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Environmental Medicine: Integrating a Missing Element into Medical Education
Clinical Evaluation
History and Physical Examination
❑ The onset of symptoms due to chronic vinyl chloride exposure may be delayed for several years after the actual exposure has ceased.
A detailed occupational history should include any past exposure to vinyl chloride. The latency period for nonmalignant complications may be several months, while the latency period for angiosarcoma of the liver may be as long as 40 years. Workers exposed before 1974, when permissible workplace levels were still high, are at increased risk for the development of hepatic angiosarcoma into the next century. Individual susceptibility as well as intensity and duration of exposure may affect the interval before symptoms are manifested.
Persons who have been chronically exposed to vinyl chloride are likely to have worked or lived in locations where the chemical was produced, used, or stored. Such proximity to vinyl chloride plants operating before 1960, when engineering controls were inadequate, is particularly suspect. Although the number of symptomatic persons having this type of exposure is small, angiosarcoma of the liver is so rare that the incidence of even one case near such a plant may be initially regarded as evidence of environmental pollution. Documentation of environmental contamination, in air or drinking water, would suggest a need to monitor other potentially exposed members of the community, past and present residents, and workers connected with the source of exposure.
Two other chemical agents have been specifically associated with angiosarcoma of the liver, and exposure to them should be ruled out by history; these are inorganic arsenic and thorium dioxide (a component of the X-ray contrast medium Thorotrast). Anabolic and contraceptive steroids have also been associated with the induction of hepatic angiosarcoma, and their use should be determined. In addition to alcohol consumption and smoking habits, any medications that normally or adversely affect the liver should be noted. The possible use of homeopathic medications and so-called health foods should be investigated.
The physical examination for vinyl chloride-exposed persons includes a thorough abdominal and neurologic examination. The extremities of vinyl chloride workers, particularly the hands, should be examined for signs of acro-osteolysis, a result of “vinyl chloride disease,” discussed in Signs and Symptoms section.
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