Progressive Vocal Cord Dysfunction Subsequent to a Chlorine Gas Exposure
Introduction
Dyspnea, cough, and chest pain are common manifestations of vocal cord dysfunction syndrome (VCD), which is a condition characterized by paradoxical vocal cord closure during inspiration. Laryngoscopy serves as the gold standard means of achieving the diagnosis through the visualization of vocal cord adduction during inhalation maneuvers.1 Potential origins for VCD include gastroesophageal reflux disease, exercise, upper respiratory tract infections, asthma, and psychological factors. Ammonia, flux fumes, smoke, pungent odors, and dust are irritants that have also been associated with either the induction or exacerbation of “irritant” associated VCD (IVCD). It is unclear whether a single high-level or chronic low-level exposure to such agents gives rise to IVCD or, alternatively, results in discernable clinical aspects of a VCD expression of a patient.2 Depending on chemical properties and situational factors associated with a single high-concentration exposure, such agents as nitrogen dioxide or ammonia have been noted to induce a variety of upper respiratory tract disorders such as rhinitis or “reactive upper airway dysfunction syndrome” and/or VCD.3 We report the first case of a temporal association between exposure to a single incident involving a large-volume chlorine chemical spill and the eventual diagnosis of VCD.
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Case history
A 49-year-old Caucasian male firefighter was evaluated in the Pulmonary Clinic at Wilford Hall Medical Center for potential adverse health effects of a recent chemical spill. He had been in his usual good state of health without any symptoms of dyspnea, cough, wheezing, or chest pain until he responded to an incident involving the collision of two trains in a rural area near San Antonio. The collision led to the derailment of both trains and the release of approximately 15,000 gallons of
Discussion
Because of its molecular weight, chlorine gas (Cl2) is two-and-one-half times heavier than air and forms plumes of yellow-green gas. Rather than being diluted via rapid ascent into the atmosphere, this gas often lingers in high concentration at sites of release. Chlorine gas is partially water-soluble and with inhalation will often deposit on the hygroscopic surfaces such as the nose, pharynx, and airways. Situational factors such as the duration of exposure, gas concentration, and wind
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The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the U.S. Department of the Army, Department of the Air Force, or Department of Defense.