emergency telephone service inMunich verbally reported another 32 casesthat had occurred in September 2007 at atrade fair when machine parts from India were unpacked (another case associatedwith this accident is presented below as anexample). All of the patients affected showedonly mild symptoms but were admitted tohospital for observation. They could all bedischarged in a symptom-free condition onthe following day. Essentially, measurement of bromide adducts in the patients showednormal values. No methyl bromide could bedetected in the wood samples kept for refe-rence. However, it has to be taken into ac-count that a considerable period of time hadpassed between the onset of health com-plaints and sampling so that outgassing ofthe active substance was possible.

Fig. 8: Measurement before clearance


The BfR will continue to discuss this issue andmake efforts to inform the public in appropriateways.

NotesMethyl bromide, or bromomethane, is a colour-less and odourless gas. It cannot be perceivedby a warning odour if the maximum admissibleconcentration at the workplace is exceeded.This is why frequently, an odorous substance isadded to ensure a certain signalling or warningeffect. Due to its toxicity, it has been used forpest control, particularly for container fumiga-tion, to control wood pests e.g. in building mate-rials, and for soil disinfestation. Methyl bromidehas a depleting effect on the ozone layer. There-fore, its use was limited in the Montreal Protocolon Substances that Deplete the Ozone Layer.Since 1 September 2006, it has been bannedas a fumigant in Germany.

In order to prevent the introduction of pests, theInternational Plant Protection Convention (IPPC),a multilateral convention under the auspices ofthe UN Food and Agriculture Organization(FAO), has adopted ISPM 15 (International Stan-dards for Phytosanitary Measures), entitledGuidelines for Regulating Wood Packaging Ma-terial in International Trade. These guidelines require that wood packaging material should betreated with methyl bromide or heat. Meanwhile,wood used in overseas exports from Germanyis exclusively treated with heat. Nevertheless,containers used for imports from non-Europeancountries, particularly from Asia, still have to beassumed to have undergone fumigation withmethyl bromide. The provisions of the Interna-tional Maritime Organisation (IMO) requiringsuch containers to be labelled as having beenfumigated are frequently not complied with inpractice. Persons opening or unloading importcontainers or unpacking goods transported insuch containers may therefore unknowingly be-come exposed to methyl bromide.

Case reportsChronic inhalational exposure to methylbromide at the workplace associated withcontainer fumigation operationsThe female patient had frequently been ex-posed to fumigants originating from importedcontainers in her working environment. There-fore, a long-term contact with the substancehas to be assumed. Methyl bromide was stat-ed to have been the fumigant applied. Thepatient had not been informed about occupa-tional safety measures. Since the last contactwith the substance on a Friday she had beencomplaining of pronounced hoarseness anda burning sensation on all her mucous mem-branes, including the genital area. Becausethese complaints did not recede, she soughtmedical advice at the emergency unit of ahospital on the following Monday.

Manifestations/courseIn the hospital, hoarseness persisted and thepatient stated to suffer from a burning pain onher skin. The hospital staff consulted a PCC,which recommended to perform dermatologi-cal, neurological and ophthalmological diagno-sis. It was intended to contact the companyphysician in order to provide for appropriate occupational safety measures. The BfR lacks in-formation about the further course of this case.

Evaluation of the case described Based on the temporal relationship between theexposure and the appearance of symptomsand in the absence of other causes, a low-grade poisoning by methyl bromide has beenconsidered as probable.

Inhalational exposure to methyl bromide atthe workplace associated with containerfumigation operations A 35-year-old worker had been unpackingcontainers in a closed fair hall over a full


24


working day. The containers had been loadedwith machine parts in wooden boxes from In-dia. According to information given by the for-warding company, they had been fumigatedwith methyl bromide to prevent pest infesta-tion. To comply with a given deadline, the rec-ommended waiting period for ventilation hadbeen ignored. Several workers had perceivedan unpleasant odour when unpacking thegoods and complained of minor symptomssuch as headache, sore throat and general-ized itching of the skin.

After work, the patient complained of dizzi-ness and myoclonic twitches in his thighs.Due to a common cold infection he had beensuffering from cough already prior to the ex-posure. Three days later, the patient soughtmedical advice in a hospital in his home townbecause he associated his health complaintswith the container fumigation. He had in-formed himself about possible signs andsymptoms of poisoning with methyl bromidein the press and on the internet.

Manifestations/courseThe hospital consulted a Poison Control Cen-tre. A thorough physical examination andECG were recommended. The patient was re-ferred to outpatient treatment. The BfR lacksinformation about the further course of thiscase.

Evaluation of the case described Based on the temporal relationship between theexposure and the appearance of symptomsand in the absence of other causes, low-gradepoisoning by methyl bromide can be assumedas possible. In addition and already prior to theexposure, the patient had been suffering froman infection of the upper respiratory tract withcough.

Inhalational exposure to methyl bromide atthe workplace associated with containerfumigation operations In March 2007, a 44-year-old worker unloadedwood products from a fumigated containerand was exposed to the gas for about threehours. The container had been fumigated withmethyl bromide and had not been ventilatedsufficiently prior to unloading. After work, thepatient suffered from a tickle in his throat anddizziness and sought medical treatment.

Manifestations/courseOn admission, auscultatory findings of thelungs were non-significant and circulatory parameters were in the normal range as well.Lung X-ray findings were normal for the pa-tient’s age. The hospital consulted a PoisonControl Centre, which recommended inpa-tient observation. The patient was adminis-tered a corticoid spray in order to prevent tox-ic lung oedema. In addition, infusion therapywas performed for fluid replacement.

Evaluation of the case described Based on the temporal relationship between exposure and appearance of typical manifesta-tions and in the absence of other causes, a low-grade poisoning by methyl bromide has to berated as probable.

Notes regarding the three cases presentedabove:Methyl bromide is highly toxic and can be ab-sorbed by inhalation or by the dermal route(contact poison). It causes irritation to the skin,the eyes and the respiratory tract. Local effectson the eyes include reddening, pain, blurred vision with temporary visual disturbance andconjunctivitis.

Dermal effects include erythema, pain, chemi-cal burns, a burning sensation, scab formationand blistering.

25


Inhalation will cause nausea, vomiting, abdomi-nal pain, cephalgia, dizziness, tiredness, disori-entation, hallucinations, speech disorders,weakness, impaired coordination, muscularspasms, dyspnoea, and in the worst case, pul-monary oedema. Exposure to high concentra-tions may result in disturbances and loss ofconsciousness with a lethal outcome. In mostcases, there will be a latency period before theonset of manifestations. Repeated or long-termexposure may result in damage to lungs, liver,heart and central nervous system.

After contact with the substance, the patientshould be removed from the contaminated envi-ronment using a self-contained breathing appa-ratus. Decontamination should be performed,including a change of clothing and showeringor rinsing of the affected sites with water. In order to prevent toxic pulmonary oedema, pa-tients showing pulmonary manifestations shouldbe administered glucocorticoids as soon aspossible, either by means of a CFC-free me-tered-dose inhaler (e.g. Budesonide) withaerosol holding chamber or by i.v. injection ofhigh doses (preferably methylprednisolone), ifmassive exposure is assumed to have takenplace. In severe cases, oxygen supply and artificial respiration may be required. Onwardtherapy will be oriented by the existing sympto-matology. In any case, clinical observationshould follow.

When handling this substance, safety gogglesand cold-resistant protective gloves should be worn as a protective measure. Under theGerman Technische Regeln für Gefahrstoffe(TRGS 512 – Technical Rules for HazardousSubstances, Fumigation), a suitable breathingprotection, i.e. the use of a full protective maskwith a sufficient filter is required for fumigationoperations.

3.2 Selected cases by route of exposure

3.2.1 Dermal exposure

Notes regarding the skin diseases presentedbelowBelow, a number of individual cases of contacteczema are described. The following advanceinformation is given for a better understandingof all of these case reports.

Contact eczema or contact dermatitis are termsused to designate acute or chronic superficialinflammatory skin diseases.

Such diseases are referred to as non-allergiccontact eczema if caused by acute or cumula-tive toxic, physical or chemical exposure. Thisincludes, for example, the acute-toxic contactdermatitis resulting from exposure to UV radia-tion (solar dermatitis), acids or alkalis. Cumula-tive toxic contact eczemas include, for example,diaper rash in children. Otherwise, only in adultsthis type of eczema is caused by cumulativetoxic stimulation. Reddening and swelling of theskin are observed at exposed body sites.

In contrast, allergic contact eczema is causedby an acquired cell-mediated allergy to definedcontact substances. Hence, allergic contacteczema is a special form of an allergy classifiedas a delayed-type hypersensitivity reaction. It isthe classic representative of type IV reactionsaccording to the Gell and Coombs’ classifica-tion and in the majority of cases is observedamong adolescents and adults.

It can be assumed that hypersensitivity ratesamong the population are continuously on theincrease. Nickel and fragrances are among thesubstances frequently associated with sensitiza-tion. In the majority of cases, sensitization istriggered by incomplete antigens referred to ashaptens. These are predominantly fat-solublesubstances with a low molecular mass. Theybind to proteins in the epidermis, thus trans-


26


forming to complete antigens. Complete anti-gens activate Langerhans’ cells, which in turnproduce cytokines. This is followed by transfor-mation into lymphocytes and their multiplication.These will infiltrate the smallest blood vessels ofthe skin and act as memory cells. Sensitizationwill take about 8 to 21 days and in most cases,will take an asymptomatic course. Only after asecond contact, antigen-specific memory cellswill become transformed into effector cellswhich in turn, will cause the release of severalmessenger substances. More inflammatory cellswill be recruited followed by interference withthe epidermal barrier function and an excessiveinflammatory reaction of the skin. Contact withsubstances having caused an existing cell-me-diated allergy will result in erythema, oedemaand papulovesicles, sometimes also in weepingerosions, scab formation and secondary effectsfrom scratching at the contact sites.

Diagnosis is based on the patient’s history,eczematous skin changes and typical localiza-tion. If a defined substance is suspected ofhaving caused the contact allergy, a standard-ized commercial patch test (epicutaneous test)is performed. For this test, the allergen is ap-plied to the skin by means of a taped pad andleft there for 48 hours; the reaction is read 48and 72 hours later. Formation of an infiltrate isinterpreted as a positive reaction to the test.

The most important measure of treatment iselimination or avoidance of the toxicant or theallergen. Hyposensitization as performed totreat inhalation allergy has not yet become es-tablished in such cases. Therefore, treatment ofthe eczema will depend on the manifestationspresent. Corticosteroids are the medication ofchoice for initial topical therapy. After inflamma-tory manifestations have subsided, a nurturingand stabilizing treatment of the skin will follow.Weeping skin areas will be treated with moistcompresses and water-based ointments, chroni-cally dry skin changes with oil-based creams.

Sensitization will often persist for more than tenyears even if the allergen is carefully avoided.Renewed exposure will result in symptoms re-turning. This is why in a prognostic view, a defi-nite cure is considered as rather improbable.

3.2.1.1 Allergic contact eczema

Allergic contact eczema after use of ananti-wrinkle productA 51-year-old physician had used a cosmeticproduct over a period of approximately oneyear in order to treat the facial lines aroundhis eyes. For this purpose, he had applied theproduct to his upper and lower eyelids twice

27

Fig. 9: Right eye prior touse of the anti-wrinkleproduct

Fig. 10: Left eye prior touse of the anti-wrinkleproduct

Fig. 11: Allergic contacteczema after use of theanti-wrinkle product –right eye

Fig. 12: Allergic contacteczema after use of theanti-wrinkle product – left eye

a day (except for occasional single-day inter-ruptions) slightly rubbing it in as described inthe instructions for use. Eleven months afterthe first use, he noticed itching, burning andreddening of the treated skin areas. Thesemanifestations deteriorated, and an increaserather than a reduction of wrinkles was ob-served. In addition, the patient developeddesquamation (shedding of the horny outerlayers of the skin associated with scale for-mation). Therefore, he discontinued the treat-


ment three days later. The patient’s medicalhistory did not mention any other diseases,nor had he taken any medicines or used der-mal products, ointments or other cosmetics.

Manifestations/courseThe physician treated himself with 0.5 % hydrocortisone preparations as a topical therapy and with prednisolone tablets as asystemic therapy at doses of 15 mg daily ad-ministered over a period of three days. Underthis therapy, the symptomatology showed aconsiderable improvement so that treatmentcould be discontinued. Subsequently, the patient had almost no complaints and in thefurther course, he became symptom-free.

