The purpose
of this document is to enable health care workers and public health officials
to recognize when a chemical event has poisoned people by exposing them
to vesicants/blister agents. Vesicants include
distilled mustard (HD), mustard gas (H), lewisite, mustard/lewisite, mustard/T,
nitrogen mustard, phosgene oxime, sesqui mustard, and sulfur mustard.
SummaryVesicants,
also referred to as “blister agents,” were the most commonly
used chemical warfare agents during World War I. The most likely
routes of exposure are inhalation, dermal contact, and ocular contact. Vesicants
are highly reactive chemicals that combine with proteins, DNA, and other
cellular components to result in cellular changes immediately after exposure. Depending
on the vesicant, clinical effects may occur immediately (as with phosgene
oxime or lewisite) or may be delayed for 2 to 24 hours (as with mustards). Following
exposure, the most commonly encountered clinical effects include dermal
(skin erythema and blistering), respiratory (pharyngitis, cough, dyspnea),
ocular (conjunctivitis and burns), and gastrointestinal (nausea and
vomiting). The
amount and route of exposure to the vesicant, the type of vesicant,
and the premorbid condition of the person exposed will contribute to the
time of onset and the severity of illness. For example, ingestion
of a vesicant leads to gastrointestinal symptoms more prominent than those
that would result from inhalation exposure to the same dose and type of
vesicant.
Signs and symptoms
The
following is a more comprehensive list of signs and symptoms that may
be encountered in a person exposed to a vesicant. Signs and
symptoms are not listed in order of presentation or specificity. Also,
partial presentations (an absence of some of the following signs/symptoms)
do not necessarily imply less severe disease.
Respiratory signs and symptoms
- Clear
rhinorrhea
- Nasal
irritation/pain
- Sore
throat
- Cough
- Dyspnea
(shortness of breath)
- Chest
tightness
- Tachypnea
- Hemoptysis
Dermal signs and symptoms
- Itching
- Immediate
blanching (phosgene oxime)
- Erythema
(immediate with lewisite and phosgene oxime, may be delayed for 2
to 24 hours with mustards)
- Blisters
(within 1 hour with phosgene oxime, delayed for 2 to 12 hours with
lewisite, delayed for 2 to 24 hours with mustards)
- Necrosis
and eschar (over a period of 7 to 10 days)
Ocular signs
and symptoms
- Conjunctivitis
- Lacrimation
- Eye
pain/burning
- Photophobia
- Blurred
vision
- Eyelid
edema
- Corneal
ulceration
- Blindness
Cardiovascular
signs
- Hypotension
(with high-dose exposure to lewisite)
- Atrioventricular
block and cardiac arrest (with high-dose exposure)
Gastrointestinal
signs and symptoms (prominent if ingestion is a route of exposure)
- Abdominal
pain
- Nausea
and vomiting
- Hematemesis
- Diarrhea
(sometimes bloody)
Central
nervous system signs and symptoms (with exposure to high doses)
- Tremors
- Convulsions
- Ataxia
- Coma
Laboratory
findings suggestive of vesicant exposureAlthough
it is a nonspecific finding, leukopenia can indicate vesicant exposure. It usually begins 3 to 5 days after exposure. With
a white blood cell count < 500, the prognosis is poor.
Differential
diagnosis
- Barbiturates
- Chemotherapeutic
agents
- Carbon
monoxide
- Stevens-Johnson
syndrome
- Staphylococcus
scalded skin syndrome
- Toxic
epidermal necrolysis
- Bullous
pemphigoid
- Pemphigus
vulgaris
- Other
chemical burns (such as with strong acids, bases, or corrosives)
Note: The
actual clinical manifestations of a vesicant exposure may be more
variable than the syndrome described above.
This toxic syndrome description is based on CDC's best current information.
It may be updated as new information becomes available.
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