C Case Studies in Environmental Medicine
This appendix contains 55 case studies from peer reviewed literature, including journal articles and educational material developed by the Agency for Toxic Substances and Disease Registry (ATSDR). They were selected for their clinical interest with respect to environmental factors and health, relevance to particular courses and clerkships in medical school, and illustrative potential for teaching medical school students about the impact of the environment on health.
Four indexes are included in this appendix to help guide the reader in the use of the case studies. Index 1 lists the case studies according to agent or condition (in alphabetical order). Index 2 presents the case studies in terms of the most common medical school courses and clerkships where they might be used. Creative teachers and students, however, may find these case studies helpful in other educational settings and courses/clerkships as well. Index 3 presents the case studies in terms of sentinel pathophysiological conditions, and Index 4 presents the case studies according to common clinical signs, symptoms, and presenting complaints. Taken together, these indexes should help the reader recognize the many opportunities for enhancing knowledge, skills, and abilities in environmental medicine, and integrating an enhancement of environmental medicine in medical education.
The ATSDR case studies included in this appendix are part of a series of self-instructional publications designed to increase the primary provider’s knowledge of hazardous substances in the environment and to aid in the evaluation of potentially exposed patients. Original copies of the ATSDR cases contained in this appendix and others in the series can be obtained from: Continuing Education Coordinator, ATSDR, Division of Health Education (E33), 1600 Clifton Road, N.E., Atlanta, GA 30333.
INDEX 1: Case Studies Related to Chemical Agents and Conditions
Agent |
Case Study Title |
Case Study No. |
Arsenic |
Arsenic Toxicity |
1 |
|
Seasonal Arsenic Exposure from Burning Chromium-Copper-Arsenate-Treated Wood |
2 |
Asbestos |
Asbestos Toxicity |
3 |
Benzene |
Benzene Toxicity |
4 |
Beryllium |
Beryllium Toxicity |
5 |
Cadmium |
Cadmium Toxicity |
6 |
Carbon Monoxide |
Fetal Death Due to Nonlethal Maternal Carbon Monoxide Poisoning |
7 |
Carbon Tetrachloride |
Carbon Tetrachloride Toxicity |
8 |
Chlordane |
Chlordane Toxicity |
9 |
Chlorine Gas |
Chronic Reactive Airway Disease Following Acute Chlorine Gas Exposure in an Asymptomatic Atopic Patient |
10 |
Chromium |
Chromium Toxicity |
11 |
Cyanide |
Cyanide Toxicity |
12 |
Dioxin |
Dioxin Toxicity |
13 |
Ethylene/Propylene Glycol |
Ethylene/Propylene Glycol Toxicity |
14 |
Formalin |
Formalin Asthma in Hospital Staff |
15 |
Gasoline |
Gasoline Toxicity |
16 |
Hantavirus |
Hantavirus Pulmonary Syndrome: A Clinical Description of 17 Patients with a Newly Recognized Disease |
17 |
Lead |
Lead Poisoning from Mobilization of Bone Stores During Thyrotoxicosis |
18 |
|
Lead Toxicity |
19 |
Legionella |
Legionnaires’ Disease: Description of an Epidemic of Pneumonia |
20 |
Agent |
Case Study Title |
Case Study No. |
Mercury |
Mercury in House Paint as a Cause of Acrodynia: Effect of Therapy with N-Acetyl-D, L-Penicillamine |
21 |
|
Mercury Toxicity |
22 |
Methanol |
Methanol Toxicity |
23 |
Methylene Chloride |
Methylene Chloride Toxicity |
24 |
|
Paint Remover Hazard |
25 |
Nitrates/Nitrites |
Fatal Outcome of Methemoglobinemia in an Infant |
26 |
|
Nitrate/Nitrite Toxicity |
27 |
Nitrogen Dioxide |
An Outbreak of Nitrogen Dioxide-Induced Respiratory Illness Among Ice Hockey Players |
28 |
Pentachlorophenol |
Pentachlorophenol Toxicity |
29 |
Pesticides |
Aldicarb Poisoning: A Case Report with Prolonged Cholinesterase Inhibition and Improvement After Pralidoxime Therapy |
30 |
|
Cholinesterase-Inhibiting Pesticide Toxicity |
31 |
|
Infertility in Male Pesticide Workers |
32 |
|
Pesticide Food Poisoning from Contaminated Watermelons in California, 1985 |
33 |
|
Poisoning of an Urban Family Due to Misapplication of Household Organophosphate and Carbamate Pesticides |
34 |
Polynuclear Aromatic Hydrocarbon (PAH) |