NotesIn the above case, it has to be assumed that thepatient suffered from an allergic contacteczema. The typical symptoms developed onrepeated contact and after a sensitization peri-od. The patient became symptom-free as a re-sult of allergen avoidance and an appropriatetreatment with steroids.

Evaluation of the case described Based on the information given on the temporalrelationship between contact with the allergenand the appearance of manifestations, and inthe absence of other causes, a causal relation-ship has been rated as probable in the case described.

3.2.1.2 Non-allergic contact eczema

Severe inflammatory reaction with scarformation after use of a tattoo remover A 28-year-old patient had a tattoo removalperformed. This was to be achieved by intra-dermal injection of a substance which has remained unknown to the BfR. The media(press and TV) had promoted this method as

the most up-to-date and harmless procedurefor tattoo removal. The active substance wasnot revealed. Allegedly, this treatment wascarried out in Germany by only one tattoo re-moval consultant who for this purpose import-ed the substance from the United Kingdom.

Manifestations/courseIn the context of the removal attempt, the pa-tient developed severe inflammatory reactionsof the skin followed by a formation of raisedscars. Dark shades of the former tattoo werestill visible under the skin. The patient pre-sented to a laser centre for further removaltreatment. His skin above the former tattoo


28

Fig. 13, Fig. 14, Fig. 15: Severe inflammatory reactionwith scar formation after use of a tattoo remover

Fig. 13

Fig. 14

Fig. 15


exhibited numerous scars which probablycannot be removed. The BfR lacks informa-tion about the further course of this case.

Evaluation of the case described Based on the information given on the temporalrelationship between administration of the sub-stance and the appearance of manifestations,and in the absence of other causes, a causalrelationship with the tattoo removal has beenrated as probable.

Severe inflammatory reaction with scar formation after use of a permanent make-up removerA 55-year-old patient, who was a cosmeticianherself, had a permanent make-up of her eye-brows performed eight years ago. Becauseshe was discontent with it, she had it re-moved by a permanent make-up designer.The tattoo and permanent make-up removershe had bought for this purpose was adminis-tered by subcutaneous injection, in compli-ance with the instructions for use. Accordingto the information provided by the manufac-turer, the product contained certain fruit acidsintended to remove the permanent make-up.The ingredients of this remover product areunknown to the BfR.

After the treatment, the patient developed amassive purulent inflammation in the region of the eyebrows. She complained of swelling,itching, burning, severe headache and se-verely inflamed eyes. She tried to soothe hersymptoms by means of local ice packs, as itwas recommended by the seller of the prod-uct, and then she consulted a dermatologypractitioner.

Manifestations/courseThe dermatologist’s findings included severe-ly inflamed and weeping skin changes in theregion of the patient’s eyebrows. A toxic con-

tact dermatitis caused by the remover was diagnosed. Treatment consisted in topical application of a cream containing antibioticsand cortisone. Two weeks later, the areas affected still exhibited massive keratinizationand scab formation with additional superin-fection in part. In addition, a slight swelling ofthe eyelids was observed. Even two monthsafter the attempted removal, the patient wasstill experiencing pain. Two flesh-coloureditchy scars formed in the region of the eye-brows. It has remained unclear whether thiscondition can be cured. The resulting disfig-urement means a considerable mental strainand a high degree of suffering for the patient.

Evaluation of the case described Based on the information given on the temporalrelationship between administration of the sub-stance and the appearance of manifestations,and in the absence of other causes, a causalrelationship has been rated as probable in theabove case.

Notes referring to both cases (tattoo and per-manent make-up remover)As suggested by the purpose of the productstated, the ingredients of the tattoo and perma-nent make-up removers might contain aggres-sive substances causing skin damage (non-al-lergic contact eczema). Both cases describedmay be classified under this category.

If a preparation is injected, treatment undernon-sterile conditions may as well result in atransmission of pathogenic microorganisms.This will increase the risk of infection.

It has remained unclear whether in the abovecases the presence of an aggressive ingredientof the removal preparation resulted in acute-toxic dermatitis, or the skin damage has to beattributed to an infection due to non-sterile con-ditions.

29


3.2.1.3 Non-classifiable contact eczema

Contact eczema after the application of herbicidesA 41-year-old patient had applied two spraychemicals at his workplace. One of thesecontained the active substance amidosul-furon, a sulfonylurea, the other herbicide con-tained ioxynil and sodium hydroxide, the latterin a corrosive concentration. During this work,his arms and hands were uncovered. In theafternoon of the same day, he developedvesicles on both his hands and arms similarto those associated with sun allergy. Duringthe night, the patient’s condition deteriorated,he complained of severe pain. In addition,he developed blood blisters on the exposedbody parts (both arms and hands). He con-sulted a doctor. It has remained unknownwhether the patient had had contact with the two substances involved before the inci-dent. No statements can be made regardingthe patient’s medical history nor that of hisfamily.

Manifestations/courseThe attending dermatologist treated the patient with cortisone. No more information

has been available concerning the furthercourse, in particular, it has remained un-known whether epicutaneous testing was performed.

NotesThe information available to the BfR was insuffi-cient to elucidate whether in the above case, thepatient suffered from contact eczema causedby acute exposure to toxic chemicals (ingredi-ent sodium hydroxide) or from a contact allergyin the sense of a type IV reaction according tothe Gell and Coombs’ classification (cortisonetreatment).

Evaluation of the case described Based on the information given on the temporalrelationship between the contact with the prod-ucts and the appearance of manifestations, andin the absence of other causes, a causal rela-tionship has been rated as probable in theabove case.

3.2.1.4 Special forms

Meadow grass dermatitis due to hogweedcontactAs part of his job in the waste managementindustry, a 25-year-old metalworker had con-tact with hogweed during mowing operations.It has remained unknown to the BfR whetherthe plant involved was the common hogweed(Heracleum sphondylium) or the giant hog-weed (Heracleum mantegazzianum). The pa-tient developed dermal symptoms and there-fore consulted a doctor.

Manifestations/courseThe “Durchgangsarzt” diagnosed contactdermatitis due to hogweed. After a course of outpatient treatment, the patient recov-ered. No more details were available on thiscase.


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Fig. 16: Contact eczema after the application ofherbicides


NotesBoth the giant hogweed (Heracleum man-tegazzianum) and the common hogweed (Hera-cleum sphondylium) belong to the genus Hera-cleum.

The common hogweed is frequently found onmeadows and along roadsides and forestedges in central Europe. Its typical characteris-tics include flat umbels of mostly five white,greenish or reddish blossoms. The fruit is flatand mostly of elliptic form, with a length of6–10 mm, and its lateral ridges are prolonged toform broad wings. It is a herbaceous plant of0.5–1.5 m height with bristly-hairy stalks becom-ing puffy sheaths near the stem.

The giant hogweed is often found along road-sides and forest edges, on moist rich soils andon fertilized meadows in Europe. The plant mayreach a height of more than 3.5 m and has thickstalks of ca. 10 cm in diameter with purpleblotches. Its leaves are deeply incised andthree-lobed, single leaves are five-lobed andpointed. The impressive white flowers are flatumbels reaching up to 50 cm in diameter.

All parts of plants belonging to the genus Hera-cleum are toxic. The responsible substances

31

are referred to as furocoumarins. In commonhogweed, these plant ingredients are mainlyfound in the unripe fruits, in giant hogweed, par-ticularly in the sap. On contact with the skin andsimultaneous or subsequent exposure to sun-light, furocoumarins cause a phototoxic reactionresulting in meadow grass dermatitis. Initialmanifestations include itching, burning and erythema with oedema. About 10–48 hours later,a clearly circumscribed dermatitis will developon the skin areas affected, it is associated withitching, reddening and blistering. These skinchanges take a long time to heal (one to twoweeks). They may remain visible up to one yearand leave scar-like hyperpigmentation. Acutetoxicity of furocoumarins is low in the absenceof light. Therefore, exposed persons should ab-solutely avoid exposure to sunlight. Treatmentwill depend on the symptoms experienced andmay include e.g. topical administration of anti-swelling and antiphlogistic agents. Once theblisters have dried up, most persons affectedwill no longer suffer from complaints. In cases ofingestion, fluid should be given for dilution.

In the case described above, it can be assumedthat the contact dermatitis diagnosed wasmeadow grass dermatitis.

Evaluation of the case described Based on the information given on the temporalrelationship between the contact with the plantand the appearance of manifestations typical ofcontact dermatitis, and in the absence of othercauses, a causal relationship has been rated asprobable in the case described.

Allergic exanthema after contact withinsectsA 34-year-old forester had occupational con-tact with insects which, according to the in-formation submitted, also included the oak processionary moth. The patient developeddermal symptoms and therefore consulted adoctor.

Fig. 17: Giant Hogweed (Heracleum mantegazzianum),toxic


Manifestations/courseThe patient was diagnosed with allergic exan-thema after contact with insects, probably the oak processionary moth. He was adminis-tered an unspecified infusion treatment. Fol-lowing this treatment, his symptomatology improved. No more details about the coursehave become available to the BfR.

NotesThe oak processionary moth (Thaumetopoeaprocessionea) has been named after the habitof its larvae (caterpillars) to form processions atnight when crawling from their nests to thecrowns of oaks to feed on the foliage. It is nativeto central Europe and thrives in a warm and dryclimate. A growing occurrence of the specieshas been observed since the mid-1990ies. Aparticularly steep increase in the populationdensity of the moth tending towards mass re-production was found to occur after the ex-tremely hot and dry summer of the year 2003.Kindergartens and schools had to be shut downtemporarily due to caterpillar infestation in their

vicinity. Control of the spreading has been par-ticularly difficult because some methods of me-chanic elimination have proved to be problemat-ic. For example, removal of the webs by meansof water jets may promote swirling of the toxiccaterpillar hairs. A method that has proved to besuccessful is spraying of the larval nests with abinder. Afterwards, the nests are collected anddisposed of in closed plastic bags in a wasteincineration plant. Operators performing thiswork should wear full protective suits and respi-ratory protection.

A particular health risk for humans is posed bythe hairs of older caterpillars. These urticatinghairs possess barbs and therefore may remainstuck in the skin. They break readily, releasingthe urticating toxin, thaumetopoein, which maycause allergic skin reactions. Dermal contactwill immediately result in unpleasant itching fol-lowed by skin rash. In addition to inflammatoryskin reactions, also wheals or persistent nod-ules may develop macroscopically resemblinginsect bites. Exposure of the eyes will result ineye irritation, on inhalation there will be irritationof the upper respiratory tract, which in predis-posed subjects may result in dyspnoea. In veryrare cases, also general manifestations such asdizziness, drowsiness and fever may occur.

After contact with caterpillar hairs in the ab-sence of protective clothing, a thorough show-ering and laundering of clothes are recom-mended. Onward therapy will be oriented by theexisting symptomatology.

Caterpillar hairs accumulate particularly in un-derwood and ground cover and adhere toclothes and shoes. They preserve their activityover a long period and remain dangerous forapproximately one year. Thus, they may causereactions again and again.

It has to be assumed that in the case describedabove, the forester had worked without wearingprotective clothing. Contact with the urticating


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Fig. 18 and Fig. 19: Oak processionary moth (Thaumetopoea processionea)


hairs caused the release of thaumetopoein re-sulting in the manifestations described above.

Evaluation of the case described Based on the information given on the temporalrelationship between contact with the caterpil-lars and the appearance of manifestations, andin the absence of other causes, a causal rela-tionship has been rated as probable in the casedescribed.

3.2.2 Oral exposure

3.2.2.1 Water intoxication

Severe hypotonic hyperhydration fromdrinking ca. 4 L of tap water followingaccidental ingestion of a descaling agentA 57-year-old patient had accidentally ingest-ed a sip of a descaling agent containing ami-dosulfonic acid. Therefore, she decided todrink about 4 L of tap water subsequently.This large quantity was confirmed by her hus-band. By doing so, she intended to preventhealth damage possibly caused by thedescaling product. Shortly afterwards, nau-sea set in and she experienced two episodesof vomiting. Because the accident occurredduring the Christmas holidays, she consultedthe medical emergency service. In order toexclude a chemical burn due to the descalingproduct, the patient was admitted to hospitalby the physician on duty. In the ambulance,the patient began to suffer from increasingmental clouding and developed recurrentgeneralized convulsions.

The patient’s medical history revealed regularalcohol consumption. She had stated to con-sume one or two glasses of wine per day.

