CBRNE - T-2 Mycotoxins Clinical Presentation

  • Author: Chan W Park, MD; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Jul 9, 2010
 

History

  • Patients with cutaneous symptoms may report seeing clouds of a yellow-colored smoke or aerosol, but blue and green aerosols have also been reported.[12]
  • Patients may report yellow droplets on clothing.
  • Immediate skin pain and burning on exposed surfaces is described. Eye pain and burning also should be reported.[3]
  • Suspicion of the toxin being placed in an ingested food source may exist. Ingested toxin probably has no taste, since no documentation supports a foul odor or taste in previous epidemics of toxin ingestion. This is further supported by the historical experience that many individuals become ill when exposed to contaminated food without any suspicion of having ingested tainted food.[18]
  • The most common symptoms occurring with most exposures include skin (or oral) pain (burning) and redness or rash, vomiting, diarrhea, dyspnea, and bleeding.[2]
Next

Physical

The early signs and symptoms of T-2 toxin poisoning do reflect the route of exposure. However, irrespective to the route of entry, the systemic toxicity follows a protracted course of illness that is well characterized. Early symptoms can manifest within seconds of exposure depending on the dose of exposure. Symptoms become prominent after minutes to hours upon exposure. They are described by the respective organ system.

  • Neurologic: No specific neurologic signs or symptoms are related to the toxin except for mild ataxia, which reflects systemic toxicity.
  • Head, eyes, ears, nose, throat (HEENT)
    • Ocular exposure causes tearing, pain, conjunctivitis, and blurred vision.
    • Nasal mucosa results in sinus irritation, pain, rhinorrhea, sneezing, and potentially epistaxis.
    • Oral and oropharyngeal exposure results in pain and blood-tinged saliva and sputum.
  • Respiratory
    • Cough, dyspnea and wheezing
    • Delayed signs can include hemoptysis.
  • Cardiovascular
    • Tachycardia
    • Vascular collapse in severe toxin exposure
  • Gastrointestinal
    • Nausea and vomiting
    • Anorexia
    • Watery diarrhea with abdominal cramping
  • Dermal
    • Painful erythema and tenderness
    • Blistering and bullous lesions, leading to desquamation
    • Necrosis and sloughing of dermal layer
  • Systemic
    • Severe toxin exposure can result in early systemic toxicity.
    • Severe dizziness, ataxia, and prostration
    • Tachycardia
    • Hypothermia
    • Vascular collapse
  • Hematologic: Upon chronic exposure to T-2 toxin, the clinical syndrome of alimentary toxic aleukia (ATA) ensues.[2] This presentation mirrors the stages of radiation sickness. The 4 stages are as follows:
    • Stage 1: This stage may be seen in the emergency department. This stage results from the acute injury to the exposed cells and tissue. The symptoms reflect the route of toxin exposure.
    • Stage 2: This stage occurs weeks after the exposure. Insult to the bone marrow initially produces a transient lymphocytosis. This is soon followed by bone marrow suppression due to the antimitotic effects of T-2 toxin. The result is significant leukopenia, granulocytopenia, and thrombocytopenia.
    • Stage 3: This stage also occurs weeks after the exposure and is considered the hemorrhagic stage. The patient exhibits petechial hemorrhages, especially of the mucosal areas of the nasopharynx and oropharynx. These lesions develop to form ulcerated and necrotic lesions, which can result in significant bleeding from the esophagus and the gastrointestinal tract. Moreover, the edema that accompanies the mucosal injury may threaten the airway. Also, severe coagulopathy may occur. During this stage, the patient is at a higher risk for sepsis because the immune system is significantly compromised.
    • Stage 4: During the recovery phase, the necrotic lesions heal and the bone marrow recovers.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Chan W Park, MD  Attending Physician, Research Coordinator, Naval Medical Center Portsmouth

Chan W Park, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Kevin Scott Koehler, MD  Resident Physician, Department of Emergency Medicine, Naval Medical Center, Portsmouth

Disclosure: Nothing to disclose.

Michael R Melia, MD  Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia

Michael R Melia, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Lanny F Littlejohn, MD  Staff Emergency Physician and Medical Director for Tactical Combat Casualty Care, Department of Emergency Medicine, Naval Medical Center, Portsmouth, Virginia

Lanny F Littlejohn, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, Special Operations Medical Association, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Thomas M Stein, MD, FACEP  Assistant Professor, Department of Emergency Medicine, Medical College of Pennsylvania-Hahnemann University; Medical Director, Emergency Medical Support Services and LifeFlight, Department of Emergency Medicine, Allegheny General Hospital

Thomas M Stein, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jerry L Mothershead, MD  Medical Readiness Consultant, Medical Readiness and Response Group, Battelle Memorial Institute; Advisor, Technical Advisory Committee, Emergency Management Strategic Healthcare Group, Veteran's Health Administration; Adjunct Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences

Jerry L Mothershead, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Rick Kulkarni, MD  Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References

  1. Joffee A. Fusarium Species: Their Biology and Toxicology. NY: John Wiley & Sons; 1986:225-292.

  2. Darling, Woods, et al. USAMRIID's Medical Management of Biological Casualties Handbook. 5th. Fort Detrick, Frederick, MD: USAMRIID; 2004. [Full Text].

