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

Joffee A. Fusarium Species: Their Biology and Toxicology. NY: John Wiley & Sons; 1986. 225-292.
Withers MR, et al. USAMRIID's Medical Management of Biological Casualties Handbook, 8th Edition. USAMRIID. 2014. Available at https://www.usamriid.army.mil/education/bluebookpdf/USAMRIID%20BlueBook%207th%20Edition%20-%20Sep%202011.pdf.
McGovern TW, Christopher GW. Biological warfare and its cutaneous manifestations. The Electronic Textbook of Dermatology. 1995-2001. [Full Text].
Ueno Y. Trichothecene mycotoxins: Mycology, chemistry, and toxicology. Advances in food and nutrition research. 1989. 3:301-353.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
Zilinskas RA. Iraq's biological weapons. The past as future?. JAMA. 1997 Aug 6. 278(5):418-24. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
Schieffer HB. Facts, not Rhetoric, on Yellow Rain. Nature. July 1983. 304:10.
Wang J, Yang C, Yuan Z, Yi J, Wu J. T-2 Toxin Exposure Induces Apoptosis in TM3 Cells by Inhibiting Mammalian Target of Rapamycin/Serine/Threonine Protein Kinase(mTORC2/AKT) to Promote Ca²⁺Production. Int J Mol Sci. 2018 Oct 27. 19 (11):[QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Henghold WB 2nd. Other biologic toxin bioweapons: ricin, staphylococcal enterotoxin B, and trichothecene mycotoxins. Dermatol Clin. 2004 Jul. 22(3):257-62, v. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Adhikari M, Negi B, Kaushik N, Adhikari A, Al-Khedhairy AA, Kaushik NK, et al. T-2 mycotoxin: toxicological effects and decontamination strategies. Oncotarget. 2017 May 16. 8 (20):33933-33952. [QxMD MEDLINE Link]. [Full Text].
Centers for Disease Control and Prevention (CDC). Update: pulmonary hemorrhage/hemosiderosis among infants--Cleveland, Ohio, 1993-1996. MMWR Morb Mortal Wkly Rep. 1997 Jan 17. 46 (2):33-5. [QxMD MEDLINE Link]. [Full Text].
Richards CA. Stachybotrys atra suspected in three infant deaths: 18 others sickened. Journal of Pediatric Infectious Disease. 1997. 10:1-8.
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. [QxMD MEDLINE Link].
Schoenthal. Mycotoxins in food and the plague of Athens. Journal of Nutritional Medicine. 1994. 4:83-85.
Dohnal V, Jezkova A, Jun D, Kuca K. Metabolic pathways of T-2 toxin. Curr Drug Metab. 2008 Jan. 9(1):77-82. [QxMD MEDLINE Link].
Zapor M, Fishbain JT. Aerosolized biologic toxins as agents of warfare and terrorism. Respir Care Clin N Am. 2004 Mar. 10(1):111-22. [QxMD MEDLINE Link].
Wannemacher RW. Dermal toxicity of T-2 toxin in guinea pigs, rats and cynomolgus monkeys. Tricothecenes and Other Mycotoxins. 1985. 423-432.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Shohami E, Wisotsky B, Kempski O, Feuerstein G. Therapeutic effect of dexamethasone in T-2 toxicosis. Pharm Res. 1987 Dec. 4(6):527-30. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

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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, Association of Military Surgeons of the US, 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

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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, Association of Military Surgeons of the US, 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

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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

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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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