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C Case Studies in Environmental Medicine

This appendix contains 55 case studies from peer reviewed literature, including journal articles and educational material developed by the Agency for Toxic Substances and Disease Registry (ATSDR). They were selected for their clinical interest with respect to environmental factors and health, relevance to particular courses and clerkships in medical school, and illustrative potential for teaching medical school students about the impact of the environment on health.

Four indexes are included in this appendix to help guide the reader in the use of the case studies. Index 1 lists the case studies according to agent or condition (in alphabetical order). Index 2 presents the case studies in terms of the most common medical school courses and clerkships where they might be used. Creative teachers and students, however, may find these case studies helpful in other educational settings and courses/clerkships as well. Index 3 presents the case studies in terms of sentinel pathophysiological conditions, and Index 4 presents the case studies according to common clinical signs, symptoms, and presenting complaints. Taken together, these indexes should help the reader recognize the many opportunities for enhancing knowledge, skills, and abilities in environmental medicine, and integrating an enhancement of environmental medicine in medical education.

The ATSDR case studies included in this appendix are part of a series of self-instructional publications designed to increase the primary provider’s knowledge of hazardous substances in the environment and to aid in the evaluation of potentially exposed patients. Original copies of the ATSDR cases contained in this appendix and others in the series can be obtained from: Continuing Education Coordinator, ATSDR, Division of Health Education (E33), 1600 Clifton Road, N.E., Atlanta, GA 30333.



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Environmental Medicine: Integrating a Missing Element into Medical Education C Case Studies in Environmental Medicine This appendix contains 55 case studies from peer reviewed literature, including journal articles and educational material developed by the Agency for Toxic Substances and Disease Registry (ATSDR). They were selected for their clinical interest with respect to environmental factors and health, relevance to particular courses and clerkships in medical school, and illustrative potential for teaching medical school students about the impact of the environment on health. Four indexes are included in this appendix to help guide the reader in the use of the case studies. Index 1 lists the case studies according to agent or condition (in alphabetical order). Index 2 presents the case studies in terms of the most common medical school courses and clerkships where they might be used. Creative teachers and students, however, may find these case studies helpful in other educational settings and courses/clerkships as well. Index 3 presents the case studies in terms of sentinel pathophysiological conditions, and Index 4 presents the case studies according to common clinical signs, symptoms, and presenting complaints. Taken together, these indexes should help the reader recognize the many opportunities for enhancing knowledge, skills, and abilities in environmental medicine, and integrating an enhancement of environmental medicine in medical education. The ATSDR case studies included in this appendix are part of a series of self-instructional publications designed to increase the primary provider’s knowledge of hazardous substances in the environment and to aid in the evaluation of potentially exposed patients. Original copies of the ATSDR cases contained in this appendix and others in the series can be obtained from: Continuing Education Coordinator, ATSDR, Division of Health Education (E33), 1600 Clifton Road, N.E., Atlanta, GA 30333.

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Environmental Medicine: Integrating a Missing Element into Medical Education INDEX 1: Case Studies Related to Chemical Agents and Conditions Agent Case Study Title Case Study No. Arsenic Arsenic Toxicity 1   Seasonal Arsenic Exposure from Burning Chromium-Copper-Arsenate-Treated Wood 2 Asbestos Asbestos Toxicity 3 Benzene Benzene Toxicity 4 Beryllium Beryllium Toxicity 5 Cadmium Cadmium Toxicity 6 Carbon Monoxide Fetal Death Due to Nonlethal Maternal Carbon Monoxide Poisoning 7 Carbon Tetrachloride Carbon Tetrachloride Toxicity 8 Chlordane Chlordane Toxicity 9 Chlorine Gas Chronic Reactive Airway Disease Following Acute Chlorine Gas Exposure in an Asymptomatic Atopic Patient 10 Chromium Chromium Toxicity 11 Cyanide Cyanide Toxicity 12 Dioxin Dioxin Toxicity 13 Ethylene/Propylene Glycol Ethylene/Propylene Glycol Toxicity 14 Formalin Formalin Asthma in Hospital Staff 15 Gasoline Gasoline Toxicity 16 Hantavirus Hantavirus Pulmonary Syndrome: A Clinical Description of 17 Patients with a Newly Recognized Disease 17 Lead Lead Poisoning from Mobilization of Bone Stores During Thyrotoxicosis 18   Lead Toxicity 19 Legionella Legionnaires’ Disease: Description of an Epidemic of Pneumonia 20