  3. McGovern TW, Christopher GW. Biological warfare and its cutaneous manifestations. The Electronic Textbook of Dermatology [serial online]. 1995-2001;Available from: The Internet Dermatology Society, Inc. Accessed 2010. Available at http://www.telemedicine.org/biowar/biologic.htm.

  4. Ueno Y. Trichothecene mycotoxins: Mycology, chemistry, and toxicology. Advances in food and nutrition research. 1989;3:301-353.

  5. Franz DR, Jahrling PB, Friedlander AM, McClain DJ, Hoover DL, Bryne WR, et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA. Aug 6 1997;278(5):399-411. [Medline].

  6. Marrs TC, Edginton JA, Price PN, Upshall DG. Acute toxicity of T2 mycotoxin to the guinea-pig by inhalation and subcutaneous routes. Br J Exp Pathol. Apr 1986;67(2):259-68. [Medline].

  7. Wannemacher RW Jr, Wiener SL. Trichothecene mycotoxins. In: Sidell FR, Takafuji ET, Franz DR. Medical Aspects of Chemical and Biological Warfare. Falls Church, Va: Office of the Surgeon General, US Dept of the Army; 1997:655-676.

  8. Blazes DL, Lawler JV, Lazarus AA. When biotoxins are tools of terror. Early recognition of intentional poisoning can attenuate effects. Postgrad Med. Aug 2002;112(2):89-92, 95-6, 98. [Medline].

  9. Zilinskas RA. Iraq's biological weapons. The past as future?. JAMA. Aug 6 1997;278(5):418-24. [Medline].

  10. Holstege CP, Bechtel LK, Reilly TH, Wispelwey BP, Dobmeier SG. Unusual but potential agents of terrorists. Emerg Med Clin North Am. May 2007;25(2):549-66; abstract xi. [Medline].

  11. Haig AM. Chemical Warfare in Southeast Asia and Afghanistan: Report to the Congress From Secretary of State Alexander M. Haig. Special Report No. 98. Washington, DC: US Department of State; March 22, 1982.

  12. Schieffer HB. Facts, not Rhetoric, on Yellow Rain. Nature. July 1983;304:10.

  13. Henghold WB 2nd. Other biologic toxin bioweapons: ricin, staphylococcal enterotoxin B, and trichothecene mycotoxins. Dermatol Clin. Jul 2004;22(3):257-62, v. [Medline].

  14. Johnsen H, Odden E, Johnsen BA, Bøyum A, Amundsen E. Cytotoxicity and effects of T2-toxin on plasma proteins involved in coagulation, fibrinolysis and kallikrein-kinin system. Arch Toxicol. Jan 1988;61(3):237-40. [Medline].

  15. Dearborn DG, Smith PG, Brooks LJ, Carroll-Pankhurst C, Kosick R, Dahms BB. Update: pulmonary hemorrhage/hemosiderosis among infants-Cleveland, Ohio 1993-1996. MMWR Morbidity Mortality Weekly Report. 1997;46:33-35.

  16. Richards CA. Stachybotrys atra suspected in three infant deaths: 18 others sickened. Journal of Pediatric Infectious Disease. 1997;10:1-8.

  17. Pestka JJ, Yike I, Dearborn DG, Ward MD, Harkema JR. Stachybotrys chartarum, trichothecene mycotoxins, and damp building-related illness: new insights into a public health enigma. Toxicol Sci. Jul 2008;104(1):4-26. [Medline].

  18. Schoenthal. Mycotoxins in food and the plague of Athens. Journal of Nutritional Medicine. 1994;4:83-85.

  19. Dohnal V, Jezkova A, Jun D, Kuca K. Metabolic pathways of T-2 toxin. Curr Drug Metab. Jan 2008;9(1):77-82. [Medline].

  20. Zapor M, Fishbain JT. Aerosolized biologic toxins as agents of warfare and terrorism. Respir Care Clin N Am. Mar 2004;10(1):111-22. [Medline].

  21. Wannemacher RW. Dermal toxicity of T-2 toxin in guinea pigs, rats and cynomolgus monkeys. Tricothecenes and Other Mycotoxins. 1985;423-432.

  22. Fricke RF, Jorge J. Assessment of efficacy of activated charcoal for treatment of acute T-2 toxin poisoning. J Toxicol Clin Toxicol. 1990;28(4):421-31. [Medline].

  23. Shohami E, Wisotsky B, Kempski O, Feuerstein G. Therapeutic effect of dexamethasone in T-2 toxicosis. Pharm Res. Dec 1987;4(6):527-30. [Medline].

  24. Poppenga RH, Lundeen GR, Beasley VR, Buck WB. Assessment of a general therapeutic protocol for the treatment of acute T-2 toxicosis in swine. Vet Hum Toxicol. Jun 1987;29(3):237-9. [Medline].

  25. Tucker JB. Mycotoxins and Gulf War Illness: A Possible Link [The National Gulf War Resource Center Web site]. The National Gulf War Resource Center. Available at http://www.ngwrc.org/. Accessed 2001.

 
Previous
Next
 
Chemical Terrorism Agents and Syndromes. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/chemical.html.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.