In this issue, we provide a case study of an auto body shop worker exposed to isocyanates. The case study, previously presented by Dr. William Beckett and the American Thoracic Society(1), describes a classic case of occupational asthma (OA). Following the case description are questions posed to highlight some of the key issues related to diagnosis of work-related asthma. Since 1992, the Occupational Health Surveillance Program (OHSP) has received reports of 24 cases of asthma related to isocyanate exposure. Remember to report suspected and confirmed cases of work-related asthma to OHSP by phone, fax or mail. A 24-year-old male auto body shop worker presents with a 4-year history of slowly progressive respiratory complaints which include chest tightness, wheeze, cough productive of minimal white phlegm, and dyspnea. Over the last 4 months, the patient has awakened from sleep twice weekly. His use of albuterol metered dose inhaler has gradually increased to a current level of 10-12 puffs daily. The past medical history is unremarkable, with no history of childhood asthma. He is a smoker with no history of substance abuse. He started working in the auto body shop roughly 4½ years ago, at which time he was symptom-free. Detailed occupational history, including review of Material Safety Data Sheets (MSDS), suggests the use of polyurethane (two-component, hexamethylene diisocyanate or HDI) spray paints. No seasonal symptoms or home precipitants are reported. The physical examination suggests a normal oropharynx and prolonged expiratory phase on chest auscultation. His prebronchodilator spirometry was within normal limits according to ATS criteria. His methacholine challenge test confirmed hyper-reactive airways. He was asked to maintain a record of his peak expiratory flow rates at least four times daily for 2 weeks, both on and off work.
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