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Metal fume fever
Metal Fume Fever* A. IRVING SWILLER,
M.D.
and HELEN
EMMER
SWILLER, M.D.
Brooklyn, New York
T
can
HE
purpose
of this
report
attention
of physicians
be readily
overlooked
“virus
infection,”
is to bring a condition
and characterized
“influenza”
or “grippe,”
to the which as a but
in reality is a distinct, self-Iimited but disabling disease. It is a syndrome which is ignored in the standard textbooks of medicine but which can be found in texts on toxicology and industrial hygiene. It is apparently better known to plumbers than to physicians and is called “galvo” by them. However, the disease occurs also among workers in brass foundries, hence is often called brass-founders’ ague and brasiers’ disease. Although it is most commonly caused t)y zinc fumes, it apparently can be caused by other metals and is therefore called metal fume fever. Metal fume fever is an industrial disease produced by the inhalation of zinc oxide fumes when zinc is heated in an oxidizing atmosphere to a temperature near the boiling point, as in smelting, galvanizing, brass-founding, brazing and oxyacetylene welding of galvanized iron. The symptoms are systemic, disabling and resemble those of influenza. It is characterized I))- chills, fever, muscular pains, nausea and vomiting, followed by some degree of prostration. Complete recovery occurs in twenty-four to forty-eight hours. Workers exposed to the disease acquire immunity to attacks but, given a period of removal from the environment as occurs following week ends or holidays, susceptitjility returns. l (:ASE
REPORT
.-I thirty-two year old white man, a plumber, was seen four hours after exposure to fumes excited by the oxyacetylene burning of galvanized pipe. He complained of malaise, generalized aches and pains in the muscles, shaking chills and fever. He also had a burning sensation in the nose and throat and a harsh dry non-productive cough. Examination revealed an acutely ill man, febrile (102OF.), his face flushed; he \vas extremely weak, almost to prostration. Respira-
* From the Jewish Hospital [ANUARY,
1957
tions were 22 per minute. Pulse rate at 110 per minute. The nasal mucosa and pharynx were reddened and moist rales were noted at both lung bases. Although breathing sounds were alveolar, pneumonia was suspected because of the symptoms and the presence of rales. Ai this time peripheral blood studies revealed the hemoglobin to be 16 gm. per 100 cc.; erythrocytes, 5,950,OOO per cu. mm.; platelets, 200,000 per cu. mm.; leukocytes, 14,750 per cu. mm., with staff forms 4 per cent, polymorphonuclear leukocytes 78 per cent, lymphocytes 17 per cent and monocytes 1 per cent. He was given 1 ,OOO,OOOunits of procaine penicillin intramuscularly. The same evening the symptoms disappeared and when he was seen the following day he was entirely symptom free and devoid of signs referable to infection in the upper respiratory tract or lungs. Nevertheless, the penicillin injection was repeated and the patient was instructed to come to the office the following day, at which time a chest x-ray was taken and proved to be entirely negative. At this time the erythrocyte sedimentation rate was 2 mm. per hour (Westergren). Repeat blood studies revealed the hemoglobin to be 15 gm. per 100 cc.; erythrocytes, 5,150,OOO per cu. mm.; platelets, 250,000 per cu. mm.; leukocytes, 6,600 per cu. mm., with staff forms 0 per cent, polymorphonuclear leukocytes 76 per cent, eosinophilic leukocytes 2 per cent, lymphocytes 20 per cent and monocytes 2 per cent. COMMENTS
The syndrome had occurred many times in this patient, at least ten, and on each occasion the symptoms were similar, although not so severe. He had never acquired immunity, since exposure to the zinc fumes was not a daily occurrence. On each occasion he was aware of exposure, and the symptoms were anticipated, unless he was fortunate enough to burn the galvanized pipe in an unconfined area. Gonzales et al.2 refer to this as chronic zinc poisoning and thry believe it is due to the burning of impure zinc or spelter. Sir Sidney Smith” refers to the disease as zinc chill and says it is due to volatilized zinc. Dart4” believes it is due to a foreign protein reaction similar to cotton fever incotton
of Brooklyn,
'73
Brooklyn,
New York.