Manifestations/courseAfter admission to the intensive care unit, thepatient suffered again a convulsive seizurewhich was associated with a persistent drop

33

in oxygen saturation requiring intubation andartificial respiration. Clinical and radiologicalfindings revealed pulmonary oedema. Al-ready after a short period of time, the patientshowed sufficient gas exchange and respira-tion and could be extubated. Clinical chem-istry revealed massive metabolic acidosis,mild leukocytosis of 11.6 103 /L, CRP increaseof 48 mg/L and a mild increase in liver en-zymes. Problems arose from a severe distur-bance of the water and electrolyte balancethat had been the cause of the central mani-festations including the convulsive seizures.Laboratory measurements found sodium lev-els of 112.6 mmol/L, a decrease in osmolalityto 265 mosmol/kg H2O, a reduced red bloodcell count of 3.4 1012 /L and a reducedhaematocrit of 33 %. These findings indicat-ed severe water intoxication. Since the condi-tion was still at an early stage, it was decidedto perform haemofiltration. A few hours afterthe incident it could be assumed that a finalredistribution had not yet taken place in thebody. The treatment was aimed at the restora-tion of the physiological volume homoeosta-sis. After successful haemofiltration, the alertpatient could be transferred to a normalward, with normal reflexes and a compensat-ed acid-base balance. At that time, alsospontaneous respiration had been restored.No more convulsive seizures were observed.The patient’s cardiovascular condition hadbeen stable throughout the inpatient treat-ment.

The BfR has not received any informationabout the further course of this case. It is as-sumed that the patient recovered and wasdischarged from hospital after appropriateobservation and follow-up examinations.

NotesDescalers contain acids. Depending on theconcentration, they may cause chemical burns.


Symptoms include dizziness, nausea and vomit-ing. In extremely severe cases, drinking of largeamounts of water may result in water intoxica-tion with hyponatraemia if the intake of mineralsand common salt is insufficient. Low sodiumlevels may lead to disorientation and severe or-gan damage such as cerebral dysfunction(cerebral oedema) and thus, to a lethal out-come. Therefore, it is recommended not to con-sume large amounts of water at once. If never-theless, large quantities of water were con-sumed without the simultaneous supply of anyother food, electrolyte control should be per-formed. Findings of imbalance require intensivemedical monitoring including careful assess-ment of the water and electrolyte balance and acautious and slow electrolyte replacement.

In the case described above, the symptoms ex-perienced by the patient indicated that sheneeded to see a physician in order to excludepossible chemical burns. As recommended,she drank a rapidly available fluid as a firstmeasure, however, without consuming anythingelse in addition. Presumably, the quantity of 4 Lshe consumed was too high and probably notexcreted in full later on. The lack of a simultane-ous supply of minerals together with insufficientexcretion of the excessive amounts of water re-sulted in water intoxication. As a consequence,the patient suffered a disturbance of her waterand electrolyte balance. The high water reten-tion can probably be attributed to an increasedrelease of the antidiuretic hormone (ADH) underconditions of nausea. Nausea or vomiting stimu-late the release of ADH, which reduces fluid excretion in order to protect the body from fluidloss.

The mild increase in liver enzymes may be at-tributed to regular alcohol consumption. Therewere no indications of alcohol withdrawal symp-toms. The metabolic acidosis observed wasmost probably caused by the derailed meta-bolic situation. The absorptive effect of thedescaler was considered as less probable.


34

Manifestations of chemical burns include nau-sea, vomiting, hypersalivation, pain (in the oralcavity, retrosternal) resulting in refusal to eatparticularly in children, and signs of burns inthe oral and pharyngeal regions. The latter maybe absent in cases of fluid ingestion becausefluids will quickly pass the oral cavity prior tocausing visible lesions.

Symptomatic patients should always see a doc-tor to exclude chemical burns.

In any case, drinking of a quickly available fluidsuch as tap water is recommended as an imme-diate measure. This is done to flush the oesoph-agus. The ingredients of tea, tap water and min-eral water do not correspond to what the bodyneeds. If ingestion of too high amounts of thesefluids is not accompanied by the consumptionof other foods, this will result in sodium chloridedeficiency, also referred to as hyponatraemia.There will be a state of salt-to-water imbalancein the body.

Fig. 20: Descaling product


Quantities of about 100 mL would be insuffi-cient to cause such an effect. Higher amountsare only ingested with suicidal intent. A suicideattempt was however excluded on account ofthe medical history in the case describedabove.

Evaluation of the case describedBased on the temporal relationship between the drinking of large amounts of water and theappearance of typical symptoms, a causal rela-tionship has been rated as possible in theabove case. Nevertheless, such pronouncedcases have been observed extremely rarely inpractice.

3.2.2.2 Accidental intake of cleaning agent

Cleaning agent mistaken for orange juiceby elderly patientA 69-year-old patient had accidentally in-gested a sip of a cleaning agent. Due to theproduct’s colour and a package design re-sembling that of a food product, it was mis-taken by him for orange juice. In addition, thelabel showed a picture of oranges and theword “Orange” appeared in the productname.

The patient saw a doctor because of a burn-ing sensation in his mouth and throat. Nocough was observed.

Manifestations/courseThe attending physician consulted a PoisonControl Centre to assess the risk and initiateappropriate treatment. Because the cleanercontained a surfactant, the patient was ad-ministered an agent to prevent foam forma-tion. In addition, he was recommended todrink fluid. Physical examination findingswere non-significant, and admission to hospi-tal was not required.

NotesAn enquiry at the Berlin poison emergency tele-phone service revealed that the product con-cerned had been involved in only one case ofpoisoning so far.

In addition to surfactants, the cleaner involvedcontains a relatively high share of synthetic es-sential oils.

Essential oils have been used as a commoncold remedy in medicine, as indoor air freshen-ers or conditioners in the household, for aro-matherapy, in stain removers or other cleaningagents, in cosmetics, and also in industry, forexample as a fat solvent.

As far as is known, they are readily absorbedfrom the gastrointestinal tract, the lungs and theskin and mucous membranes.No exact toxicological datahave been published recently.Lethal doses stated in thepast were 50–500 mg/kgbody weight. It has to betaken into account thatthe toxicity of the individ-ual essential oils varies.Special caution should beexercised when usingcamphor, eucalyptus,thyme and peppermint oil(menthol). These essen-tial oils are considered asparticularly problematic.Camphor is extremely tox-ic, ingestion even of smallamounts may cause con-vulsions. Synthetic oilsare considered as harm-less rather than danger-ous. Otherwise, minorsymptoms may occur al-ready after ingestion of afew droplets irrespectiveof the dose. Severe symp-

35

Fig. 21: This cleaningagent can easily bemistaken for a beverage


toms have to be expected only after ingestion oflarge amounts but due to the irritating effect onthe mucous membranes, intake of large quanti-ties is rather improbable. There are, however,numerous essential oils whose taste is similar tothat of fruit juice. All manifestations will occurwithin the first two hours after ingestion. Irritationof the mucous membranes will result in gas-trointestinal complaints, absorption may be fol-lowed by CNS manifestations similar to those ofalcohol intoxication such as ataxia, sedation, un-rest, tremor and a lack of distance. In rare cas-es, severe symptoms such as unconsciousnessand convulsive seizures may occur.

Therapy will depend on the symptoms ob-served. In cases where the amounts ingesteddo not exceed a sip, administration of fluid and observation at home for two hours are sufficient.

Surfactants (anionic and non-ionic) are rathersafe in terms of health. In addition to the irritat-ing effect on mucous membranes, foam forma-tion is the predominant problem. Manifestationsmay also include vomiting, abdominal pain, flat-ulence and diarrhoea. In rare cases, vomiting orformation of considerable amounts of foam inthe mouth involve an aspiration risk. Aspirationmay have taken place if persistent cough andrespiratory complaints are observed. For heal-thy children and adults, ingredients containingsurfactants do not pose a particular risk. Forelderly persons, however, shower gels, bubblebaths, shampoos, all-purpose cleansers, liquiddetergents etc. may be life-threatening. Theyare more prone to foam aspiration, which mayresult in severe pulmonary manifestations. In thecontext of the reports entitled Cases of Poison-ing Reported by Physicians, a total of 23 caseshave come to the knowledge of the BfR since1990 where the ingestion of large amounts ofhousehold cleaners and disinfectants resultedin severe manifestations. A lethal outcome wasrecorded in 17 cases. All of these cases re-ferred to disoriented elderly persons. There has

certainly been a considerable number of unde-tected and unreported cases.

Another risk group is that of infants particularlyin their oral phase because coloured fluids maybe considered by them as attractive “toys” andare explored by putting them into the mouth. Asa rule, these children will develop only minorgastrointestinal symptoms. Treatment will con-sist in the administration of an anti-foamingagent, which, however, has to be procured orprescribed before it can be used.

Elimination of the risk of accidental ingestiondue to mistake, e.g. by different designs ofpackage and choice of colours for such prod-ucts, could spare patients unpleasant com-plaints and medical consultations and avoid un-necessary treatment costs. A positive exampleto be mentioned is the ban on coloured lampoils. Such measures could reduce the risk in-volved for elderly individuals who otherwisemight mistake certain substances for foods,thus preventing cases of severe poisoning anda lethal outcome.

Evaluation of the case described Based on the information given on the temporalrelationship between the ingestion and the ap-pearance of manifestations, and in the absenceof other causes, a causal relationship has beenrated as probable in the above case.

3.2.2.3 Carbon grease remover

Severe chemical burns in a young childafter ingestion of a carbon grease removercontaining sodium hydroxideA 4-year-old child accidentally drank one ortwo sips of a carbon grease remover contain-ing sodium hydroxide. The product had beenfilled into a lemonade bottle and could there-fore be mistaken for a beverage. The childwas immediately given water to drink by hermother. Subsequently, the child vomited sever-


36


prophylaxis. During the following days, thepatient still complained of pronounced diffi-culty to swallow. Local findings improvedslowly, and steroid doses could be graduallyreduced. On the sixth day, the patient’s condi-tion had stabilized so that the girl was allowedto drink in small sips, followed by a liquid dietgiven from the seventh day. On the ninth day,the CVC could be removed, and partial par-enteral nutrition was performed over a periph-eral access. The latter as well as the adminis-tration of steroids and antibiotics were dis-continued on the following day. Solid foodcould be gradually reintroduced. Local find-ings made by non-invasive examination weresatisfactory at that time.

Follow-up gastroscopy performed almost twoweeks after the incident revealed stenosispassable for a 6mm device. Therefore, gas-troscopy was repeated several times and

37

al times, and the emergency medical servicewas called. When the emergency physicianarrived, vomiting had stopped. Oral lavagewith isotonic saline was performed repeatedly,and the child transported to a hospital.

Manifestations/courseDuring admission to the paediatric hospital,the child vomited again. During medical ex-aminations, she was found to be in a reducedgeneral condition. Symptoms of chemicalburns included swelling of the lower lip andoral mucosa. Except for stress-related tachy-cardia (130/min), no abnormality was detect-ed with regard to the status of other organs.Laboratory parameters routinely examinedshowed normal levels except for a leukocyto-sis of 19 200/µl. Radiology performed oneday after admittance revealed an infiltrate inthe right upper lobe of the lung.

On the next morning, gastroscopy was per-formed under endotracheal anaesthesia. Theexamination revealed pronounced changes ofthe hypopharynx, epiglottis and larynx withoedematous swelling. The oesophagus exhib-ited second-degree, mostly circular, chemicalburns with fibrinous deposits, and the gastriccardia was covered with altered blood(haematin). Due to these pronounced find-ings, the child received parenteral nutrition,and a central venous catheter (CVC) was im-planted for this purpose. According to thescheme for treatment of chemical burns, shewas administered systemic steroids and puton antibiotic cover with cefotaxime. In addi-tion, she was administered omeprazol. Duringthe first night, the patient was monitored atthe intensive care unit and analgosedatedwith midazolam and piritramide.

This therapy was continued after transfer to anormal ward. Paracetamol and if required,metamizole were now administered for pain

Fig. 22: X-ray picture of extended oesophageal stenosis


bougienage performed. The first bougienagelead to lesions of the mucous membranewhich again required temporary abstinencefrom food. Subsequently, food was graduallyreintroduced without problems. Afterwards,repeated gastroscopy and bougienage wereperformed and the child was discharged inthe meantime with appropriate food to be giv-en at home. Extended oesophageal stenosisrequired implantation of a stent.

About six months after the poisoning acci-dent, the child had to be admitted to hospitalagain because of difficulties to ingest evenliquid foods and increasing difficulty to swal-low, which suggested dislocation of the stent.This was confirmed by gastroscopy and inaddition, another stenosis was found, locatedcranial to the stent. After initial bougienage,attempts were made to relocate the stent.However, these attempts remained unsuc-cessful since the stent was non-relocatable.Another attempt was made a few days laterfollowed by the decision to remove the stent.Due to the resulting severe irritation of the oe-sophagus, a new stent was not yet implanted.Five days later, the clinical course was com-plicated due to a perforation of the oesopha-gus which occurred during an attempt to im-plant a new stent.