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Environmental Medicine: Integrating a Missing Element into Medical Education Agent Case Study Title Case Study No. Mercury Mercury in House Paint as a Cause of Acrodynia: Effect of Therapy with N-Acetyl-D, L-Penicillamine 21   Mercury Toxicity 22 Methanol Methanol Toxicity 23 Methylene Chloride Methylene Chloride Toxicity 24   Paint Remover Hazard 25 Nitrates/Nitrites Fatal Outcome of Methemoglobinemia in an Infant 26   Nitrate/Nitrite Toxicity 27 Nitrogen Dioxide An Outbreak of Nitrogen Dioxide-Induced Respiratory Illness Among Ice Hockey Players 28 Pentachlorophenol Pentachlorophenol Toxicity 29 Pesticides Aldicarb Poisoning: A Case Report with Prolonged Cholinesterase Inhibition and Improvement After Pralidoxime Therapy 30   Cholinesterase-Inhibiting Pesticide Toxicity 31   Infertility in Male Pesticide Workers 32   Pesticide Food Poisoning from Contaminated Watermelons in California, 1985 33   Poisoning of an Urban Family Due to Misapplication of Household Organophosphate and Carbamate Pesticides 34 Polynuclear Aromatic Hydrocarbon (PAH) Polynuclear Aromatic Hydrocarbon (PAH) Toxicity 35 Polychlorinated Biphenyl (PCB) Polychlorinated Biphenyl (PCB) Toxicity 36 Radiation Ionizing Radiation 37

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Environmental Medicine: Integrating a Missing Element into Medical Education Agent Case Study Title Case Study No. Radon Radon Toxicity 38 Radon Residential Radon Exposure and Lung Cancer in Sweden 39 Soybean Dust Community Outbreaks of Asthma Associated with Inhalation of Soybean Dust 40 Tetrachloroethylene Tetrachloroethylene Toxicity 41 Toluene Toluene Toxicity 42 Toluene Diisocyanate Occupational Asthma Due to Toluene Diisocyanate Among Velcro-like Tape Manufacturers 43 1,1,1-Trichloroethane 1,1,1-Trichloroethane 44 Trimethyltin Trimethyltin Encephalopathy 45 Trichloroethylene Trichloroethylene Toxicity 46 Vinyl Chloride Vinyl Chloride Toxicity 47 Condition Case Study Title Case Study No. Carpel Tunnel Syndrome Work-Related Disorders of the Neck and Upper Extremity 48 Dermatitis Contact Dermatitis in Surgeons from Methylmethacrylate Bone Cement 49   Skin Lesions and Environmental Exposures: Rash Decisions 50 Hearing Loss Acoustic Trauma Caused by the Telephone: A Report of Two Cases 51   Behavioral and Audiologic Manifestations of Noise-Induced Hearing Loss 52

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Environmental Medicine: Integrating a Missing Element into Medical Education Condition Case Study Title Case Study No. Reproductive and Developmental Effects Reproductive and Developmental Hazards 53   See also Lead, Pesticides, and Radiation 18, 19, 32, 37 Respiratory Conditions Childhood Asthma and Indoor Environmental Risk Factors 54   Populations at Risk From Particulate Air Pollution—United States, 1992 55   See also Chlorine Gas, Formalin, Hantavirus, Legionella, Soybean Dust, and Toluene Diisocyanate 10, 15, 17, 20, 40, 43