Metal Fume Fever-Swiller, mill workers. Lehmannj agrees and suggests that finely divided zinc fumes come in contact with the epithelial layer in the alveoli in the respiratory tract and damage the tissue protein, and subsequent absorption of the denatured protein is the cause of physiologic response, resemprotein reaction similar to bling a foreign that found in persons having had vaccine therapy. Schmidt-Keh16 supports this theory. He observed elevation of temperature could be produced experimentally in animals by injecting blood serum that had been denatured by spraying it into a chamber containing fumes of zinc. Burstein7 disagrees with this theory; he believes that the effect is due to the zinc per se after absorption into the circulation. It is Burstein’s contention that the syndrome can be induced by subcutaneous or intravenous injection of zinc salt. Lehmannj injected finely powdered zinc into animals and was unable to produce the symptoms. Although other metals may cause the symptoms,4b zinc is the most common cause. This is probably because zinc has such a low boiling point (300“~.), because it has such widespread use and because zinc fumes tend to be dispersed so finely that they can penetrate the alveoli of the lungs. Larger particles of zinc oxide when inhaled do not reach the lungs but are caught and settle on the tracheal mucosa; these particles do not cause the characteristic symptoms. Sturgis et al.,s report that the typical illness has been produced repeatedly in volunteer subjects who inhaled fumes of zinc or freshly burning magnesium or a suspension of finely divided heated zinc oxide, the particles of which were 0.4 microns in size. They also observed leukocytosis of 12,000 to 16,000 per cu. mm., which persisted for twelve hours after the temperature returned to normal. It is important to note that this is a self limited disease with no complications and is not to be confused with the more dangerous form of the disease engendered by exposure to other zinc salts, namely, the fumes of zinc chloride.g Evans reports ten deaths and twenty-five cases of nonfatal injury which occurred among seventy per-
Sadler
sons exposed to zinc chloride fumes in a tunnel from the burning of a smoke generator. The main effects were damage to the mucous membranes of the nasopharynx and respirator)- tract and a pale grey cyanosis. SUMMARY AND
CONCLUSIONS
A case is presented of metal fume fever due to zinc fumes generated by the burning of galvanized pipe by a plumber. The resemblance of this metal fume fever to severe upper respirator). infection is indicated and its short, self-limited nature is described. The temporary leukocytosis previously observed is verified and the paucity of other objective findings noted. The case is reported and the extremely sparse literature on the subject discussed because knowledge of the disease is not as widespread as might be supposed. REFERENCES
1. 2.
3. 4.(a)
5.
6.
7. 8.
9.
FAIRHALL, L. T. Industrial Toxicology. Baltimore, 1949. Williams & Wilkins Co. GONZALES, T. A., VANCE, M. HELPERN, M. and UMBERGER, C. J. Legal Medicine, Pathology and Toxicology, 2nd ed. New York, 1954. AppletonCentury-Crofts, Inc. SMITH, S. Forensic Medicine. Boston, 1939. Little, Brown & Co. DART, E. B. Dust in the causation of industrial disease. In: Industrial Hygiene and Toxicology, vol. 1, p. 517. Edited by Patty, F. A. New York, 1948. Interscience Publishers, Inc.; (b) HEYROTH, F. F. The metals (except lead). In: Industrial Hygiene and Toxicology, vol. 2, p. 737. Edited by Patty, F. A. New York, 1948. Interscience Publishers, Inc. LEHMANN, K. B. Studien iiber technisch und hygienisch wichtige Gase and DLmpfe: XVI. Das Giess oder Zinkfieber. Arch. f. Hyg., 72: 358, 1910. SCHMIDT-KEHL,J. How can inhalation of zinc oxide produce fever? J. Indust. Hyg., 12: 115, 1930. BURSTEIN,A. Brassfounders’ ague. J. Indust. Hyg., 8: 110, 1926. STURGIS, C. C., DUNKEN, P. and THOMSON, R. M. Metal fume fever: clinical observations on the effect of experimental inhalation of zinc oxide by two apparently normal persons. J. Zndust. Hyg., 9: 88, 1927. I
AMERICAN
JOURNAL
OF MEDICINE
M.D.
and HELEN
EMMER
SWILLER, M.D.