The child was transferred to the paediatricsurgery ward for onward treatment. On ad-mission to this ward, the girl’s circulation wasstable but she was very restless and com-plained of severe upper abdominal pain. Shewas transferred to the intensive care unit.During tracheoscopy and oesophagoscopy,a gastric tube using a guide wire, as well as a suction drain tube for saliva drainagewere inserted. In order to prevent mediastini-tis resulting from pneumomediastinum, thepatient was administered triple antibiotictreatment. There were no clinical signs of in-fection observed at any time of the treatment.An initial increase in CRP was followed by aclear decrease in the further course. Foodabstinence was required and parenteral nu-trition given. As a result of this therapy, thepatient’s general condition improved. Afterlong-term parenteral nutrition via a CVC, con-tinuation of relief through gastric tube andcontinuous saliva draining, the patient’s clinical condition improved. An initial skin emphysema on the left coastal arch had disappeared. Antibiotic therapy could be discontinued as inflammatory parameters remained in the normal range. When X-ray of the gastrointestinal tract showed that theoesophageal leakage had disappeared,the suction drain tube was removed andgradual reintroduction of food started. No hypersalivation or vomiting occurred in thefurther course so that a gradual change tohigh-caloric enteral feeding and a likewisegradual reduction of parenteral feedingcould be performed. Eventually, total enteralfeeding of the child was possible, also oralfluid intake did no longer cause any prob-lems and the patient could be dischargedhome.

Repeated follow-up oesophagoscopy includ-ing bougienage is envisaged the results ofwhich have not yet been established. It re-


38

Fig. 23: Chemical burn of mucous membranes with lesions in the oral region


mains to be seen how the further gradualreintroduction of food and the eventualchange to solid foods will develop.

NotesChemical burns are caused by exposure toacids, alkalies or other chemicals having corro-sive or colliquative effects. Body areas particu-larly at risk include the mucosae of the uppergastrointestinal tract, mainly the oesophagus,after oral ingestion of a corrosive substance.Based on the clinical course, there are essen-tially two types of chemical burns.� Acids will cause immediate precipitation of

proteins resulting in coagulation necrosis,which will prevent further deep action andthus protect the underlying tissue. Sulfuricacid causes dehydration and strong heatingof the tissue and thus may cause damage toall layers of the skin, mucous membranesand the eyes. Similarly, deep action is produ-ced by hydrofluoric and nitric acids. There-fore, the extent of the damage can be asses-sed only after a certain latency period.

� Exposure to alkalies will result in colliquativenecrosis. Due to cell lysis, the chemical willrapidly penetrate the outer layers of the skin.Among alkaline burns those caused by limeare prominent. Exposure to unslaked lime(calcium oxide, also referred to as quicklimeor burnt lime) will result in the formation ofcalcium hydroxide on the mucous membra-nes and in the eyes (lacrimal fluid). This isaccompanied by heat formation, which maycause additional damage to the skin, the mucosa and the eyes.

After exposure to low concentrations of corro-sive substances, a clear differentiation of clini-cal manifestations is often impossible. Both acidand alkaline substances will cause no morethan various degrees of irritation of the skin ormucosa because the underlying tissue is affect-ed to a minor degree only.

39

Oesophageal burns are classified by three de-grees of severity:� First-degree burns are characterized by su-

perficial lesions of the mucosa with erythemaand oedema and without epithelial damage.In most cases they will heal without sequelae.

� Second-degree burns are associated withminor erosions, ulcerations and fibrin exudati-on. They reach the submucosa which showstissue necrosis. Their healing process will in-clude reactive granulation followed by scarformation.

� Third-degree burns are characterized bydeep ulceration reaching into the muscularismucosae and being associated with bacterialpenetration into the perioesophageal tissueand perforation followed by mediastinitis. Thiswill result in the formation of stenosing scarsimpairing food intake.

Most corrosive poisons act very quickly. There-fore, immediate action is of essential impor-tance. Less rapid action is developed by drysubstances in granular form because these canact only after having become dissolved. Afteroral ingestion, the first measure to be taken bythe person affected is to spit out the corrosivesubstance. Particularly in the case of childrenand after ingestion of solid corrosive sub-stances such as granular dishwasher cleaners,the patient’s mouth should be wiped out with adamp cloth as soon as possible. To make use ofthe dilution effect, the patient should be prompt-ed to immediately drink water or another (non-alcoholic, non-carbonated) fluid quickly avail-able such as tea or juice. If some of the gran-ules are stuck e.g. in one of the oesophagealsphincters, drinking of large amounts of fluidmay also be effective some minutes later: theoesophagus becomes flushed. Any administra-tion of milk in cases of poisoning is of no practi-cal benefit; rather, it is contraindicated. Sincepoisons are either fat-soluble or water-soluble,milk will constitute an ideal transport medium,and the toxicants will be absorbed with particu-lar readiness. In children, milk will often have an


additional emetic effect so that the corrosivesubstance passes the oesophagus twice, thuscausing double damage. Therefore, vomitingmust never be induced. Also for a so-calledneutralization, milk is of minor importance be-cause its buffering capacity is minimal. Drinkingof milk is only recommended in exceptionalcases such as after accidental ingestion of fluo-rides, tetracyclines or iron since the poisontypes formed as a result are less readily ab-sorbed. Also gastric lavage is not recommend-ed. However, it may be indicated to remove thecorrosive substance ingested through a feedingtube if in addition, there is a risk of poisoning byabsorption (e.g. hydrofluoric acid, formic acid).

All cases of confirmed ingestion of a corrosivesubstance will require treatment. In cases ofsuspected ingestion, a chemical burn is sug-gested by at least one of the following manifes-tations observed within the first 24 hours afterthe incident:� Signs of burns in the oral and pharyngeal

regions� Hypersalivation� Retching� Vomiting� Retrosternal or epigastric pain and refusal

to eat (in children, an indirect manifestation of pain).

It has to be taken into account that althoughsings of burn may be absent in the mouth afteringestion of a corrosive fluid due to the rapidpassage and short duration of exposure, con-siderable chemical burns may be present in theoesophagus. Patients who are initially symptom-free after suspected ingestion do not undergotreatment. However, they should see a physicianfor control and observation.

Immediate measures to be taken still on thescene of the accident may include pain relief,circulatory assistance, and intubation or tra-cheotomy. Systemic administration of 3 mg/kgbody weight prednisolone should be performed

to prevent glottic oedema. Oesophagoscopyshould be performed later when this can bedone on a routine basis (as a rule, on the follow-ing morning) and should be carried out by anexperienced team. This will ensure that the ex-tent of damage suffered is correctly identified.Inspection is performed until the first sign ofburn becomes visible. The stomach has to beinspected only after ingestion of strong acids,soldering fluid or potassium permanganatecrystals in order to exclude lesions of the stom-ach wall or to remove remaining crystals to prevent them from penetrating into deeper re-gions. If findings are negative, the patient canbe discharged without any further measures.Also first-degree chemical burns do not requireany treatment or follow-up examination. In casesof second-degree chemical burns, administra-tion of prednisolone at a dose of 1 mg/kg bodyweight is recommended until healing has beenverified by endoscopy. In animal studies, pred-nisolone has reduced abnormal growth of fi-broblasts. Therefore, it was assumed to be ableto prevent the formation of oesophageal stric-tures in humans. However, this assumption hasnot been confirmed in follow-up examinations ofpatients after chemical burns. In cases of third-degree burns, steroid therapy is discontinued.Such lesions may require surgical intervention.In cases of severe chemical burns where a highrisk of stricture formation is involved or oe-sophageal stenosis has developed after heal-ing, treatment may consist in (early) bougien-age, insertion of a permanent gastric tube, orpercutaneous endoscopic gastrostomy (PEG).

Onward therapy will be oriented by the symp-toms. It may include administration of antibioticsto control mediastinitis and secondary infectionsassociated with gastric ulcers, of proton pumpinhibitors to reduce the production of gastricacid, and dietetic measures to ensure food in-take (liquid or mushy diet or parenteral nutritiondepending on findings). After ingestion of largequantities of acids, possible effects from ab-sorption such as acidosis, haemolysis or renal


40


uretics. As a result of this therapy, her symp-tomatology improved rapidly. Pulmonary con-gestion as initially seen was no longer foundto be present in the further course. After twodays of inpatient treatment, the patient couldbe discharged and referred to outpatienttreatment. She was recommended to consulta pulmonologist for follow-up examinations.

NotesIn the above case, the spray may have beenused excessively. Also ventilation and wind di-rection, respectively, would have to be taken intoaccount. This is the only explanation why thepatient’s husband did not experience any symp-toms. Probably, he was less exposed. The pa-tient became symptom-free within a short peri-od of time owing to an effective therapy whichhad been initiated without delay.

A rapid communication on this case was distrib-uted.

Evaluation of the case describedBased on the information given on the temporalrelationship between the exposure and the oc-currence of manifestations, and in the absenceof other causes, a causal relationship has beenrated as probable.

Severe inhalation poisoning with pulmona-ry oedema after exposure to impregnationspray for tents (product identical with thatof the previous case)A 35-year-old female patient had treated twoigloo tents with an impregnation spray in theopen air. The product used was identical withthat involved in the case described above.The patient had also sprayed one of the tentsalong the seams from inside with the tentdoor remaining open. One hour after expo-sure she complained of dry cough during theslightest physical effort.

41

failure have to be taken into account. Finally,follow-up endoscopy is required, with the ap-propriate time of such examination depending on the extent and severity of the initial findings.Contrast X-ray examinations should be per-formed not earlier than three to four weeks later, in cases where apparent stenosis in theoesophagus or in the pyloric region has to beconfirmed or excluded.

Evaluation of the case describedBased on the information given on the temporalrelationship between exposure and the occur-rence of the manifestations observed, and inthe absence of other causes, a causal relation-ship has been rated as probable.

3.2.3 Inhalation exposure

3.2.3.1 Impregnation spray for tents

Severe inhalation poisoning with pulmona-ry oedema after exposure to impregnationspray for tentsTogether with her husband, the patient hadtreated an awning with impregnation spray inthe open air. She was situated at a distance of one or two meters from the spraying actionperformed by her husband. Shortly after-wards, the patient began to suffer from dysp-noea, shivers, a feeling of cold and weak-ness. For this reason, she sought assistanceat the emergency unit of a hospital.

Manifestations/courseExaminations on admission and ECG re-vealed tachycardia with heart rates of about100/min, and moist rales on lung auscultation.Radiological findings revealed pulmonaryoedema. Blood gas levels taken on the day ofdischarge and lung function (date of exami-nation unknown) were normal. Treatment ofthe patient included inhalatory and systemicadministration of corticoids (initially i.v., laterorally). In addition, she was administered di-


The attending physician consulted a PoisonControl Centre seven hours after the patient’sexposure to the product. At that time, his find-ings included minimal pulmonary spasms,tachypnoea and diffuse bilateral rales. Thepatient was administered corticoids and be-tamimetics by inhalation and was admitted tohospital.

In the patient’s history, bronchial asthma notrequiring treatment had been known for threeyears. It should be added that the patient wasa smoker with a daily consumption of onepackage of cigarettes.

Manifestations/courseOn admission, the patient was in a reducedcondition in a status asthmaticus. Findings in-cluded orthopnoea and tachypnoea as well astachycardia of about 100/min. On auscultation,consonating medium rales and slight wheezesand rhonchi were heard over the entire chest.X-ray examination revealed the presence ofpulmonary oedema. Conspicuous findingsmade by clinical chemistry included leukocyto-sis of max. 27 200/µL, an increase in ESR andin CRP to 58.85 mg/dL. The other laboratoryparameters routinely measured such as elec-trolytes, renal retention values, hepatic param-eters and coagulation were within normalranges. The patient was administered salbuta-mol by inhalation, a single dose of 40 mgfurosemide and 2 g corticosteroids (i.v.). As a result of this therapy, the pulmonary com-plaints soon receded completely, the pul-monary oedema improved promptly and theheart rate returned to normal. Follow-up X-rayfindings were non-significant so that after threedays of inpatient treatment, the patient, whowas in an improved general condition, couldbe discharged and referred to her family doc-tor for onward attendance. She was recom-mended to avoid physical strain for two weeksand to continue therapy with corticosteroids, a

proton pump inhibitor for gastric ulcer prophy-laxis and an antibiotic.

