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Case Study

A hazardous waste worker with delayed onset abdominal pain, nausea, vomiting, and diarrhea

As the physician on duty at a hospital emergency department (ED) in an urban community, you are notified that three hazardous waste workers—two men and a woman—are being transported from their worksite by ambulance. All three workers are complaining of headache, dizziness, and nausea.

You learn that the workers were handling several dozen barrels of a sweet-smelling hazardous waste liquid in a hot, unventilated room. Their work required taking samples from barrels, which were obtained from a defunct chlorofluorocarbon manufacturing plant. All three workers were initially wearing full-face respirators and protective clothing, but the younger man removed his respirator early in the day because he had a hangover and was nauseated; he felt it was more convenient to work without being hampered by the respirator. The other two workers continued in full protective gear. After 3 to 4 hours, the three workers began to experience symptoms.

Physical examinations of the workers are conducted in the ED. The older man’s and woman’s results are normal. Their symptoms subside within 2 hours, and they are discharged.

The younger man, however, has trouble concentrating and is mildly ataxic. His initial blood laboratory data are within normal limits, but he is kept under close observation. You learn from the young man that he is aged 25 and has been in good health with no history of similar problems. Last night, in celebration of his birthday, uncharacteristically he drank 9 to 12 beers, which accounts for his hangover this morning. He also mentions that this morning, while cleaning several wounds sustained in a fight the prior evening, he spilled a can of isopropyl alcohol on his hands and clothes but did not bother to change his clothing.

Six hours later, while still in the ED, the young man becomes acutely ill. He has abdominal pain, nausea, vomiting, and diarrhea. His rectal temperature is now 101°F, pulse 140/min, and he has become disoriented and drowsy. Two days after hospital admission he still has an elevated temperature and abnormal laboratory tests as follows: serum creatinine 2.0 mg/dL (normal 0.7 to 1.5); SGOT or AST 80 U/L (normal 7 to 45); total bilirubin 2.4 mg/dL (normal 0.1 to 1.4); PT 15 seconds (normal 10 to 13). Urinalysis reveals 2+ proteinurea, and urine output has decreased despite intravenous hydration.

(a) What is the possible clinical course for this young man?

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(b) How will you identify the material to which the workers have been exposed?

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(c) What treatment or antidote would you consider for the patient?

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Answers to pretest questions may be found on page 15.



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