Hydrogen sulfide exposure in an adult male

CASE

The patient was a 31-year-old male who worked in an oil refinery. He was brought to the emergency department with fever (a temperature of 39.3°C) and respiratory symptoms. He was hypotensive with a blood pressure of 68/40 mm Hg. He reported that he had been welding in a large container used for the storage of sulfur compounds in an open space before the onset of symptoms. No other chemical compounds were used and the container was clean at that time, but there were some unknown fluid residues on the floor. At the beginning of the welding process, white fumes with a “rotten egg” odor emanating from the container. The patient immediately felt dizzy and developed rhinorrhea, teary eyes, nausea, and shortness of breath, chest tightness and cough. These symptoms increased over the following hours followed by hemoptysis. He was seen by first aid providers and was removed from the scene, given oxygen, and was transported to the emergency room. There were no other workers in the same place during the event of the poisoning. He was using his personal protective equipment, including gowns and a mask.

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Subsequently, the patient was admitted to the intensive care unit. On examination, he was found to be hypotensive (BP 68/40 mm Hg) and tachypneic (respiratory rate of 26/min). The neck was supple without any lymphadenopathy. A chest examination revealed bilateral rhonchi, but examination of the heart and abdomen found no abnormalities. Neurologically, he was combative and confused initially and became lethargic and obtunded later. There were no skin lesions. Shortly after admission, the patient developed acute respiratory failure requiring mechanical ventilation. Chest radiography (CXR) showed right pleural effusion and consolidation (Figure 1). Initial and subsequent laboratory (Table 1) revealed signs of ischemic cardiac injury, abnormal coagulation profile, renal insufficiency, and slight leukocytosis. Arterial blood gas showed a pH of 7.34; PCO2: 44 mm Hg; PO2: 77 mm Hg; and oxygen saturation: 95% on an inspired oxygen of 35%. Other laboratory data were as follows: BUN 43 mEq/L, creatinine 2.6 mg/dL, Na 135 mEq/L, K 4.8 mEq/L, Cl− 105 mEq/L, and CO2 19 mEq/L.

As the patient was hypotensive, he was resuscitated with intravenous fluid and vasopressors. Intravenous hydrocortisone was started for chemical pneumonitis, but it was stopped after four days because there were no signs of improvement. Infections were ruled out and empirical broad-spectrum antibiotics were subsequently discontinued. All serological studies were negative, including Mycoplasma, Legionella, and HIV. A thoracentesis revealed an exudative pleural fluid. The gram stain showed many cells, 90% neutrophils, no organisms, and the cultures were negative. Cytology on bronchoalveolar lavage showed a few cells consistent with herpes simplex infection, thought to be a contamination from an upper airway and nasal infection. After several days of supportive care, the patient became hemodynamically stable with improved cardiac function and was extubated successfully.

However, he continued to have a right lower lobe consolidation (Figures 2a and ​and2b)2b) despite appropriate antimicrobial therapy, including acyclovir. Lung biopsy via video-assisted thoracoscopic surgery was performed and showed diffuse alveolar damage with organizing pneumonia. Special stains for herpes viruses were negative. Sections of the lung showed the presence of numerous alveolar spaces lined by reactive pneumocytes type II. Many of the alveolar spaces were filled with an admixture of macrophages, scattered eosinophils, and neutrophils. In addition, several alveoli showed clumps of proliferating fibroblasts admixed with histiocytes and other inflammatory cells, denoting the presence of organizing pneumonia. He was restarted on intravenous hydrocortisone and showed a remarkable response with significant improvement in respiratory symptoms and radiographic findings (Figure 3).

About 40 days after the incident, spirometery revealed a mild obstruction with an insignificant response to bronchodilators. Lung volume showed mild restriction and the diffusion capacity was at low-normal levels after correction for alveolar volume. The findings were consistent with mixed restrictive and obstructive pulmonary disease. He developed grayish nail-bed discoloration, suggestive of an exposure to a sulfur compound. Neurological evaluation, including an electromyography, revealed evidence of peripheral neuropathy. A follow-up chest x-ray after discharge showed complete resolution of his pulmonary infiltrate.

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