NotesImpregnating agents are used in the householdto restore the water and dirt repelling propertiesof textiles and leather products and for sanitaryfacilities to act as a sealing coat for surfaces.The agent is a liquid available in pump spray orconvenient aerosol cans providing for an evendistribution. These are pressure-tight cans con-taining the impregnating agent consisting of pro-pellants, solvents and the active substance. Pro-pellants used include propane, butane, and air.Typical solvents used include petrol or short-chain alcohols, and in a few products, xylene.Active substances used include silicones (poly-siloxanes), fluorocarbon and melamine resins,beeswax or wool fat. The impregnating liquid hasa low toxicity. Also in the form of pump sprays,impregnating or sealant sprays have been con-sidered as safe in terms of health. In contrast,problems have been associated with aerosolsprays. In Germany, attention was directed to thepulmonary toxicity of impregnation sprays al-ready in 1981. Because of their inherent healthrisk, several sprays for the impregnation ofleather were withdrawn from the market. In addi-tion, numerous modifications of the respectiveformulations by the manufacturers contributed toa reduction in the number of cases of poisoningshowing relevant manifestations. In 2002, anoth-er rise was recorded in the number of reportsconcerning impaired airway functions associat-ed with impregnation sprays for leather and tex-tiles in the Netherlands and in Switzerland. A lastcase series was reported in spring 2006. Withina short period of time, Poison Control Centres inthe German federal Länder reported a greatnumber of cases with severe health disorders.Persons affected complained of cough andshortness of breath and in several cases, devel-oped lung oedema. The causes of these mani-festations have not yet been elucidated.


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The use of sprays in small and insufficiently ven-tilated rooms may result in conjunctival irritation,dyspnoea or in rare cases, narcosis-like manifes-tations due to the solvents contained. Based onsystematic animal studies in birds, a key role hasbeen attributed to fluorocarbon resins and/or reactive polysiloxanes in combination with sol-vents. In addition, improper use such as spray-ing for extended periods or failure to shake thecontents sufficiently etc. should also be taken in-to account. However, it is mainly the physicalproperties such as the droplet size of the spraysthat decide on whether and which toxic effectsare caused in the respiratory tract. Obviously, thepersons affected had inhaled components of theatomized sprays that had remained in the indoorair as fine aerosols. Due to the small droplet size,these components may have reached the alveo-lar region causing accumulation of fluid, whichresulted in an impairment of the oxygen andmoisture exchange, respectively. The smalldroplet size is only achieved if the liquid appliedcontains a propellant and is applied by means ofa correspondingly small nozzle in the sprayhead. If, in contrast, the same liquid is appliedby means of a pump mechanism, the dropletsare larger than 100 micrometres and therefore,cannot penetrate into the alveolar tissue. This isprobably the reason why products applied tosurfaces by means of pump spray bottles havenot caused any problems so far. Hence, toxic ef-fects may only occur if the product itself, i.e. theentire substance mixture of the formulation is in-haled as a fine spray mist characterized by acorrespondingly small droplet size.

Patients developing symptoms are providedwith a fresh air supply as a first measure. Thereshould be an early inhalation therapy using topi-cal steroids and the patient should present to ahospital, to exclude a presence of lung infil-trates. Onward therapy will be oriented by theexisting symptomatology.

In the above case, the spray might have beenused improperly. The product had not been

used in the open air only but also inside the tentwith insufficient ventilation. Therefore, no rapidcommunication was distributed. The patient’shistory of pulmonary disease and nicotineabuse have certainly to be taken into accountas risk factors in addition. The patient becamesymptom-free within a short period of time ow-ing to an effective therapy which had been initi-ated without delay.

Evaluation of the case describedBased on the information given on the temporalrelationship between exposure and the occur-rence of the manifestations, and in the absenceof other causes, a causal relationship has beenrated as probable.

3.2.3.2 Glyphosate

Severe dyspnoea after spraying of a pesti-cide – Lung damage histologically confir-medIn May 2007, a 59-year-old farmer had ap-plied a pesticide on a wooded area measur-ing 5000 m2 for three hours in the morning.The weather was very warm with tempera-tures of about 25 °C. Altogether, a total quan-tity of three litres of glyphosate herbicide diluted at the proper ratio were applied bymeans of a knapsack sprayer. The farmer didnot wear any respiratory protection. After hav-ing finished this work, he experienced firsthealth complaints. Due to increasing dysp-noea, he had to be admitted to hospital andmonitored at the intensive care unit. Aftertwelve days of inpatient treatment, the patientwas discharged in an improved condition andreferred to his family doctor for onward atten-dance.

Manifestations/courseFirst symptoms developed about seven hoursafter the pesticide had been sprayed. Initially,the patient complained of aching muscles inhis chest, then he developed rapidly increas-

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ing shortness of breath, initially only underconditions of exercise, later on also at rest,with neither expectoration nor cough. Simul-taneously, his body temperature rose to ca.38 °C. On account of this symptomatology,the patient was admitted to hospital on thefollowing evening and initially monitored at theintensive care unit.

On admission, findings included slight dysp-noea at rest with minor coarse and moistrales bilaterally, a temperature of 38 °C, aslightly reduced general condition and a nor-mal nutritional status. X-ray revealed a diffuseinfiltration in the area of the right lateral lowerlung field on the day of admission. In the leftparacardiac region, a peribronchial thicken-ing was seen corresponding to a peri-bronchial infiltration. Already on the followingday, this infiltration was no longer seen. Clini-cal chemistry revealed a minor increase in in-flammatory parameters. On admission to thehospital, blood gas analysis revealed largelynormal values: PCO2: 23.5 mmHg; PO2: 83.3mmHg; oxygen saturation: 97.1 %. ECG find-ings were non-significant. In this context, ahistory of cardiac valve surgery (mitral valvereplacement) in January 2006 should be not-ed. Nevertheless, a cardiac aetiology of thesymptoms experienced could be excluded.

Also during the following days, auscultatorylung findings remained normal. Due to pre-vailing diffuse infiltration, a special pulmonaryexamination was performed (spiral CT scan).This revealed an extensive ground-glass infil-tration in the left upper lobe. Because ofthese pathological findings, the patient wastransferred to the pulmonological departmentof another hospital for diagnostic work-up af-ter five days.

Lung biopsy was performed by means ofbronchoscopy. The pathological/histological

opinion revealed changes characteristic ofacute alveolitis and accompanying cellularbronchitis with intra-alveolar foam cell reac-tion – inflammation of the alveoli and smallestbronchi. The opinion emphasized that the his-tomorphological picture was well compatiblewith lung damage induced by an irritant gasand was not that of a conventional bacterialinfection.

The patient was put on antibiotic cover forseven days and simultaneously administeredi.v. steroids at high initial doses, which weregradually reduced to 50 mg on the day of hisdischarge, and in general, were well tolerat-ed. Follow-up CT revealed an obvious rever-sal of the ground-glass lung changes previ-ously described. Lung function testing re-vealed largely normal values.

Six months after the incident, the patient stillcomplained of moderate breathing difficultiesunder conditions of exercise. He had contin-ued with outpatient treatment by a pulmonolo-gist which included follow-up examinations atquarterly intervals. According to the patient,chest X-ray findings continued to improve,however, changes were still found.

NotesThe main component of the pesticide used is aglyphosate salt in aqueous solution. The wettingagent contained is a tallow alkylamine salt (tallow amine). The biological action of theglyphosate consists in the blocking of a certainenzyme needed by plants for the synthesis ofaromatic amino acids (phenylalanine, trypto-phan, tyrosine). Animals lack this enzyme.Therefore, they cannot perform de novo syn-thesis of these amino acids and also, they areinsensitive to this herbicide.

In humans, signs of poisoning have so far onlybeen described after oral exposure to pesti-


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cides containing glyphosate. However, very lowquantities are sufficient to cause life-threateninghealth disorders. The clinical picture will becharacterized by mucosal lesions of the gas-trointestinal tract and diffuse lung damage andmay even include non-cardiac pulmonary oede-ma, cardiovascular failure and prerenal failure.So far, severe signs of poisoning after inhalationof pesticides containing glyphosate had beenunknown.

In the period between 1990 and 2007, the BfRreceived reports on a total of 60 cases of healthimpairment after exposure to pesticides con-taining glyphosate. Even after inhalation (20cases), there had been only minor breathingdisorders. Dermal exposure (25 cases) resultedin health disorders classified as moderate infour cases. Symptoms included for exampleblistering as characteristic of an allergic skin re-action. When stating the route of exposure, mul-tiple mentioning was possible. Eye irritation wasdescribed in 22 cases. Eight cases were char-acterized by the oral route of exposure, but onlyone of these was associated with life-threaten-ing signs of poisoning as in the case describedabove. A 33-year-old mentally ill male had in-gested 200 mL of a pesticide containingglyphosate with suicidal intent.

With regard to the persistent extreme breathingdifficulties with histologically confirmed toxic in-flammatory reaction of the lungs experiencedby the patient in the case described above, themechanism of exposure is of importance: Thepatient had inhaled the atomized spray underconditions of a high outside temperature andminor air movement over several hours (knap-sack sprayer, closed woodland area). Accord-ing to the safety data sheet valid at that time, theproduct was classified as dangerous for the en-vironment and irritant. Also, a warning was is-sued that contact might result in the risk of seri-ous damage to the eyes. The risk of damage tothe airways had not been expressly mentionedin the warnings up to that time. First aid meas-

ures in the event of accidental inhalation con-sisted in the suggestion to “get fresh air” as theonly immediate measure. The safety data sheetrecommended skin and eye protection but stat-ed that no respiratory protection was required.

Since according to the knowledge gained so far,the active substance, glyphosate, has only a lowtoxicity, it has been assumed that the completeformulation, i.e. in particular the combination ofthe contained surface active wetting agent,tallow amine (surfactant) with the active sub-stance, glyphosate, was the cause of the toxiceffect observed. Wetting agents generally en-hance the uptake of active substances into the plant tissue. The same mechanism could explain a possible toxic effect in humans afterconsiderable inhalational exposure to this pesti-cide.

Evaluation of the cases reported to the BfR,particularly of this recent case, has shown thata more explicit warning is required with regardto severe lung damage due to exposure to theatomized spray of this type of pesticides. Re-sponsible bodies have already pointed out thepossibly toxicity-enhancing effect of tallowamines in combination with glyphosate. For rea-sons of preventive health care, the BfR therefore

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Fig. 24: Knapsack sprayer with protective mask for the application of pesticides


deems it necessary to label all pesticides con-taining glyphosate and tallow amines with thecorresponding safety advice in addition, warn-ing about possible health risks for the respirato-ry system. The responsible government authori-ty has already been informed by the BfR andhas been asked to provide for a correspondingadditional labelling of all pesticides concerned.

Evaluation of the case describedBased on the information given on the temporalrelationship between the inhalational exposureto the pesticide and the appearance of signs ofsevere dyspnoea with histologically confirmedlung damage, and in the absence of othercauses, a causal relationship has been as-sumed to exist in the case described.

3.2.3.3 Bromine

Inhalational exposure to bromine at theworkplaceIn a pharmacy, an initially unknown chemicalleaked out, which quickly evaporated. The flu-id emitted brown pungent vapours. Three

members of thepharmacy staffinhaled thesevapours for ashort period oftime. Subse-quently, all ofthem com-plained about ir-ritation of the air-ways. The firebrigade wascalled and thepatients present-ed at a toxico-logical outpatient

clinic. Based on the history and above all, onthe characteristic brown colour and the pun-gent odour, leaked bromine could be identi-fied as the causative substance.

Case No 1:Manifestations/courseThe first patient complained of dizziness, atickle in her throat and slight burning in hernose and throat. Physical examination did notresult in any significant findings. No spasticrales were heard on auscultation of the chest,also oxygen saturation was normal (97 %). Aslightly elevated bromide level (57 mg/L) wasdetected in the serum (therapeutic levels upto 50 mg/L). Clinical chemistry revealed mildleukocytosis (10 360 /µL). In addition, an increase in cholestatic liver enzymes was noticed as a secondary finding. This patienthad presented herself at the same clinic already three years before. At that time, thegamma GT level was slightly higher than thenormal value. Diagnostic work-up was recom-mended.

Based on the fact that serum levels were onlyslightly elevated, massive bromine contami-nation could be excluded.

The patient left the clinic contrary to medicaladvice. Since bromine is an irritant gas withan moderate latency period, a follow-up visiton the next day was proposed to performlung function testing. The peak flow valuemeasured on this occasion was 490 L/min,thus corresponding to the normal value.

