Diagnostic Considerations

Vesicant (mustard and lewisite) exposure

Onset of pain may mimic T-2 mycotoxin exposure. To differentiate lewisite from T-2 mycotoxin exposure, test the skin and clothing for the arsenic component of lewisite. Onset of dermal symptoms (blistering, pain) from mustard exposure typically is delayed.^[15]

Staphylococcal enterotoxin B

Staphylococcal enterotoxin B may cause respiratory and GI symptoms, but the burning dermal and mucocutaneous symptoms are absent.^[15]

Ricin intoxication

All symptoms for ricin intoxication are similar to T-2 mycotoxin with the exception of the painful dermal symptoms, which are not observed in ricin intoxication.^[2]

Other considerations

Symptoms of T-2 mycotoxin exposure are radiomimetic; thus, one must consider radiation sickness in the differential diagnosis. Nausea and vomiting have a large differential diagnosis. Examine patients with these symptoms without any suggestion of toxin exposure for other more common etiologies. The patient who may be more suggestive of a toxin exposure is a high-profile individual (ie, government official) who is vomiting with oral or cutaneous symptoms.

Patients presenting long after the initial exposure who now may be manifesting symptoms of the second stage of ATA may need to be investigated for a malignant process causing bone marrow replacement. Skin and mucosal erythema, blistering, ulceration, and necrosis can be the manifestation of many systemic diseases, which need to be considered.

Differential Diagnoses

Workup

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Author

Chan W Park, MD, FAAEM Adjunct Assistant Professor, Division of Emergency Medicine, Duke University Medical Center; Director of Simulation Medicine, Co-Director of Advanced Interprofessional Fellowship in Clinical Simulation, Durham VA Medical Center

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

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Coauthor(s)

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

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Thomas M Stein, MD Assistant Professor of Emergency Medicine, MCP Hahnemann University; Physician, Medical Director, Emergency Medical Support Services, Medical Director, LifeFlight, Director, EMS Fellowship, Department of Emergency Medicine, Allegheny General Hospital

Thomas M Stein, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, The Society of Federal Health Professionals (AMSUS), National Association of EMS Physicians, Society for Academic Emergency Medicine

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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

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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, MS, MPH, 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; Senior Research Scientist, Data Science IV, Battelle Memorial Institute, Battelle Connecticut Operations

Zygmunt F Dembek, PhD, MS, MPH, LHD is a member of the following medical societies: American Chemical Society, American Legion, American Public Health Association, The Society of Federal Health Professionals (AMSUS), Council of State and Territorial Epidemiologists, Delta Omega Public Health Honorary Society, New York Academy of Sciences, Polish Legion of American Veterans, Reserve Organization of America, Society of American Federal Medical Laboratory Scientists, Veterans of Foreign Wars

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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.

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

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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

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

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