Laboratory Studies

No clinically available laboratory test exists to identify or quantify mustard exposure. Mustard is biotransformed in tissues within minutes of exposure. Detection of mustard metabolites (thiodiglycol (TDG), thiodigylocol sulfoxide (TDG-sulfoxide), 1-methylsulfinyl-2-[2-(methylthio)ethylsulfonyl]ethane (MSMTESE), 1,1’-sulfonylbis[2-(methylsulfinyl)ethane (SBMSE), and 1,1’-sufonylbis[2-S-(N-acteylcyteinyl)ethane]) requires more advanced detection methods.^[32]

Results of blood studies include the following:

Complete blood count – Reactive leukocytosis occurs initially after chemical injury with leukopenia developing by day 3-5. Leukopenia < 200 cells/mm ³ is a poor prognostic sign. Thrombocytopenia and anemia follow due to bone marrow suppression.
Metabolic panel – Electrolyte derangements can occur from nausea/vomiting. Acute kidney injury may occur from dehydration.

Other Tests

The US military, as well as state and local emergency responders, have the capability to detect mustard agents on the battlefield or at the sites of suspected mustard agent release in the civilian environment. This capacity is effectively accomplished through the use of specialized equipment such as chemical detection papers, chemical detection alarms, gas detection tubes, photometric detection, ion mobility spectroscopy, Raman spectroscopy, and portable gas chromatography–mass spectroscopy. Some specific examples include the following^{[33, 34, 35, 36]}:

M8 and M9 chemical detection paper
Joint Chemical Agent Detector (JCAD)
Improved chemical Agent Monitor (ICAM)
M256A1 chemical agent detector kit
M272 chemical agent water testing kit
M22 automatic chemical agent detector and alarm
M21 remote sensing alarm
M90 chemical agent detector
Joint Services Lightweight Standoff Chemical Agent Detector (JSLSCAD)
M93A1 Fox Nuclear Biological and Chemical Reconnaissance System

Imaging Studies

Inhalation of mustard vapor causes chemical pneumonitis, which may progress to pneumonia. Serial chest x-rays are recommended to track progression. Chest computed tomography (CT) is more sensitive than chest x-rays in detecting chronic changes caused by mustard exposure.^[37]

Treatment & Management

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Author

Christopher P Holstege, MD Professor of Emergency Medicine and Pediatrics, University of Virginia School of Medicine; Chief, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, UVAHS Blue Ridge Poison Center; Executive Director, Department of Student Health and Wellness, University of Virginia

Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College Health Association, American College of Emergency Physicians, American College of Medical Toxicology, European Association of Poisons Centres and Clinical Toxicologists, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ryan J Cole, MD Fellow, Division of Medical Toxicology, Clinical Instructor, Department of Emergency Medicine, University of Virginia School of Medicine

Ryan J Cole, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Association of Poison Control Centers, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Paul M Maniscalco, MPA, MS, EMT-P National Director of Emergency Management, Medxcel/Ascension; Maniscalco and Associates, LLC

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, 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

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Dire, MD, FACEP, FAAP, FAAEM Professor of Pediatrics and Emergency Medicine, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, The Society of Federal Health Professionals (AMSUS)

Disclosure: Nothing to disclose.

Fred Henretig, MD Director, Section of Clinical Toxicology, Professor, Medical Director, Delaware Valley Regional Poison Control Center, Departments of Emergency Medicine and Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital

Disclosure: Nothing to disclose.