Evaluation of the case described The increase in cholestatic liver enzymes in thepatient was not consistent with the clinical pic-ture of poisoning. Therefore, it cannot be attrib-uted to the bromine exposure and requires fur-ther diagnostic work-up. Based on the temporalrelationship between exposure and appearanceof symptoms (except for the pathological liverparameters) as well as the slight increase in theserum bromine level, a mild bromine poisoninghas to be rated as confirmed.


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Fig. 25: Bromine


Case No 2:Manifestations/courseThe second patient complained of a sorethroat and a tickle in her throat after exposureto the vapours. Physical examination on ad-mission did not result in any significant find-ings. In particular, no spastic rales wereheard on auscultation of the chest. Also oxy-gen saturation was within the normal range(97 %). No elevated bromide level could bedetected in the serum. The value measuredwas 4.7 mg/L, i.e. a level corresponding to a physiological one (therapeutic levels up to 50 mg/L) and thus excluding massive bro-mine exposure. Clinical chemistry did not reveal any significant findings, except for aslight increase in TSH levels. This finding wasunrelated to the exposure and had to be at-tributed to iodine deficiency. Probably, the pa-tient was to be given iodine supplementation.

Since bromine is an irritant gas with a moder-ate latency period, a follow-up visit on thenext day was proposed to perform lung func-tion testing. The peak flow value obtained onthis occasion was 420 L/min, which still corre-sponded to a normal value.

Evaluation of the case described Based on the temporal relationship between theexposure and the appearance of symptoms aswell as the detection of bromine in the serum, amild bromine poisoning could be confirmed.

Case No 3:Manifestations/courseThe third female patient also experienced asore and tickling throat. The physical exami-nation performed on admission did not revealany significant findings except for reddenedconjunctivae. In particular, no spastic raleswere heard on auscultation of the chest. Oxy-gen saturation was within the normal range

47

(95 %). No elevated bromide level could bedetected in the serum. The value measuredwas 25 mg/L, i.e. a level corresponding to aphysiological one (therapeutic levels up to50 mg/L) and thus excluding massive bromineexposure. Clinical chemistry revealed a slightretention of substances usually eliminated inthe urine (creatinine: 1.4 mg/L, normal up to1.3 mg/L; blood urea nitrogen: 20 mg/L, nor-mal up to 18 mg/L), which was probably un-related to the incident. Follow-up examinationafter sufficient fluid intake was recommend-ed. This was to include also CK, showing anincrease to 322 U/L (normal value up to 174U/L) possibly due to physical activity.

Since bromine is an irritant gas with a moder-ate latency period, a follow-up visit on thenext day was proposed to perform lung func-tion testing. The peak flow value obtained onthis occasion was 600 L/min, correspondingto the normal range.

Evaluation of the case described Based on the temporal relationship between theexposure and the appearance of symptoms aswell as the detection of bromine in the serum, amild bromine poisoning has to be rated as con-firmed.

Notes regarding all three casesBromine is a halogen and was isolated for thefirst time from marine algae in 1826. Technologi-cal production started in 1860. Due to its pun-gent odour, it was named after the Greek word“bromos“, meaning the stench characteristic ofhe-goats. It is of high reactivity. Bromine is adark-brown and heavy liquid forming dark red-dish-brown and pungent vapours on contactwith air, which are five times heavier than the latter and therefore, will accumulate on theground. It is used as a disinfectant and a medi-cine (narcotics, sedatives and soporifics, anti-convulsants), and it has a variety of other uses.


It has to be stored in containers made fromglass, lead, monel (a copper/nickel alloy) ornickel because coatings, rubber and plasticmaterials are attacked.

The substance may be absorbed by the oral orinhalational route. Oral or inhalational exposurewill cause cough, dyspnoea, headache, dizzi-ness, chemical burns, abdominal cramps, circu-latory disorders and collapse. Inhalation of theirritant gas having a moderate water solubilitymay result in toxic pulmonary oedema, after alatency period. Due to the substance’s causticeffects, direct contact of the skin may causebadly healing wounds and produce reddeningof and pain in the eyes.

Exposed persons should quickly leave the gas-contaminated area. Other measures include im-mobilization and if required, sedation and pro-tection against a loss of body heat. Patients suffering from symptoms such as cough shouldsee a doctor and undergo inpatient observationto account for the latency period. In order toprevent lung oedema, glucocorticoids shouldbe administered as soon as possible, either bymeans of a CFC-free metered-dose inhaler (e.g.Budesonide) with aerosol holding chamber orby i.v. injection of high doses (preferablymethylprednisolone), if a massive exposure isassumed to have taken place. Onward therapywill be oriented by the symptoms.

From the dangerous substances reported to theBfR, bromine is the toxic agent involved mostfrequently in school accidents (> 20 %). Alto-gether, 106 reports of cases involving brominehave been submitted to the BfR so far. Typically,such poisoning accidents resulted in series ofcases because commonly, many persons (entireschool classes) were affected. In the school accidents, the cause was always a glass bottlewhich fell down and broke on the floor. As men-tioned above, glass containers are needed forstorage because unbreakable plastic contain-ers would be attacked by the substance. Possi-

bly, this was also the cause of the accidents in-volving the cases described. However, it shouldalso be discussed whether safety regulationshad been complied with. It has remained un-known to the BfR whether the patients hadworked under a ventilation hood.

The majority of persons affected in cases re-ported to the BfR (67 %) experienced mildsymptoms as described above. Typically,breathing difficulty (ca. 70 %) predominated,followed by nausea and headache (almost50 %). The majority of patients was observed as inpatients in a hospital setting, and all ofthem, except for one patient who had no mani-festations, saw a doctor. Owing to quick and ef-fective therapeutic measures, severe poisoningresulting in pulmonary oedema or irreversiblehealth damage could be prevented.

Evacuation measures and medical care re-quired after such incidents involve high expen-diture on labour and other costs. Storage of thechemical in unbreakable containers (e.g. monel)could probably help to prevent such accidentsin the future.

3.2.3.4 Cannabis and lead

Chronic lead poisoning aftersmoking/abuse of contaminated cannabisA 23-year-old student of mathematics hadsmoked between one and two grams ofcannabis daily. He had obtained the drug al-ways from the same source in a city in Saxony.He had noticed black smut adhering to thecannabis. Earlier, he had been supplied withcannabis with sugar-like smut. For the first timein October 2007, he experienced symptoms oflead poisoning characterized by severe col-icky abdominal pain. Having read a newspa-per article about cases of lead poisoning dueto contaminated cannabis in Saxony, the stu-dent associated his complaints with the samecause. On his initiative, his blood lead level


48


was determined in November after prior diag-nostic efforts had not resulted in any findings.Analysis revealed a grossly elevated lead levelof 1 850 µg/L (average blood lead level in chil-dren 50–70 µg/L). Findings also revealed thepresence of anaemia. When asked, he deniedhaving experienced headache, mentalchanges observed by himself or others, andany impairment of mental ability. No history ofphysical or mental illness was known. He wasadmitted to the toxicological department of aspecial hospital for treatment.

Manifestations/courseExaminations performed on admission of thevery slim patient, who weighed only 57 kg andhad a body height of 175 cm (BMI 18.6),recorded a strikingly pale skin. No lead hem(Burtonian line) was found. Findings includedunsteadiness in the finger-to-nose test, normalgross strength, propioceptive reflexes equalon both sides and no tremor. In addition topersisting strong abdominal colic, furthersymptoms of lead poisoning were found suchas arterial hypertension and short-term ortho-static dysregulation probably caused by vol-ume deficiency. His heart rate was elevated(101/min). Clinical chemistry revealed leuko-cytosis of 21 100/µL (follow-up examination 15 200/µL) with normal CRP and anaemia with a Hb of 7.9 g/dL (follow-up examination8.3 g/dL) with low mean corpuscular haemo-globin levels. Other pathological findingsworth mentioning included an increase ingamma-GT of 69 U/L, increasing to 93 U/L(normal up to 28 U/L), GOT of 99 U/L (normalup to 35 U/L) and GPT of 319 U/L, on follow-up examination 282 U/L (normal up to 30 U/L).By means of toxicological analysis, cannabi-noids could be detected in the urine. Bloodlead levels had remained high, with a maxi-mum of 1 562 µg/L on admission. In addition,severe lead poisoning was confirmed by anincrease in the urine levels of delta-amino-

laevulinic acid (160 mg/24 h, normal up to49 mg/24 h), porphobilinogen (22.27 mg/24 h,normal up to 7.5 mg/24 h) and a very strongincrease in total porphyrin levels in the urine tomore than twenty times the normal value(3767 µg/24 h, normal up to 145 µg/24 h).Additional diagnostic procedures includedsonography of the upper abdomen, which didnot reveal any pathological findings except fora pre-existing pyelectasis. ECG findings werenon-significant. Results of electromyography(EMG) performed on the day of dischargeand of the measurement of nerve conductionvelocity were not yet available when the dis-charge summary was written. Due to the con-firmed lead intoxication, antidote therapy witha chelating agent was required. This was veryproblematic because the medicinal productapproved for this indication in Germany,namely DMPS, was not available. Therefore, achelating agent tried and tested in the USA incases of lead poisoning, namely DMSA, wasobtained from an international pharmacy, andtreatment of the patient with this agent wasinitiated (see below). The duration of the firstcourse of treatment was 19 days. Becausethe therapy could be continued on an outpa-tient basis, the patient was discharged aftersix days of inpatient treatment.

It was recommended to perform follow-upmeasurements of blood lead levels after thefirst course of treatment lasting for 19 daysand to discontinue treatment for 14 days.After this period of time, the blood lead levelwas to be measured again and if levels stillexceeded 400–600 µg/L, another course oftreatment with a chelating agent was to beadministered.

Notes In late July 2007, an increased incidence ofcases of lead poisoning of initially unclear ori-gin was observed in Saxony and Thuringia. The

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persons affected were exclusively young adultswho in their majority were known to consumenarcotic drugs. An association with lead-con-taminated narcotic drugs was therefore sug-gested, which could be confirmed later. Twentycases similar to that described above have be-come known from Saxony. In addition to the re-sponsible ministries, also the BfR was informedabout this problem by the Erfurt Poison ControlCentre. So far, known sources of chronic leadexposure had included lead-containing cosmet-ics or natural remedies, particularly of Asian origin. In contrast to what has been seen in theUSA, chronic poisoning due to exposure tolead-based paint chips or peels from deteriorat-ed surfaces does not play any role in Germany.

The absorption rate after inhalation of lead(dust) or its compounds is as high as 30–85 %.Subsequent distribution will take place in athree-compartment system: A share of 95 % of the lead is bound to red blood cells and the remaining part, to plasma proteins. Afterdistribution, lead will initially accumulate in theparenchymatous organs such as the liver, thekidneys and the brain. Afterwards, approximate-ly 95 % of the lead is firmly bound in the hydrox-ylapatite crystals of the bones. Lead is non-tox-ic in bone, however, it is released into the othercompartments as part of the bone metabolism.Therefore, only little information about a historyof lead exposure can be derived from bloodlead levels.

For example, the average blood lead level inGerman children aged six to seven years is55–70 µg/L. Lead is of no physiological impor-tance. No safe lower limit level has been definedso far. From ca. 100 µg/L, growth and hearingdisturbances associated with a reduced intelli-gence quotient, an increase in erythrocyte protoporphyrin levels and an inhibition of delta-aminolaevulinic acid dehydratase have beendescribed. Levels exceeding 200 µg/L will re-duce nerve conduction velocity, disrupt vitaminD metabolism and inhibit haemoglobin synthe-

sis. Levels between 500 and 1 000 µg/L areknown to potentially cause encephalopathy andnephropathy, higher levels may lead to death.

The mechanism of action proper has not yetbeen completely elucidated, only the effect onthe haematopoietic system is well known. Lowblood lead levels will cause inhibition of delta-aminolaevulinic acid dehydratase activity. It isthe most sensitive of the parameters and be-comes reduced already at blood lead levels of100 µg/L. About two to three weeks later, thiswill result in an increase in delta-aminolaevulinicacid in the blood and its elevated excretion inthe urine. Delta-aminolaevulinic acid has beenassumed to be responsible for neurotoxicity anda number of other effects. In addition, inhibitionof cellular functions requiring zinc and calciumhas been discussed because lead is known tointerfere with calcium. Also ferrochelatase, anenzyme responsible for iron incorporation intoporphyrin, is inhibited, which will cause an in-crease in erythrocyte porphyrin. This will resultin elevated excretion of coproporphyrin III inurine and anaemia with basophilic stippling.