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Environmental Medicine: Integrating a Missing Element into Medical Education INDEX 2: Selected Case Studies Related to Common Medical School Courses and Clerkships/Clinical Rotations Selected Courses Selected Case Studies Biochemistry and Physiology 7, 12, 18, 19, 24, 25, 26, 27, 29, 35, 36 Community Medicine/Public Health 17, 20, 30, 31, 32, 33, 34, 38, 39, 40, 54, 55 Epidemiology and Biostatistics 17, 20, 31, 32, 33, 38, 39, 40, 54, 55 Genetics 29, 37, 38 Introduction to Clinical Medicine See Appendix A Microbiology 17, 20 Neuroscience 1, 2, 8, 9, 18, 19, 21, 22, 23, 24, 30, 31, 33, 34, 41, 42, 45, 48 Nutrition 2, 6, 18, 33 Pathology 3, 4, 8, 37, 38 Pharmacology 4, 7, 8, 12, 16, 18, 19, 26, 27, 28, 30, 31, 33, 34 Selected Clerkships/Clinical Rotations Selected Case Studies Cardiovascular Medicine 7, 12, 19, 23, 24, 25, 26, 27, 29, 30, 31, 33, 34 Dermatology 1, 2, 11, 13, 21, 22, 29, 36, 49, 50 Emergency Medicine 2, 7, 10, 12, 30, 31, 33, 34 Endocrinology 18, 32 Family Medicine 1, 2, 3, 4, 5, 8, 11, 13, 14, 15, 17, 18, 19, 20, 21, 22, 24, 26, 27, 28, 30, 31, 32, 33, 34, 42, 43, 48, 54 Gastrointestinal Disease 8, 11, 18, 27, 30, 31, 33, 34, 36, 47 Hematology/Oncology 3, 4, 11, 13, 18, 19, 26, 35, 37, 38, 39, 46, 47 Infectious Disease 17, 20 Internal Medicinea 1, 2, 4, 8, 11, 14, 15, 17, 18, 20, 24, 30, 31, 32, 33, 34, 42, 43, 48

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Environmental Medicine: Integrating a Missing Element into Medical Education Selected Clerkships/Clinical Rotations Selected Case Studies Nephrology 1, 2, 6, 8, 14, 18, 19, 21, 22, 23 Neurology 1, 2, 8, 9, 18, 19, 21, 22, 23, 24, 30, 31, 33, 34, 41, 42, 45, 48 Obstetrics-Gynecologya 7, 9, 18, 19, 30, 31, 33, 34, 37, 44, 53 Orthopedics 6, 48 Otolaryngology 11, 19, 40, 51, 52, 54 Pediatricsa,b 2, 3, 5, 13, 14, 17, 18, 19, 21, 22, 26, 27, 28, 34, 54 Pulmonary Medicinec 3, 5, 10, 11, 12, 14, 15, 17, 20, 26, 27, 28, 30, 31, 33, 34, 40, 42, 43, 54, 55 Psychiatrya 8, 21, 22, 41, 42, 45, 46 Appendix A Radiology 3, 5, 11, 35, 38, 39 aRequired clerkships/clinical rotations in all U.S. medical schools. bAdditional information on curriculum content in pediatrics can be found in the Children’s Environmental Health Network manual entitled Kids and the Environment: Toxic Hazards—A Course on Pediatric Environmental Health. For more information, contact the California Public Health Foundation, Rod Armstrong, The Children’s Environmental Health Network, 5900 Hollis Street, Suite E, Emeryville, CA 94608, Telephone (510) 540–3657, Fax (510) 540–2673. cAdditional information on curriculum development in pulmonology can be found in the reports: Preventive Pulmonary Academic Award Program. 1993. Guidelines for Curriculum Development for Undergraduate Medical Education in the Prevention of Pulmonary Diseases. Bethesda, MD: Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, November. Preventive Pulmonary Academic Award Program. 1994. Knowledge Bases and Sample Curricula. Bethesda, MD: Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, March.

