Page 83 - JSOM Summer 2019

Sulfur Mustard Exposure

Review of Acute, Subacute, and Long-Term Effects and Their Management

1
2
Glenn A. Wolfe, 18D *; Sarah M. Petteys, MD ; Jillian F. Phelps, MD ;
3
4
Joshua B. Wasmund, MD ; Timothy P. Plackett, DO, MPH 5

ABSTRACT
Sulfur mustard has been used in conflicts for more than a production. This leaves the skin, cornea, and upper airways as
century. Despite international recognized bans on the use of the most at-risk regions of the body for exposure. Following
chemical weapons, there continue to be reports of their use. exposure, sulfur mustard remains on the surface for 2–3 min-
The authors provide a contemporary overview of sulfur mus- utes and then is slowly absorbed into deeper tissues at a rate
tard injury and its management in the acute, subacute, and of 0.5–4mg/cm /min. Within 10–15 minutes, almost all the
2
5,7
chronic periods. sulfur mustard is absorbed by the body. It remains detectable
7,8
in the soft tissue for longer than 24 hours postexposure and
9
Keywords: mustard gas; chemical terrorism; chemical war- detectable in plasma for longer than 100 days postexposure.
fare agents; blister/chemically induced; warfare The clinical significance of this reservoir remains debated but
likely contributes to many of the chronic effects.
Introduction Acute Effects and Management
Sulfur mustard, more commonly referred to as mustard gas, The acute time period (herein defined as up to 24 hours post-
was synthesized by chemists in the 19th century and first used exposure) can have varying presentations. Depending on the
1,2
in warfare during the Third Battle of Ypres in July 1917. It vehicle of distribution and proximity to explosion, one may
4
was originally used as a defensive agent due to its low lethality experience burning eyes, sore throat, dry cough, and dyspnea.
3
but persistence in the environment. During the ensuing cen- These symptoms significantly decreased once one leaves the
tury, it has been intermittently used by nation states and, more vicinity of the explosion. A latent period of 4–12 hours is typ-
recently, by nonstate actors. ical prior to onset of acute clinical features of erythema and
blisters. 10–12 Concentration of the sulfur mustard exposure also
The use of chemical weapons by state governments is banned affects severity of symptoms. 13,14
by the Geneva Protocol of 1925 and the Chemical Weapons
Convention. Their use by nonstate actors highlights the need The eyes are the most sensitive organ to exposure to sulfur
for continued awareness for the signs of chemical weapons mustard. Symptoms may exist as early as 1 hour from expo-
4
exposure and requisite knowledge to manage these problems. sure and can range from mild conjunctivitis, to corneal in-
To this end, we provide an overview of the acute, subacute, volvement with associated iritis, to dense corneal opacification
and long-term issues associated with the use of mustard gas and blindness. Temporary vision loss is also possible, lasting
exposure. 24 hours then completely resolving without chronic ophthal-
mologic complications. 4
Mechanism of Action
The skin is the next most commonly affected organ. Sulfur
Sulfur mustard is a bifunctional alkylating agent that is most mustard has a slight oily component that becomes more re-
known for the development of vesicles. As an alkylating agent, active with heat. This results in sulfur penetrating deeper and
the molecule attaches itself to both DNA and RNA, result- preferring sebaceous areas. As such, skin is most affected at the
5
ing in destruction of the strands and eventual cell death. This thinnest or sweatiest areas, such as the genitalia, axilla, neck,
12
produces an inflammatory response and oxidative stress that and the skin between. The oily nature of sulfur mustard is
typify many of the clinical findings. The classic vesicant re- also highly lipophilic, so those with elevated body fat are
15
6
sponse is a result of cleavage of laminin and collagen, causing more likely to have a more severe course. Depending on the
16
separation of the epidermis and dermis. 5 severity of exposure and concentration of chemical exposed,
dermatologic symptoms may delay from 1 to 48 hours from
When used as a warfare agent, it is generally in a liquid or exposure. Skin exposure starts with erythematous patches
vaporized form. Mustards are persistent in cold and temperate then progress to small vesicles, eventually coalescing to larger
climates. With increased temperatures, there is increased vapor blisters (Figure 1). While erythema and blistering can occur
*Correspondence to Timothy Plackett, DO, MPH, FACS, 759th Forward Surgical Team (Airborne), A-6631 Gorham Street, Fort Bragg, NC
28310 or timothy.p.plackett.mil@mail.mil
1 SSG Wolfe served 5 years on an Operation Detachment Alpha in 10th Special Forces Group (Airborne) and transitioned from active military
service to the National Guard to pursue a career as a physician’s assistant. MAJ Petteys is a board-certified pulmonary and critical care physician
2
stationed at William Beaumont Army Medical Center. MAJ Phelps is an austere and wilderness emergency medicine physician at Joint Base
3
5
4
Lewis-McCord. LT Wasmund is an undersea medical officer assigned to the 1st Reconnaissance Battalion, Camp Pendleton, CA. LTC Plackett
is a trauma surgeon currently assigned to Fort Bragg, NC.
81