In addition to the bone marrow and the nervoussystem, also the kidneys and smooth musclesare affected by lead poisoning. Manifestationsof acute and subacute poisoning include ab-dominal pain, nausea and a transient renalproximal tubular dysfunction similar to Fanconisyndrome. Chronic exposure may lead toanorexia, lethargy, irritability, ataxia, weaknessof muscles, colicky abdominal pain, reduced in-telligence, renal damage, hypertension, visualdisturbances and lead lines in the tubular bonesfound by radiology.

Diagnostic parameters should include determi-nation of lead and delta-aminolaevulinic acidlevels in the patient’s blood and urine and of theerythrocyte protoporphyrin concentration.

Asymptomatic patients with blood lead levelsbelow 250 µg/L do not require treatment. Pa-


50


tients exhibiting higher levels and clinical signs,respectively, (as in the above case) should re-ceive antidote therapy with a chelating agent. InGermany, the medicinal product DMPS (dimer-captopropane sulfonate) has been approved forthis indication. However, this product is not man-ufactured and supplied at present. In the USA,where long-term experience with lead poisoningexists due to a high exposure of the population,the chelating agent DMSA (2,3-dimercaptosuc-cinic acid) has been recommended, which iseven more effective. The older chelating agents,EDTA (ethylenediaminetetraacetic acid) andBAL (British anti-lewisite, dimercaprol) have be-come obsolete based on recent evidence be-cause they are toxic on their own and possiblyincrease lead absorption.

Therapy is performed in several phases: Initially,the lead contained in the blood compartment isremoved by means of the chelating agent. Dur-ing chronic lead exposure, lead is accumulatedin the bones and from there only slowly re-dis-tributed in the blood. This is why after the firsttreatment cycle, treatment should be discontin-ued for at least 14 days. During this period, leadcan be mobilized from the bones and return tothe blood where it binds to the chelating agentand is excreted.

Based on the massively elevated blood andurine lead levels found, it can be assumed thatin the above case the patient suffered from severe chronic lead poisoning. Given the char-acteristic manifestations including markedanaemia, anorexia and ataxia, it has been as-sumed that poisoning had set in already beforeOctober 2007, i.e. before the patient noticed thesymptoms. He had become intoxicated bysmoking lead-contaminated cannabis.

Evaluation of the case describedBased on the toxic blood lead level, the elevat-ed porphyrin and delta-aminolaevulinic acid levels in the urine as well as the characteristicmanifestations including colicky abdominal

pain, hypertension, ataxia, anorexia andanaemia, and in the absence of other causes, acausal relationship is to be rated as confirmed.

3.2.3.5 Rust remover spray

Lethal case – Association with the use ofrust remover/corrosion-protective spraycannot be ruled outA 69-year-old male had treated the under-body of his car with a lubricant/penetratingoil. He had used a commercial rust removerspray consisting of petrol hydrocarbons as amain component and carbon dioxide as apropellant. Molybdenum disulfide was con-tained in amounts not requiring labelling. Thespray had been applied in a lying position un-der the car for about 15 minutes on a wind-less day in front of a carport. No special pro-tective clothing, particularly no respiratoryprotection had been worn by the patient. Im-mediately after this operation, the patient de-veloped acute dyspnoea, nausea and circula-tory shock. In spite of early resuscitationmeasures, the patient died at the intensivecare unit of a hospital ca. four hours after theonset of first symptoms without having re-gained consciousness.

Since an association of the severe shock withthe inhalation of the lubricant could not be ex-cluded, the criminal investigation departmentwas informed. The latter had a post-mortemexamination carried out. The cause of deathhas not been fully elucidated so far in spite ofextensive expert examinations.

Manifestations/courseNo serious diseases were reported in the de-ceased patient’s medical history. After spray-ing of the lubricant, he had suddenly com-plained of nausea and severe dyspnoea. Hiswife reported that he had touched his throatseveral times and cried ”I cannot breathe any-more.“ He had repeatedly expectorated thick

51


yellow mucus. Cough and retching had thenincreased. Since she had deemed the situa-tion to be life-threatening, she had called theemergency medical service immediately.When the latter arrived after a few minutes,they found the patient already in an acroticand cyanotic condition. Immediate resuscita-tion measures resulted in a stabilization of cir-culation in the still unconscious patient on thescene after about 40 minutes, and he was ad-mitted to the intensive care unit of a hospital.

On admission, the deeply comatose patient,who was artificially respirated, showed thetypical signs of a circulatory shock (bloodpressure not measurable, irregular cardiacaction, heart rate 70/min). On auscultation,both lungs were ventilated and a few finerales were heard at the bases. The patient’sbody temperature had dropped to 31.8 °C. Inspite of intensive medical therapy includingmaximum doses of catecholamines, fluidsupply, buffering of metabolic acidosis andventilation with high oxygen concentration,stabilization of circulation could not beachieved anymore. The patient died approxi-mately four hours after resuscitation meas-ures had been initiated.

Post-mortem findings included pronouncedgeneral arteriosclerosis, particularly of thecoronary vessels, and signs of recurrent myocardial infarctions suffered in the past.However, no recent myocardial damage wasfound. Macroscopic examination of the lungsdid not result in any pathological findings thatcould have explained the patient’s death. Ac-cording to the post-mortem report, the severepathological changes of the cardiovascularsystem found in the patient could have led tohis death at any point in time, however, not in-evitably at the time when death actually oc-curred. An obvious cause of death was notstated in the most-mortem records.

NotesBoth the way the accident happened and theclinical course, as well as the evaluation ofthe post-mortem records suggest recurrent myocardial infarction to have been the mostprobable cause of death. However, post-mortem findings of the lungs do not excludepulmonary illness caused by aspiration of thelubricant used. Further analyses to detectresidues of the product used in the lung tissuemight have produced more precise results.However, this possibility was omitted since inthe experts’ opinion, no change of the assumedcause of death could have been expected.

This tragic death has again drawn attention tohealth damage possibly attributable to the useof chemical products in the form of aerosolsprays. According to the safety data sheet, theproduct concerned is not classified as harmfulto health. It is stated that general personal protection measures are sufficient during use.No respiratory protection was required as longas the room was well ventilated. It seems thatthis information was not alarming enough as awarning.

Aliphatic hydrocarbons are known to have a toxic effect on the lungs. Accidental ingestion of even minor quantities may lead to aspirationwhich, in turn, may result in most severe pul-monary manifestations with a possibly lethaloutcome. In most cases, symptoms will only in-clude cough and temporary breathing difficulty.There is, however, also the possibility that chem-ical pneumonia with a long duration of the dis-ease may develop. In very rare cases, rapidlydeveloping and life-threatening symptoms wereobserved including severe cough and earlycyanosis. Causes that could be established in-cluded glottis or pulmonary oedema, pleuritis orpneumothorax, again in very rare cases only.

According to the present state of knowledgegained from comparable accident reports, moreand more indications have suggested that the


52


possibly toxic effect on the lungs may be attrib-uted to additives or solvents contained inaerosols. It may also be assumed that the veryfine dispersion of the spray mist results in criti-cal droplet sizes so that components of thechemical product may penetrate deeply into thesmallest alveoli and cause toxic effects in thesestructures. In the opinion of the BfR, further re-search is urgently required in this field. There-fore, a number of research projects has been

53

initiated by the institute which are dealing for example with surface sealant sprays.

Evaluation of the case described Based on the information given on the temporalrelationship between the use of the chemicalproduct and the appearance of the symptomsdescribed, a causal relationship between the in-halation of rust remover aerosol containing pen-etrating oil and the patient’s death is possible.


Incriminated products/uses

Reports, total numbersHealth impairmentmoderate/severe

First levelSecond level

Third level

Total Chil-dren

A-dults

Home Work Total Chil-dren

A-dults

Home Work

I. Medicinal products 180 11 169 2 167 5 2 3 2 1

II. Veterinary medicinal products

3 3 3

III. Chemical products 2.440 30 2.410 24 2.386 166 7 159 12 147

Wastes, solid 27 27 27 1 1 1

Waste gases 179 179 2 177 10 10 2 8

Sewage 16 16 16

Paints and related materials 146 146 4 142 9 9 2 7

Paint removers/strippers 9 9 9

Alkyd resin paints

Emulsion paints 7 7 7

Artist’s painting materials

Glossy paints 23 32 32 1 1 1

Parquetry sealers 1 1 1 1 1 1

Pigments 1 1 1

Primers 15 15 3 12 3 3 2 1

Paint thinners 51 3 51 51 3 3 3

Fire lighting products 3 3 2 2


22 22 2 20 3 3 1 2

Building materials 123 123 123 19 19 19

Fuels, solid; auxiliary products

3 3 3

Fuels, liquid; auxiliary products

29 5 24 24 1 1

Petrol 12 12 12

Ethanol for technical use 4 1 3 3

Lamp oil 4 4 1 1

Fuels, gaseous 2 2 2

Offi ce materials, chemical 19 19 1 18 1 1 1

Decoration materials 2 2 2

Dental materials 5 5 5


54

4.1 Spectrum of cases reported during the period 1 January–31 December 2007

4 Annex

Table 12: 4 086 reports vs. degree of severity of health disturbances, classified by children and adults, with the adult cases differentiated by exposure in the private sphere and the working environment (except for cases with a causal rela-tionship rated as Òabsent” or “excluded”)





Third level

Total Chil-dren

A-dults


A-dults

Home Work

Disinfectants/sterilizers 369 369 2 367 14 14 1 13

Deodorants for technical use 6 1 5 5

Diagnostic agents/reagents 2 2 2

Printing, auxiliary products 3 3 3

De-icing products 1 1 1

Fire extinguishing media 15 15 15 1 1 1

Flame retardants

Galvanic cells 87 87 87 4 4 4

Dry cells

Button batteries

Accumulators 87 87 87 4 4 4

Galvanizing agents 1 1 1

Galvanizing agents, auxiliary products

2 2 2

Gases for technical use 2 2 2

Antifreezes 2 2 2

Glass-working, auxiliary products

Rubber, production materials 3 3 3

Semiconductors, production materials

Household auxiliary pro-ducts, chemical-technical

Hydraulic fl uids 26 26 26

Refrigerants 3 3 3

Ceramics, auxiliary products 1 1 1

Ceramic materials 2 2 2

Glues 87 87 2 85 5 5 1 4

Coolants 13 13 13

Plastics, starting materials 14 14 14 1 1 1

Plastics, formulating materials

3 3 3

Leather processing products

Luminophors 6 6 1 5

Solvents for technical use 60 60 1 59,3 3 3

Soldering and welding products (except welding fumes)

3 33

55



56




Third level

Total Chil-dren

A-dults


A-dults

Home Work

Measuring equipment, chemical-technical

Heating meters

Mercury thermometers

Thermometer fl uids

Metallurgy, auxiliary products

13 13 13 3 3 3

Dairy, auxiliary products

Paper-making, auxiliary products

Photography, auxiliary products

9 9 9

Radioisotopes, radionuclides

Cleaning products 778 19 759 10 749 72 4 68 5 63

Drain cleaners 15 15 15 3 3 3

All-purpose cleaners 47 2 45 45 2 2 2

Oven and grill cleaners 27 3 24 24

Cleansers for electronic products

Descaling products 19 19 3 16 1 1 1

Front wall and stone cleaners

4 4 4

Stain removers 2 2 2 1 1 1

Floor polishes 4 1 3 3

Washing-up detergents (manual use)

