Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

CBRNE - T-2 Mycotoxins Clinical Presentation

  • Author: Chan W Park, MD, FAAEM; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD  more...
 
Updated: Mar 09, 2016
 

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.[20]

The most common symptoms occurring with most exposures include the following[2] :

  • Skin (or oral) pain (burning)
  • Skin redness or rash
  • Vomiting
  • Diarrhea
  • Dyspnea
  • Bleeding
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.

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) manifestations are as follows:

  • 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 manifestations are as follows:

  • Cough, dyspnea and wheezing
  • Delayed signs can include hemoptysis

Cardiovascular manifestations are as follows:

  • Tachycardia
  • Vascular collapse in severe toxin exposure

Gastrointestinal manifestations are as follows:

  • Nausea and vomiting
  • Anorexia
  • Watery diarrhea with abdominal cramping

Dermal manifestations are as follows:

  • Painful erythema and tenderness
  • Blistering and bullous lesions, leading to desquamation
  • Necrosis and sloughing of dermal layer

Systemic manifestations are as follows:

  • Severe toxin exposure can result in early systemic toxicity.
  • Severe dizziness, ataxia, and prostration
  • Tachycardia
  • Hypothermia
  • Vascular collapse

Alimentary toxic aleukia

Alimentary toxic aleukia (ATA) is a clinical syndrome that results from chronic exposure to T-2 toxin.[2] ATA has four stages, which mirror the stages of radiation sickness.

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
 
 
Contributor Information and Disclosures
Author

Chan W Park, MD, FAAEM Adjunct Assistant Professor, Division of Emergency Medicine, Duke University Medical Center; Director of Simulation Medicine, Durham Veterans Affairs Medical Center

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

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas M Stein, MD 

Thomas M Stein, MD 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, Society for Academic Emergency Medicine

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.

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

Disclosure: Nothing to disclose.

Chris Luttig, MD, MPH Resident Physician, Departments of Emergency Medicine and Internal Medicine, Virginia Commonwealth University Health System

Chris Luttig, MD, MPH is a member of the following medical societies: American College of Physicians, American Medical Association, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Zygmunt F Dembek, PhD, MPH, MS, LHD is a member of the following medical societies: American Chemical Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

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, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Michael P Allswede, DO Program Director, Disaster and Emergency Medicine Residency, Conemaugh Memorial Hospital; Director, Strategic Medical Intelligence, Inc

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.

Donald A Locasto, MD Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

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. USAMRIID. 2004. Available at http://www.usamriid.army.mil/education/bluebookpdf/usamriid%20blue%20book%205th%20edition.pdf.

  3. McGovern TW, Christopher GW. Biological warfare and its cutaneous manifestations. The Electronic Textbook of Dermatology. 1995-2001. [Full Text].

  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. 1997 Aug 6. 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. 1986 Apr. 67(2):259-68. [Medline].

  7. Wannemacher RW Jr, Wiener SL. Trichothecene mycotoxins. 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. 2002 Aug. 112(2):89-92, 95-6, 98. [Medline].

  9. Zilinskas RA. Iraq's biological weapons. The past as future?. JAMA. 1997 Aug 6. 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. 2007 May. 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. US Department of State. March 22, 1982.

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

  13. Wu J, Jing L, Yuan H, Peng SQ. T-2 toxin induces apoptosis in ovarian granulosa cells of rats through reactive oxygen species-mediated mitochondrial pathway. Toxicol Lett. 2011 May 10. 202(3):168-77. [Medline].

  14. Bouaziz C, Sharaf El Dein O, El Golli E, Abid-Essefi S, Brenner C, Lemaire C, et al. Different apoptotic pathways induced by zearalenone, T-2 toxin and ochratoxin A in human hepatoma cells. Toxicology. 2008 Dec 5. 254(1-2):19-28. [Medline].

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

  16. 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. 1988 Jan. 61(3):237-40. [Medline].

  17. 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.

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

  19. 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. 2008 Jul. 104(1):4-26. [Medline].

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

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

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

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

  24. Schwartz MD, Hurst CG, Kirk MA, Reedy SD, Braue EH Jr. Reactive Skin Decontamination Lotion (Rsdl) For the Decontamination of Chemical Warfare Agent (Cwa) Dermal Exposure. Curr Pharm Biotechnol. 2012 Feb 20. [Medline].

  25. 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].

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

  27. 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. 1987 Jun. 29(3):237-9. [Medline].

  28. 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
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.