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Environmental Medicine: Integrating a Missing Element into Medical Education INDEX 3: Selected Case Studies Related to Sentinel Pathophysiological Conditions for Environmental/Occupational Evaluation Sentinel Pathophysiological Conditions Agent or Exposure Discussed Selected Case Studies CARDIOVASCULAR Bradycardia Pesticide 30, 33 Chest Pain Methylene Chloride 24, 25 DERMATOLOGIC Acne Dioxin 13 Acne Polychlorinated Biphenyl (PCB) 36 Acrodynia Mercury 22 Contact Dermatitis Chromium 11 Contact Dermatitis Methylmethacrylate 49 Hyperkeratosis Arsenic 1, 2 ENDOCRINOLOGIC Thyrotoxicosis Lead 18 GASTROINTESTINAL Abdominal Pain Lead 18 Abdominal Pain, Nausea, and Vomiting Carbon Tetrachloride 8 Diarrhea Nitrates 27 Diarrhea Pesticides 30, 31, 33, 34 Vomiting Pesticides 30, 31, 33, 34 HEMATOLOGIC/ ONCOLOGIC Hypochronic Anemia Lead 19 Leukemia Benzene 4 Liver Cancer Vinyl Chloride 47 Lung Cancer Asbestos 3 Lung Cancer Polynuclear Aromatic Hydrocarbon (PAH) 35 Lung Cancer Radon 39

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Environmental Medicine: Integrating a Missing Element into Medical Education Sentinel Pathophysiological Conditions Agent or Exposure Discussed Selected Case Studies HEMATOLOGIC/ ONCOLOGIC Methemoglobinemia Nitrate 26 HEPATIC Cancer Vinyl Chloride 47 Hepatitis Carbon Tetrachloride 8 Hepatitis Polychlorinated Biphenyl (PCB) 36 INFECTIOUS Respiratory Hantavirus 17 Respiratory Legionella 20 NEUROLOGIC Ataxia Mercury 21 Carpel Tunnel Syndrome (CTS) Repetitive Motion 48 Dysarthria Mercury 21 Encephalopathy Trimethyltin 45 Headache Carbon Tetrachloride 8 Headache Methanol 23 Headache Methylene Chloride 24 Headache Tetrachloroethylene 41 Headache Toluene 42 Hearing Loss Lead 19 Hyperactive Lead 19 Peripheral Neuropathy Arsenic 1, 2 Tremor Mercury 21

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Environmental Medicine: Integrating a Missing Element into Medical Education Sentinel Pathophysiological Conditions Agent or Exposure Discussed Selected Case Studies OBSTETRIC/GYNECOLOGIC Miscarriage and Fetal Death Carbon Monoxide 7 ORTHOPEDIC Carpel Tunnel Syndrome (CTS) Repetitive Motion 48 Osteomalacia Syndrome (CTS) Cadmium 6 RENAL Acute Renal Failure Carbon Tetrachloride 8 Acute Renal Failure Ethylene/Propylene Glycol 14 Acute Renal Failure Methanol 23 Chronic Renal Failure Cadmium 6 Chronic Renal Failure Mercury 21, 22 Chronic Renal Failure Lead 18, 19 REPRODUCTIVE AND DEVELOPMENTAL Birth Defects Various 53 Birth Defects Mercury 22 Birth Defects Radiation 37 Developmental Defects Polychlorinated Biphenyl (PCB) 36 Developmental Defects Lead 18, 19 Infertility 1,2-Dibromo-3-Chloropropane (DBCP) 32 RESPIRATORY Asthma Formalin 15 Asthma Indoor Environment 54

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Environmental Medicine: Integrating a Missing Element into Medical Education Sentinel Pathophysiological Conditions Agent or Exposure Discussed Selected Case Studies RESPIRATORY Chronic Upper Airway Chromium 11 Cyanosis Nitrate 27 Interstitial Fibrosis Beryllium 5 Irritation Symptoms Chromium 11   SOURCE: Kipen, HM and Craner, J. 1992. Sentinel pathophysiologic conditions: An adjunct to teaching occupational and environmental disease recognition and history-taking. Environmental Research 59:93–100.

