CBRNE - T-2 Mycotoxins Treatment & Management

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

Prehospital Care

  • Warning: Mycotoxin is a potent dermally active toxin that is transmissible in the health care setting. Do not approach the patient without observing universal precaution.
  • Use hazardous materials teams in patient rescue and decontamination.
  • Decontamination is of paramount importance to avoid cross-contamination. Remove all clothing, and wash the patient in soap and water.
  • For patients in extremis, attention to airway, breathing, and circulation per Advanced Trauma Life Support (ATLS) protocol needs to occur immediately as decontamination is being performed.
    • While one team member is caring for issues involving the airway, breathing, and circulation, another member should be concerned primarily with patient decontamination.
    • Remove all clothing, and clean and scrub the patient's entire skin surface with soap and water. Washing the contaminated area of the skin within 6 hours postexposure can remove 80-98% of the toxin and has been demonstrated to prevent skin lesions and death in experimental animals.[21]
    • Contain clothing to avoid contamination of the health care environment.
  • Provide supportive measures addressing cardiovascular status as necessary.
  • If the patient complains of eye pain or tearing, irrigate the eyes with copious amounts of water.
  • No specific antidote exists for this toxin. General supportive measures are indicated.
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Emergency Department Care

  • Warning: Mycotoxin is a potent dermally active toxin that is transmissible in the health care setting. Do not approach the patient without observing universal precaution.
  • Never assume that a patient has been decontaminated in the prehospital setting. Reassess the patient's decontamination status. If the degree of prehospital decontamination is uncertain, rewash the patient to ensure the safety of staff and facility.
  • For patients in extremis, attention to airway, breathing, and circulation per ATLS protocol needs to occur immediately as decontamination is being performed.
    • While one team member is caring for issues involving the airway, breathing, and circulation, another member should be concerned primarily with patient decontamination.
    • Remove all clothing, and clean and scrub the patient's entire skin surface with soap and water. Washing the contaminated area of the skin within 6 hours postexposure can remove 80-98% of the toxin and has been demonstrated to prevent skin lesions and death in experimental animals.[21]
    • Contain clothing to avoid contamination of the health care environment.
  • While no human studies have been conducted, survival benefits have been shown in animal models with the following treatment after T-2 toxin exposure.
    • Use of activated charcoal to absorb T-2 toxin from the gut regardless of the portal of entry within 1 hour of exposure.[22]
    • Dexamethasone administration (1 mg/kg at 12, 24, and 48 h) increased the survival rate in mice from zero to greater than 50%.[23]
  • No specific antidote is available for T-2 mycotoxin exposure. Provide supportive measures, addressing respiratory and cardiovascular status as necessary.
  • If the patient complains of eye pain or tearing, irrigate the eyes with copious amounts of water.
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Consultations

  • Required consultants are dictated by the disease course. Pulmonary consultation may be required for severe dyspnea of hemoptysis. A hematologist may be consulted for patients presenting with severe pancytopenia.
  • Contact the local poison control center for additional clinical guidance. Some larger cities' poison control centers may have specific guidelines to follow concerning weapons of mass destruction.
  • Consult the Federal Bureau of Investigation and Department of Homeland Security in any situation when nuclear, biological, or chemical weapon exposure is suspected.
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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

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  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].

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  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.

 
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