The following cases were developed to give the student an appreciation for the manner in which a toxic exposure situation might present to a primary car provider. This is especially important in our present climate of increased threat from acts of Bioterrorism. The principles involved extend to the recognition of the clinical presentation of a wide variety of signs and symptoms that might result from a Bioterrorism incident as well as a toxic exposure. The goal is to use examples of representative cases involving toxins to which a broad range of our population is exposed. This recognition extends to many other scenarios, which could be the first indicator of a terrorist related incident or a clinical problem with public health implications.
Toxic exposures can occur in a wide variety of situations and settings. As an example, and contrary to popular belief, most pesticide exposures in Pennsylvania occur in urban or suburban environment rather than on the farm. Awareness of an unusual grouping of symptoms or a specific risk activity can be the key to diagnosis in individual cases. Often the patient can provide this information, though it may not be readily volunteered. This re-emphasizes the importance of a careful history. An unusual clustering of cases with common or unique symptomology may indicate a disease outbreak or mass exposure. An example of this was the original recognition of Legionnaires Disease through the alert reporting of a cluster of cases of a severe respiratory syndrome in older men who had attended a convention in Philadelphia by a local physician in upstate Pennsylvania.
Recognition of illness associated with the intentional release of a Biologic Agent is, as previously described, another aspect of this subject area. The following are some indicators and diagnostic clues to the possible presence of a Bioterrorism related presentation.
- An unusual temporal or geographic clustering of illness;
- Signs and symptoms suggesting an unusual infectious disease outbreak, especially involving unexplained febrile illness associated with sepsis, pneumonia, respiratory failure or rash;
- An unusual age distribution for common diseases. An example would be a chicken pox like outbreak in adults, which could indicate smallpox.
- A large number of cases of flaccid paralysis, which might indicate a Botulism toxic exposure.
- A clustering of patients presenting with signs and symptoms of organophosphate poisoning – rhinorrhea salivation, brocho-spasm dyspnea, vomiting, diarrhea, fasciculation’s, agitation, seizures, paralysis, etc. Several common toxins with Bioterroristic potential are related to this class of pesticides.
Hopefully these cases will give you a broad appreciation for the importance of the recognition of the unique and unusual or the common syndrome with a twist, which may have profound implications for your individual patient or for your community and nation.
The development of these cases was supported by the Pennsylvania Agromedicine Program and funded by the Pennsylvania Department of Agriculture.
Resources
CDC website
http://www.cdc.gov – A tremendous resource for any physician including health statistics, signs and symptoms of various exposures and disease, contacts and much more.
Poison Control Hotline
1-800-222-1222 –entrance point into the Poison Control Center System, which can help with directing the caller to appropriate resources for signs symptoms, diagnosis, treatment, etc.
Pennsylvania Department of Health contact line
1-877-724-3258
(717) 737-5349 (24-hour emergency) Can direct the caller to appropriate contact for disease reporting or refer to a local health department.
PAN Pesticide Database
http://www.pesticideinfo.org/ - Pesticide database giving a wide variety of information including chemical and product names, diagnostic tools and numerous valuable links.