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Environmental Medicine: Integrating a Missing Element into Medical Education INDEX 4: Selected Case Studies Related to Clinical Signs, Symptoms, and Presenting Complaints Clinical Signs, Symptoms, and Presenting Complaints Agent or Exposure Discussed Selected Case Studies ABDOMINAL PAIN Carbon Tetrachloride 8 Lead 18, 19 Pesticides 30, 31, 33, 34 ABORTIONS, SPONTANEOUS Chlordane 9 1,1,1-Trichloroethane 44 Various 53 ACNE Polychlorinated Biphenyl (PCB) 36 ALOPECIA Arsenic 2 ALTERED MENTAL STATUS WITH UNCONSCIOUSNESS Arsenic 2 Carbon Monoxide 7 Cyanide 12 Pesticides 30, 31, 33, 34 ANOREXIA Chlordane 9 Chromium 11 Pentachlorophenol 29 Vinyl Chloride 47 ATAXIA Mercury 21 Methanol 23 BIRTH DEFECTS Reproductive and Developmental Hazards 53 1,1,1-Trichloroethane 44 BRADYCARDIA Pesticides 30, 31, 33, 34 CHEST PAIN Asbestos 3

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Environmental Medicine: Integrating a Missing Element into Medical Education Clinical Signs, Symptoms, and Presenting Conditions Agent or Exposure Discussed Selected Case Studies CHEST PAIN Methylene Chloride 24, 25 Nitrogen Dioxide 28 Toluene Diisocyanate (TDI) 43 CONFUSION Carbon Tetrachloride 8 Gasoline 16 Lead 18, 19 Methylene Chloride 24 Pesticides 30, 31, 33, 34 COUGH Beryllium 5 Hantavirus 17 Indoor Environment 54 Legionella 20 Nitrogen Dioxide 28 Radon 39 Toluene 42 CYANOSIS Nitrates 27 DELIRIUM Arsenic 1, 2 Chromium 11 Dioxin 13 Gasoline 16 Mercury 21, 22 Methylmethacrylate 49 Trimethyltin 45 DIFFICULTY CONCENTRATING Lead 18 Tetrachloroethylene (TCE) 41

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Environmental Medicine: Integrating a Missing Element into Medical Education Clinical Signs, Symptoms, and Presenting Conditions Agent or Exposure Discussed Selected Case Studies DIAPHORESIS Mercury 21, 22 Pentachlorophenol 29 Pesticides 30, 31, 33, 34 DIARRHEA Carbon Tetrachloride 8 Hantavirus 17 Nitrates 26, 27 Pesticides 30, 31, 33, 34 DYSARTHRIA Mercury 21 DYSPNEA Asbestos 3 Beryllium 5 Hantavirus 17 Indoor Environment 54 Nitrogen Dioxide 28 Pentachlorophenol 29 Pesticides 30, 31, 33, 34 Polynuclear Aromatic Hydrocarbon (PAH) 35 Toluene 42 Toluene Diisocyanate (TDI) 43 EPISTAXIS, ECCHYMOSES, and PETECHIA Arsenic 2 Benzene 4 Chromium 11 FATIGUE Arsenic 2 Benzene 4 Lead 18 Methylene Chloride 24

