Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical WarfareFig. 8-13. A surgically excised lung from an Iranian mustardcasualty showing bronchiectasis and severe chronicinfection.Reproduced with permission from: Freitag L, Firusian N,Stamatis G, Greschuchna D. The role of bronchoscopy inpulmonary complications due to mustard gas inhalation.Chest. 1991;100:1438.and not severe, may be caused by the cholinergicactivity of mustard, by a general reaction to injury, orbecause of the unpleasant odor. 9,33 Nausea and vomitingoccurring 24 to 36 hours later results from thegeneralized cytotoxic activity of mustard and damageto the mucosa of the gastrointestinal tract.Diarrhea is not common, and gastrointestinalbleeding seems to be even less common in humans.However, animals that were given potentially lethaldoses of mustard administered either intravenouslyor subcutaneously had profuse diarrhea, which wasfrequently bloody; however, this was unusual whenmustard was administered percutaneously or byinhalation. 61,98 Diarrhea in animals was more commonafter nitrogen mustard. 10 None of 107 autopsied humancases involved; and in the 57 cases in which thegastrointestinal tract was thoroughly examined, nonehad significant lesions. 99 In several reported series ofIranian casualties, totaling about 700 casualties, fewhad diarrhea and only a very few who died had bloodydiarrhea. 17,63,100 Constipation was noted in casualtieswith mild exposure. 61Central Nervous SystemAlthough the effects are not usually clinically prominent,mustard affects the CNS. Reports of World WarI casualties described apathy, depression, intellectualdullness, and languor. 61 Approximately 83% of the 233Iranian casualties sent to various European hospitalsfor medical care during the Iran-Iraq War had CNScomplaints; most complaints, however, were mild andnonspecific. 63Large amounts of mustard administered to animalsvia the inhalational, intravenous, subcutaneous,or intramuscular routes caused hyperexcitability,abnormal muscular movements, convulsions, andother neurological manifestations. 61,101 Animals dieda “neurological death” a few hours after receiving alethal amount of mustard. 10 Autopsies of these animalsdisclosed few abnormalities. 101After three children were accidentally exposed to alarge amount of mustard, two of them presented withabnormal muscular activity, and the third alternatedbetween coma and agitation. The first two childrendied 3 to 4 hours after exposure, possibly from neurologicalmechanisms. 23 It is unknown whether theseCNS manifestations are from a cholinergic activity ofmustard or from other mechanisms.DeathMost casualties die of pulmonary damage complicatedby infection bronchopneumonia, immunosuppression,and sepsis. When exposure is notby inhalation, the mechanism of death is less clear.In studies with animals in which mustard was administeredvia routes other than inhalational, theanimals died 3 to 7 days after the exposure; theyhad no signs of pulmonary damage and often hadno signs of sepsis. The mechanism of death was notclear, but autopsy findings resembled those seen afterradiation. 102 Mustard is considered radiomimeticbecause of the delayed onset of signs and symptomsand the accompanying immunosuppression withpotentially lethal doses.DiagnosisThe differential diagnosis of mustard casualtieson the battlefield after a known chemical attackis not difficult. The history of a chemical attack isuseful, particularly if the chemical agent is known.Simply questioning the casualty about when thepain started, whether it started immediately afterthe exposure or hours later, is very helpful. Painfrom lewisite (the other vesicant that causes blistering)begins seconds to minutes after exposure; painfrom mustard does not begin until the lesion beginsto develop hours later.Blisters appearing simultaneously in a large numberof people, in the absence of a known chemical attack,should alert medical personnel to search the area witha chemical agent detector. The appearance of one ormore blisters in an individual does not alone make a276