9 9 9

Dishwasher detergents 10 1 9 9 1 1 1

Dishwasher cleaners 6 6 6 2 2 2

Glass cleaners 6 6 1 5 1 1 1

Industrial cleaners 76 76 1 75 11 11 11

Rinsing additive for dishwashers

9 1 8 8

Plastic cleaners

Glossy paint cleaners

Milking machine cleaners 70 2 68 68 8 1 7 7

Metal cleaners 23 23 23 1 1 1

Furniture polishes 1 1

Soot remover 1 1 1 1 1 1

Lavatory cleansers 38 5 33 3 30 4 4 2 2


57




Third level

Total Chil-dren

A-dults


A-dults

Home Work

Shoe and leather cleaners 4 1 3 3 3 1 2 2

Carpet/upholstery cleaners

Detergents

Detergents, auxiliary products

10 10 10

Joke articles

Lubricants 24 24 1 23 2 2 1 1

Welding fumes 24 24 24

Dust-laying oils

Toys

Textile, auxiliary products 5 5 2 3 3 3 2 1

Propellants/sprays 2 2 2

Water treatment products 11 1 10 10 2 2 2

Pet shop products 2 1 1 1

Unknown 108 108 108 5 5 5

IV. Cosmetics/personal hygiene products

71 71 7 64 6 6 3 3

Hair care products 25 25 1 24 1 1 1

Permanent wave products 4 4 4

Depilatory products

Hair dyes/colorants 20 20 1 19 1 1 1

Hair conditioners

Hair tonics

Shampoos

Skin care products 30 30 3 27 3 3 1 2

Bath oils/salts 2 2 2

Tanning products 1 1 1

Creams/ointments/lotions 5 5 2 3 2 2 1 1

Deodorants

Face tonics

Make-up products

Oils

Perfumes/after shaves 3 3 3

Powders 1 1 1

Soaps 16 16 16 1 1 1

Sun blockers

Oral care/dental products 10 10 1 9 1 1 1

Nail care products 2 2 2



58




Third level

Total Chil-dren

A-dults


A-dults

Home Work

V. Pesticides 107 5 102 8 34 11 11 3 8

Acaricides 1 1 1

Fungicides 9 9 9 2 2 2

Herbicides 22 22 22 2 2 2

Wood preservatives 9 5 4 13

Insecticides 25 25 6 19 3 3 3

Carbamates

Chlorinated hydrocarbons

Phosphoric esters 9 9 2 7 2 2 2

Pyrethroids 6 6 1 5

Molluscicides 1 1 1

Repellents

Rodenticides 1 1 1

Anticoagulants

Phosphates

Seed dressings 1 1 1

VI. Agrochemicals other than pesticides

10 10 10 1 1 1

Fertilizers 4 4 4 1 1 1

Plant care products

Growth regulators

VII. Substances of abuse 2 2 2 1 1 1

VIII. Plants 8 5 3 3

IX. Fungi 13 6 7 6 1 5 1 4 4

X. Animals 2 1 1 1

XI. Foods and beverages 49 2 47 20 27 7 1 6 6

Alcoholic beverages 7 7 2 5 2 2 2

Food additives 1 1 1

Tobacco and tobacco prod. 2 1 1 1

Food supplements 11 11 11 2 2 2

XII. Warfare/anti-riot agents 2 2 2

Pyrotechnic products

Tear gas

XIII. Miscellaneous 112 112 1 111 8 8 8

Textiles 10 10 10

Clothing 10 10 10

Furnishing fabrics

XIV. Primary substances 1.152 2 1.150 9 1.141 113 113 5 108

XV. Industrial accidents 6 6 6 1 1 1


59

Bundesinstitut für RisikobewertungDokumentations- und Bewertungsstellefür VergiftungenPostfach 33 00 13

14191 BerlinStempel, Telefon-Nummer und Unterschrift der/des Ärztin/Arztes

Mitteilung bei Vergiftungennach § 16e Abs. 2 des Chemikaliengesetzes(Telefon: 01888-412-3460, Fax: 01888-412-3929. E-Mail: [email protected]

1. Angaben zur/zum Patientin/en:

Jahre Monate (bei Kindern unter 3 Jahren) männlich Schwangerschaft ja

Alter: weiblich (freiwillig auszufüllen) nein

2. Vergiftung Verdacht

Unbedingt Handelsname der Zubereitung/des Biozid-Produktes oder Stoffname, aufgenommene Menge und Hersteller (Vertreiber); ggf. vermutete Ursache

a.

b.

c.

3. Exposition akut chronisch

oral inhalativ Haut Auge sonstiges, welche

Art der Vergiftung: akzidentell (Unfall) gewerblich Verwechslung

suizidale Handlung Abusus Umwelt Sonstiges

Ort: Arbeitsplatz im Haus Schule

Kindergarten im Freien Sonstiges

Labor-Nachweis: ja nein

Behandlung: keine ambulant stationär

Verlauf: nicht bekannt vollständige Heilung Defektheilung Tod

Spätschäden (nicht auszuschließen)

4. Symptome, Verlauf – stichwortartig – (ggf. anonymisierte Befunde, Epikrise beilegen)(freiwillig auszufüllen)

4.2 Notification form for cases of poisoning



60

Pers. Nummer

weiblich männliich Erwachsene(r) Kind

Bereich I

Unmittelbar Betroffene(r)

(Bitte Eintrag in die Landkarte)

Direkt am Unfallort Arbeiter(in)

Nahe Unfallort Feuerwehr

m Polizei/Rettungsdienst

Privatperson

Sonstige(r)

Erstexposition Uhrzeit Datum

Dauer ständig nicht ständigStunden/Tage

Schutzmaßnahmen ja nein

Symptome ja nein

(Wenn ja, bitte Dokumentation auf dem Meldebogen)

Bereich II

Nicht unmittelbar Betroffene(r)

(Bitte Eintrag in die Landkarte)

Entfernung vom Unfallort Anwohner

m Beschäftigte(r)/Arbeitnehmer(in)

km Sonstige(r)

Erstexposition Uhrzeit Datum

Dauer ständig nicht ständigStunden/Tage

Symptome ja nein

(Wenn ja, bitte Dokumentation auf dem Meldebogen)

Biomonitoring Stoff:

Blutentnahme Datum Zeitpunkt Konzentration

Urinprobe Datum Zeitpunkt Konzentration

Spontanurin 24h Sammelurin Kreatinin

4.3 Notification form for industrial accidents

BfR-Fragebogen zur Expositionsermittlung bei Stör- und Transportunfällen


61

4.4 List of Poison Control Centres in Germany

Berlin BBGes – Giftnotruf Berlin Oranienburger D-13437 Phone: +49 (0) 30-192 40

Institut für Toxikologie Str. 285 Berlin Fax: +49 (0) 30-30 68 6721

Klinische Toxikologie und [email protected]

Giftnotruf Berlin www.giftnotruf.de

Bonn Informationszentrale gegen Adenauerallee D-53113 Phone: +49 (0) 2 28-192 40

Vergiftungen 119 Bonn Fax: +49 (0) 2 28-2 873314

Zentrum für Kinderheilkunde [email protected]

Universitätsklinikum Bonn www.meb.uni-bonn.de/

giftzentrale

Erfurt Gemeinsames Giftinformations- Nordhäuser D-99089 Phone: +49 (0) 3 61-73 0730

zentrum der Länder Str. 74 Erfurt Fax: +49 (0) 3 61-7307317

Mecklenburg-Vorpommern, [email protected]

Sachsen, Sachsen-Anhalt und www.ggiz-erfurt.de

Thüringen

Freiburg Zentrum für Kinderheilkunde Mathildenstr. 1 D-79106 Phone: +49 (0) 761-192 40

und Jugendmedizin Freiburg Fax: +49 (0) 761-270 4457

Vergiftungs-Informations-Zentrale [email protected]

www.giftberatung.de

Göttingen Giftinformationszentrum-Nord der Robert Koch-Str. D-37075 Phone: +49 (0) 5 51-38 3180

Länder Bremen, Hamburg, Nieder- 40 Göttingen Fax: +49 (0) 5 51-3 8318 81

sachsen und Schleswig-Holstein [email protected]

(GIZ-Nord) Universität Göttingen – www.giz-nord.de

Bereich Humanmedizin

Homburg Informations- und Behandlungs- Kirrberger Str. D-66421 Phone: +49 (0) 68 41-192 40

zentrum für Vergiftungen des Gebäude 9 Homburg/ +49 (0) 68 41-162 8314

Saarlandes Saar Fax: +49 (0) 68 41-162 84 38

Klinik für Kinder- und [email protected]

Jugendmedizin www.uniklinikum-saarland.de/de/

einrichtungen/andere/giftzentrale

Mainz Klinische Toxikologie und Langenbeckstr. 1 D-55131 Phone: +49 (0) 6131-192 40

Beratungsstelle bei Vergiftungen der Mainz +49 (0) 6131-23 24 66

Länder Rheinland-Pfalz und Hessen Fax: +49 (0) 6131-23 2469

Universitätsklinikum +49 (0) 6131-23 24 68

[email protected]

www.giftinfo.uni-mainz.de



62

Munich Giftnotruf München Ismaninger Str. D-81675 Phone: +49 (0) 89-192 40

Toxikologische Abteilung der II. 22 Munich Fax: +49 (0) 89-4140 24 67

Medizinischen Klinik und Poliklinik, [email protected]

rechts der Isar der Technischen www.toxinfo.org

Universität München

Nurem- Giftnotrufzentrale Nürnberg Prof.-Ernst- D-90419 Phone: +49 (0) 911-3 98 26 65

berg Medizinische Klinik 2, Nathan-Str. 1 Nurem- Fax: +49 (0) 911-3 98 2192

Klinikum Nürnberg berg Giftnotruf:

Lehrstuhl Innere +49 (0) 911-3 98 24 51

Medizin-Gerontologie, or +49 (0) 911-3 98 26 65

Universität Erlangen-Nürnberg muehlberg@

klinikum-nuernberg.de

www.giftinformation.de


63

4.5 Press releases on toxicological problemsissued by the BfR in 2007

Childproof oil lamps are possible!New design burners can effectively protect children from poisoning02/2007, 18 April 2007

Fewer experimental animals but same degreeof safety for consumers!BfR advocates shorter procedure for testing reprotoxic effects of chemicals04/2007, 9 May 2007

Detergent and cleaning agent formulationsmust be notified to the Federal Institute for RiskAssessmentElectronic notification aids available to makeprocessing easier06/2007, 5 June 2007

Bitter apricot kernels can lead to poisoningFederal Institute for Risk Assessment believesthat the packaging should carry warnings07/2007, 7 June 2007

Chromium (VI) in leather clothing and shoesproblematic for allergy sufferers!BfR recommends strictly limiting levels in leathergoods10/2007, 2 July 2007

BfR repeats its warning about henna tattoosThe ingredients may open the door to allergicreactions14/2007, 18 July 2007

It seems that ultrafine dust from laser printers and photocopiers does not containtoner particlesFinal report on the pilot study expected towardsthe end of the year18/2007, 16 October 2007



64

4.6 List of abbreviations (German notation) used in the brochure

Abbreviation Meaningµg/h Quantity per unit of time in micrograms per hour µg/L Quantity per volume in micrograms per litreADH Antidiuretic hormoneBAL British anti-lewisite, dimercaprolBfR Bundesinstitut für Risikobewertung – Federal Institute for Risk AssessmentBG Berufsgenossenschaften – institutions for statutory accident insurance and pre-

vention for trade and industry in GermanyBgVV Bundesinstitut für gesundheitlichen Verbraucherschutz und Veterinärmedizin –

Federal Institute for Health Protection of Consumers and Veterinary MedicineBMI Body mass indexBVL Bundesamt für Verbraucherschutz und Lebensmittel – Federal Office for Con-

sumer Protection and Food SafetyCEN Comité Européen de Normalisation – European Committee for StandardizationCFC Chlorofluorocarbons ChemG Chemikaliengesetz – German Chemicals Act CK Creatinine kinaseCNS Central nervous systemCRP Capsule-reactive proteinCVC Central venous catheterDIN Deutsches Institut für Normung – German Institute for StandardizationEAN European Article NumberEDTA Ethylenediaminetetraacetic acidEMG ElektromyographyESR Erythrocyte sedimentation rateFAO Food and Agriculture Organizationgamma-GT Gamma glutamyl transferase GHS Globally Harmonized System of Classification and Labelling of ChemicalsGOT Glutamate oxaloacetate transaminaseGPT Glutamate pyruvate transaminaseha HectareHb Haemoglobini.v. IntravenousIMO International Maritime OrganisationIPPC International Plant Protection ConventionISPM International Standards for Phytosanitary MeasuresmmHg Millimeters of mercurymmol/L Millimoles per litrePCC Poison Control CentrePEG Percutaneous endoscopic gastrostomyPET Polyethylene terephthalatePI element Product identification elementPRINS Product information system


TRGS Technische Regeln für Gefahrstoffe – German Technical Rules for HazardousSubstances

TSH Thyroid-stimulating hormoneU/L Units per litreUBA Umweltbundesamt – German Federal Environment Agency UN United NationsWRMG Wasch- und Reinigungsmittelgesetz – German Detergents and Cleaning

Agents ActXML file Extensible markup language fileZIP file Data compression and archival format file

65


Phone +49-30 - 84 12 -0Fax +49-30 - 84 12 [email protected]

Federal Institute for Risk AssessmentThielallee 88-92D-14195 Berlinwww.bfr.bund.de


Documents

Cases of Poisoning - Reported by Physicians 2007 · Poison Control Centres ChemG § 16e para 3 Case data bank Product data bank Assessment of individual case Analysis Risk identification