Brooklyn, New York
T
can
HE
purpose
of this
report
attention
of physicians
be readily
overlooked
“virus
infection,”
is to bring a condition
and characterized
“influenza”
or “grippe,”
to the which as a but
in reality is a distinct, self-Iimited but disabling disease. It is a syndrome which is ignored in the standard textbooks of medicine but which can be found in texts on toxicology and industrial hygiene. It is apparently better known to plumbers than to physicians and is called “galvo” by them. However, the disease occurs also among workers in brass foundries, hence is often called brass-founders’ ague and brasiers’ disease. Although it is most commonly caused t)y zinc fumes, it apparently can be caused by other metals and is therefore called metal fume fever. Metal fume fever is an industrial disease produced by the inhalation of zinc oxide fumes when zinc is heated in an oxidizing atmosphere to a temperature near the boiling point, as in smelting, galvanizing, brass-founding, brazing and oxyacetylene welding of galvanized iron. The symptoms are systemic, disabling and resemble those of influenza. It is characterized I))- chills, fever, muscular pains, nausea and vomiting, followed by some degree of prostration. Complete recovery occurs in twenty-four to forty-eight hours. Workers exposed to the disease acquire immunity to attacks but, given a period of removal from the environment as occurs following week ends or holidays, susceptitjility returns. l (:ASE
REPORT
.-I thirty-two year old white man, a plumber, was seen four hours after exposure to fumes excited by the oxyacetylene burning of galvanized pipe. He complained of malaise, generalized aches and pains in the muscles, shaking chills and fever. He also had a burning sensation in the nose and throat and a harsh dry non-productive cough. Examination revealed an acutely ill man, febrile (102OF.), his face flushed; he \vas extremely weak, almost to prostration. Respira-
* From the Jewish Hospital [ANUARY,
1957
tions were 22 per minute. Pulse rate at 110 per minute. The nasal mucosa and pharynx were reddened and moist rales were noted at both lung bases. Although breathing sounds were alveolar, pneumonia was suspected because of the symptoms and the presence of rales. Ai this time peripheral blood studies revealed the hemoglobin to be 16 gm. per 100 cc.; erythrocytes, 5,950,OOO per cu. mm.; platelets, 200,000 per cu. mm.; leukocytes, 14,750 per cu. mm., with staff forms 4 per cent, polymorphonuclear leukocytes 78 per cent, lymphocytes 17 per cent and monocytes 1 per cent. He was given 1 ,OOO,OOOunits of procaine penicillin intramuscularly. The same evening the symptoms disappeared and when he was seen the following day he was entirely symptom free and devoid of signs referable to infection in the upper respiratory tract or lungs. Nevertheless, the penicillin injection was repeated and the patient was instructed to come to the office the following day, at which time a chest x-ray was taken and proved to be entirely negative. At this time the erythrocyte sedimentation rate was 2 mm. per hour (Westergren). Repeat blood studies revealed the hemoglobin to be 15 gm. per 100 cc.; erythrocytes, 5,150,OOO per cu. mm.; platelets, 250,000 per cu. mm.; leukocytes, 6,600 per cu. mm., with staff forms 0 per cent, polymorphonuclear leukocytes 76 per cent, eosinophilic leukocytes 2 per cent, lymphocytes 20 per cent and monocytes 2 per cent. COMMENTS
The syndrome had occurred many times in this patient, at least ten, and on each occasion the symptoms were similar, although not so severe. He had never acquired immunity, since exposure to the zinc fumes was not a daily occurrence. On each occasion he was aware of exposure, and the symptoms were anticipated, unless he was fortunate enough to burn the galvanized pipe in an unconfined area. Gonzales et al.2 refer to this as chronic zinc poisoning and thry believe it is due to the burning of impure zinc or spelter. Sir Sidney Smith” refers to the disease as zinc chill and says it is due to volatilized zinc. Dart4” believes it is due to a foreign protein reaction similar to cotton fever incotton
of Brooklyn,
'73
Brooklyn,
New York.