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Environmental Medicine: Integrating a Missing Element into Medical Education Clinical Signs, Symptoms, and Presenting Conditions Agent or Exposure Discussed Selected Case Studies FATIGUE Pesticides 30, 31, 33, 34 Vinyl Chloride 47 FEVER Hantavirus 17 Legionella 20 Pentachlorophenol 29 HEADACHE Arsenic 2 Carbon Tetrachloride 8 Chlordane 9 Gasoline 16 Methanol 23 Methylene Chloride 24 Nitrogen Dioxide 28 Pesticides 30, 31, 33, 34 Tetrachloroethylene (TCE) 41 Toluene 42 HEARING LOSS Lead 19 Occupational Noise 51, 52 HEMOPTYSIS Nitrogen Dioxide 28 HEPATITIS Carbon Tetrachloride 8 Chromium 11 Polychlorinated Biphenyl (PCB) 36 HEPATOMEGALY Vinyl Chloride 47 HYPERTENSION Lead 19 HYPOTENSION Cyanide 12

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Environmental Medicine: Integrating a Missing Element into Medical Education Clinical Signs, Symptoms, and Presenting Complaints Agent or Exposure Discussed Selected Case Studies HYPOTENSION Pesticides 30, 31, 33, 34 INCONTINENCE Pesticides 30, 31, 33, 34 INFERTILITY 1,2-Dibromo-3-Chloropropane (DBCP) 32 Various 53 IRRITABILITY Gasoline 16 Mercury 22 Methylene Chloride 24 Nitrates 26, 27 Tetrachloroethylene (TCE) 41 LACRIMATION Pesticides 30, 31, 33, 34 LOW BACK PAIN Cadmium 6 MUSCLE TWITCHING Arsenic 2 Pesticides 30, 31, 33, 34 MYALGIA Cadmium 6 Lead 18 NASAL IRRITATION WITH RHINORRHEA Chromium 11 NAUSEA Carbon Tetrachloride 8 Chlordane 9 Methanol 23 Pesticides 30, 31, 33, 34 PERIPHERAL NEUROPATHY Arsenic 1, 2 Repetitive Motion 48 PROTEINURIA Cadmium 6 Carbon Tetrachloride 8 Chromium 11

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Environmental Medicine: Integrating a Missing Element into Medical Education Clinical Signs, Symptoms, and Presenting Complaints Agent or Exposure Discussed Selected Case Studies RALES Asbestos 3 Pesticides 30, 31, 33, 34 RASH Arsenic 1, 2 Chromium 11 Dioxin 13 Environmental Exposures (i.e., allergens, irritants) 50 Mercury 21, 22 Methylmethacrylate 49 Pentachlorophenol 29 Polychlorinated Biphenyl (PCB) 36 SEIZURES Arsenic 2 Pesticides 30, 31, 33, 34 Trimethyltin 45 TACHYCARDIA Cyanide 12 Hantavirus 17 Methanol 23 Methylene Chloride 24 Nitrates 26, 27 Pentachlorophenol 29 TACHYPNEA Cyanide 12 Ethylene/Propylene Glycol 14 Hantavirus 17 Nitrates 26, 27

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Environmental Medicine: Integrating a Missing Element into Medical Education Clinical Signs, Symptoms, and Presenting Complaints Agent or Exposure Discussed Selected Case Studies TACHYPNEA Pentachlorophenol 29 TINNITUS Methanol 23 VISUAL DISTURBANCE Methanol 23 VOMITING Carbon Tetrachloride 8 Ethylene/Propylene Glycol 14 Hantavirus 17 Nitrates 26, 27 Pesticides 30, 31, 33, 34 WEAKNESS Pesticides 30, 31, 33, 34 Polynuclear Aromatic Hydrocarbon (PAH) 35 Repetitive Motion 48 WEIGHT LOSS Benzene 4 Chromium 11 Pentachlorophenol 29 Polynuclear Aromatic Hydrocarbon (PAH) 35 Radon 38, 39 Vinyl Chloride 47 WHEEZING Formalin 15 Indoor Environment 54 Pesticides 30, 31, 33, 34 Soybean Dust 40 Toluene Diisocyanate (TDI) 43