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Severe Acute Respiratory Illness Linked to Use of Shoe Sprays -- Colorado, November 1993
On November 3, 1993, the Colorado Department of Health (CDH) was notified of acute respiratory illness in a Colorado woman following use of an aerosolized leather-shoe conditioner. Active surveillance by CDH identified two additional cases. This report summarizes the case investigations. Patient 1
On November 2, a 44-year-old woman sprayed the entire contents of a 5-oz can of aerosolized leather-shoe conditioner on a pair of boots; the application lasted approximately 5 minutes. She used the product in a small, poorly ventilated room. Approximately 45 minutes later, she developed a severe cough, burning of her eyes and throat, shortness of breath, weakness, wheezing, myalgia, headache, and slurred speech. She was taken to an emergency department; her temperature was 101.1 F (38.4 C); pulse, 100 per minute; blood pressure, 110/60; and respiratory rate, 28 per minute. She had bilateral rales on lung examination and an oxygen partial pressure (PO2) of 60 mmHg in arterial blood on 3 liters of oxygen through a nasal canula. A chest radiograph revealed bilateral midzone interstitial infiltrates. On admission to the hospital, her white blood cell count was 21,300 cells per cubic millimeter with 90% segmented forms, and her hematocrit was 47.3%. Results of tests for liver function, electrolytes, urea, and creatinine were normal. Within 1-8 hours following admission, she developed vomiting, chills, and epigastric cramping. Treatment was initiated with amantadine, erythromycin, and a bronchodilator.
On November 3, the patient's dyspnea had resolved, and she was afebrile; her pulse and respiratory rate were normal. Her chest radiograph showed an almost complete clearing of the pulmonary infiltrates. A persistent dry cough, abdominal cramps, and vomiting resolved gradually during the next 36 hours.
The patient had had a mild upper respiratory-tract illness for 3-4 days before using the spray. She has a 28-year history of smoking approximately 20 cigarettes per day but reportedly did not smoke on November 2 because of her respiratory-tract illness. She had no past history of severe respiratory illness.
As a result of this case, CDH initiated active surveillance for additional cases of acute respiratory illness. Directors of emergency departments and intensive-care units at hospitals in metropolitan Denver were contacted by telephone and facsimile to identify case-patients previously treated for this illness and to request reporting of future cases. In addition, CDH issued a news release to warn the public of the adverse health effects associated with use of sprays in poorly ventilated areas. CDH retrospectively identified two additional cases: patient 2 was identified by patient 1, and patient 3 was identified by a pulmonologist who had read about patient 1 in the newspaper. Patient 2
An 11-year-old boy, who was in an adjacent room when patient 1 used the leather conditioner, developed a burning throat, shortness of breath, cough, and abdominal pain approximately 45 minutes after exposure. He did not seek medical attention. Patient 3
On November 1, a 23-year-old nonsmoking man sprayed three pairs of shoes with a water and soil repellant (a nonaerosol pump spray) in an enclosed garage with a partially open door. Within 30 minutes, he developed chest tightness, a nonproductive cough, dizziness, lightheadedness, shortness of breath, and tachycardia; within 1-2 hours, he developed severe chills. On November 2, the patient continued with a nonproductive cough and had an episode of posttussive emesis, a temperature of 100 F (38 C), chest tightness, and nasal congestion. On November 3, he was admitted to the hospital with a temperature of 99.5 F (37.5 C) and pulse of 104. Chest radiograph showed bilateral upper-lobe alveolar/interstitial infiltrates. He was treated with supplemental oxygen and bronchodilators and was discharged November 4.
As a result of these cases, the manufacturer of the implicated leather conditioner spray issued a voluntary nationwide recall of the product on November 3. The Consumer Product Safety Commission is investigating the water and soil repellant as well as other products of the manufacturer. Reported by: K Kulig, MD, J Brent, MD, S Phillips, MD, T Messenger, MPH, RE Hoffman, MD, State Epidemiologist, Colorado Dept of Health. K Burkhart, MD, Central Pennsylvania Poison Control Center, Hershey; DR Tavris, MD, State Epidemiologist, Pennsylvania Dept of Health. B Oneida, Blue Ridge Poison Control Center, Charlottesville; GB Miller, Jr, MD, State Epidemiologist, Virginia Dept of Health. US Consumer Product Safety Commission, Bethesda, Maryland. Air Pollution and Respiratory Health Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Div of Field Epidemiology, Epidemiology Program Office, CDC.
Editorial Note: In December 1992, at least 157 persons nationwide consulted physicians about acute respiratory illnesses following the use of reformulated Wilsons Leather Protector (1). In August 1993, another reformulated leather conditioner, Magic Guard, was associated with 38 cases of similar respiratory illness in Pennsylvania and Virginia. Symptoms typically began within 6 hours after using the products and most frequently included shortness of breath, coughing, and chest tightness. Of these 198 reported cases (including the three described in this report), 23 persons have been hospitalized; none have died.
The shoe sprays linked recently to illness had been reformulated to eliminate 1,1,1 trichloroethane (i.e., methyl chloroform), an ozone-depleting solvent, from the formula, in accordance with Title VI of the Clean Air Act amendments of 1990 *. This legislation prohibits the sale or distribution of nonessential aerosol products that release Class I substances ** (such as 1,1,1 trichloroethane) and requires reformulation of products containing such substances by January 1994. In addition, the fluoropolymers and the propellants in these sprays had been changed. The product changes to the leather conditioner and the water and soil repellant sprays involved the solvent (from 1,1,1 trichloroethane to hexane and 2,2,4 trimethylpentane, respectively), the propellant (from carbon dioxide to isobutane and isooctane, respectively), and the fluoropolymers (from FC-905 and FC-3537, respectively, to FS-4565).
The illnesses described in this report appear to be either acute chemical pneumonitis or polymer-fume fever. Diseases with similar symptoms and signs include atypical pneumonia, congestive heart failure, hypersensitivity pneumonitis, and adult respiratory distress syndrome. Many chemicals cause pulmonary symptoms, usually related to either direct injury to airway cells or an exaggeration of normal physiologic responses (2). Chemical pneumonitis is caused by inhalation of hydrocarbons (3) and polymer-fume fever, by inhalation of fumes containing pyrolytic products released when fluoropolymers are heated to high temperatures and has been associated with smoking of cigarettes contaminated with fluoropolymers (4).
Consumers should be warned about potential adverse health effects linked to use of shoe sprays (aerosol and nonaerosol) in enclosed areas. Any spray containing polymers or solvents should be used only in adequately ventilated areas. In addition, manufacturers of shoe sprays should be aware that problems have occurred following reformulation.
State health departments are requested to report to CDC persons who have been hospitalized following exposure to any shoe spray (aerosol or nonaerosol). Standardized case-report forms are available from CDC's Air Pollution and Respiratory Health Branch, Division of Environmental Hazards and Health Effects, National Center for Environmental Health, telephone (404) 488-7320.
* Public Law no. 101-549, section 610 (42 U.S.C. section 7671).
** Controlled substances that include chlorofluorocarbons, halons, methyl chloroform, and carbon tetralchloride.
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