Metal Fume Fever-Swiller, mill workers. Lehmannj agrees and suggests that finely divided zinc fumes come in contact with the epithelial layer in the alveoli in the respiratory tract and damage the tissue protein, and subsequent absorption of the denatured protein is the cause of physiologic response, resemprotein reaction similar to bling a foreign that found in persons having had vaccine therapy. Schmidt-Keh16 supports this theory. He observed elevation of temperature could be produced experimentally in animals by injecting blood serum that had been denatured by spraying it into a chamber containing fumes of zinc. Burstein7 disagrees with this theory; he believes that the effect is due to the zinc per se after absorption into the circulation. It is Burstein’s contention that the syndrome can be induced by subcutaneous or intravenous injection of zinc salt. Lehmannj injected finely powdered zinc into animals and was unable to produce the symptoms. Although other metals may cause the symptoms,4b zinc is the most common cause. This is probably because zinc has such a low boiling point (300“~.), because it has such widespread use and because zinc fumes tend to be dispersed so finely that they can penetrate the alveoli of the lungs. Larger particles of zinc oxide when inhaled do not reach the lungs but are caught and settle on the tracheal mucosa; these particles do not cause the characteristic symptoms. Sturgis et al.,s report that the typical illness has been produced repeatedly in volunteer subjects who inhaled fumes of zinc or freshly burning magnesium or a suspension of finely divided heated zinc oxide, the particles of which were 0.4 microns in size. They also observed leukocytosis of 12,000 to 16,000 per cu. mm., which persisted for twelve hours after the temperature returned to normal. It is important to note that this is a self limited disease with no complications and is not to be confused with the more dangerous form of the disease engendered by exposure to other zinc salts, namely, the fumes of zinc chloride.g Evans reports ten deaths and twenty-five cases of nonfatal injury which occurred among seventy per-
Sadler
sons exposed to zinc chloride fumes in a tunnel from the burning of a smoke generator. The main effects were damage to the mucous membranes of the nasopharynx and respirator)- tract and a pale grey cyanosis. SUMMARY AND
CONCLUSIONS
A case is presented of metal fume fever due to zinc fumes generated by the burning of galvanized pipe by a plumber. The resemblance of this metal fume fever to severe upper respirator). infection is indicated and its short, self-limited nature is described. The temporary leukocytosis previously observed is verified and the paucity of other objective findings noted. The case is reported and the extremely sparse literature on the subject discussed because knowledge of the disease is not as widespread as might be supposed. REFERENCES
1. 2.
3. 4.(a)
5.
6.
7. 8.
9.
FAIRHALL, L. T. Industrial Toxicology. Baltimore, 1949. Williams & Wilkins Co. GONZALES, T. A., VANCE, M. HELPERN, M. and UMBERGER, C. J. Legal Medicine, Pathology and Toxicology, 2nd ed. New York, 1954. AppletonCentury-Crofts, Inc. SMITH, S. Forensic Medicine. Boston, 1939. Little, Brown & Co. DART, E. B. Dust in the causation of industrial disease. In: Industrial Hygiene and Toxicology, vol. 1, p. 517. Edited by Patty, F. A. New York, 1948. Interscience Publishers, Inc.; (b) HEYROTH, F. F. The metals (except lead). In: Industrial Hygiene and Toxicology, vol. 2, p. 737. Edited by Patty, F. A. New York, 1948. Interscience Publishers, Inc. LEHMANN, K. B. Studien iiber technisch und hygienisch wichtige Gase and DLmpfe: XVI. Das Giess oder Zinkfieber. Arch. f. Hyg., 72: 358, 1910. SCHMIDT-KEHL,J. How can inhalation of zinc oxide produce fever? J. Indust. Hyg., 12: 115, 1930. BURSTEIN,A. Brassfounders’ ague. J. Indust. Hyg., 8: 110, 1926. STURGIS, C. C., DUNKEN, P. and THOMSON, R. M. Metal fume fever: clinical observations on the effect of experimental inhalation of zinc oxide by two apparently normal persons. J. Zndust. Hyg., 9: 88, 1927. I
AMERICAN
JOURNAL
OF MEDICINE