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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


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


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.

Contributor Information and Disclosures

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.


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.


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.

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