Polynuclear Aromatic Hydrocarbon (PAH) Toxicity |
35 |
Polychlorinated Biphenyl (PCB) |
Polychlorinated Biphenyl (PCB) Toxicity |
36 |
Radiation |
Ionizing Radiation |
37 |
Agent |
Case Study Title |
Case Study No. |
Radon |
Radon Toxicity |
38 |
Radon |
Residential Radon Exposure and Lung Cancer in Sweden |
39 |
Soybean Dust |
Community Outbreaks of Asthma Associated with Inhalation of Soybean Dust |
40 |
Tetrachloroethylene |
Tetrachloroethylene Toxicity |
41 |
Toluene |
Toluene Toxicity |
42 |
Toluene Diisocyanate |
Occupational Asthma Due to Toluene Diisocyanate Among Velcro-like Tape Manufacturers |
43 |
1,1,1-Trichloroethane |
1,1,1-Trichloroethane |
44 |
Trimethyltin |
Trimethyltin Encephalopathy |
45 |
Trichloroethylene |
Trichloroethylene Toxicity |
46 |
Vinyl Chloride |
Vinyl Chloride Toxicity |
47 |
Condition |
Case Study Title |
Case Study No. |
Carpel Tunnel Syndrome |
Work-Related Disorders of the Neck and Upper Extremity |
48 |
Dermatitis |
Contact Dermatitis in Surgeons from Methylmethacrylate Bone Cement |
49 |
|
Skin Lesions and Environmental Exposures: Rash Decisions |
50 |
Hearing Loss |
Acoustic Trauma Caused by the Telephone: A Report of Two Cases |
51 |
|
Behavioral and Audiologic Manifestations of Noise-Induced Hearing Loss |
52 |
Condition |
Case Study Title |
Case Study No. |
Reproductive and Developmental Effects |
Reproductive and Developmental Hazards |
53 |
|
See also Lead, Pesticides, and Radiation |
18, 19, 32, 37 |
Respiratory Conditions |
Childhood Asthma and Indoor Environmental Risk Factors |
54 |
|
Populations at Risk From Particulate Air Pollution—United States, 1992 |
55 |
|
See also Chlorine Gas, Formalin, Hantavirus, Legionella, Soybean Dust, and Toluene Diisocyanate |
10, 15, 17, 20, 40, 43 |
INDEX 2: Selected Case Studies Related to Common Medical School Courses and Clerkships/Clinical Rotations
Selected Courses |
Selected Case Studies |
Biochemistry and Physiology |
7, 12, 18, 19, 24, 25, 26, 27, 29, 35, 36 |
Community Medicine/Public Health |
17, 20, 30, 31, 32, 33, 34, 38, 39, 40, 54, 55 |
Epidemiology and Biostatistics |
17, 20, 31, 32, 33, 38, 39, 40, 54, 55 |
Genetics |
29, 37, 38 |
Introduction to Clinical Medicine |
See Appendix A |
Microbiology |
17, 20 |
Neuroscience |
1, 2, 8, 9, 18, 19, 21, 22, 23, 24, 30, 31, 33, 34, 41, 42, 45, 48 |
Nutrition |
2, 6, 18, 33 |
Pathology |
3, 4, 8, 37, 38 |
Pharmacology |
4, 7, 8, 12, 16, 18, 19, 26, 27, 28, 30, 31, 33, 34 |
Selected Clerkships/Clinical Rotations |
Selected Case Studies |
Cardiovascular Medicine |
7, 12, 19, 23, 24, 25, 26, 27, 29, 30, 31, 33, 34 |
Dermatology |
1, 2, 11, 13, 21, 22, 29, 36, 49, 50 |
Emergency Medicine |
2, 7, 10, 12, 30, 31, 33, 34 |
Endocrinology |
18, 32 |
Family Medicine |
1, 2, 3, 4, 5, 8, 11, 13, 14, 15, 17, 18, 19, 20, 21, 22, 24, 26, 27, 28, 30, 31, 32, 33, 34, 42, 43, 48, 54 |
Gastrointestinal Disease |
8, 11, 18, 27, 30, 31, 33, 34, 36, 47 |
Hematology/Oncology |
3, 4, 11, 13, 18, 19, 26, 35, 37, 38, 39, 46, 47 |
Infectious Disease |
17, 20 |
Internal Medicinea |
1, 2, 4, 8, 11, 14, 15, 17, 18, 20, 24, 30, 31, 32, 33, 34, 42, 43, 48 |
Selected Clerkships/Clinical Rotations |
Selected Case Studies |
Nephrology |
1, 2, 6, 8, 14, 18, 19, 21, 22, 23 |
Neurology |
1, 2, 8, 9, 18, 19, 21, 22, 23, 24, 30, 31, 33, 34, 41, 42, 45, 48 |
Obstetrics-Gynecologya |
7, 9, 18, 19, 30, 31, 33, 34, 37, 44, 53 |
Orthopedics |
6, 48 |
Otolaryngology |
11, 19, 40, 51, 52, 54 |
2, 3, 5, 13, 14, 17, 18, 19, 21, 22, 26, 27, 28, 34, 54 |
|
Pulmonary Medicinec |
3, 5, 10, 11, 12, 14, 15, 17, 20, 26, 27, 28, 30, 31, 33, 34, 40, 42, 43, 54, 55 |
Psychiatrya |
8, 21, 22, 41, 42, 45, 46 |
Radiology |
3, 5, 11, 35, 38, 39 |
aRequired clerkships/clinical rotations in all U.S. medical schools. bAdditional information on curriculum content in pediatrics can be found in the Children’s Environmental Health Network manual entitled Kids and the Environment: Toxic Hazards—A Course on Pediatric Environmental Health. For more information, contact the California Public Health Foundation, Rod Armstrong, The Children’s Environmental Health Network, 5900 Hollis Street, Suite E, Emeryville, CA 94608, Telephone (510) 540–3657, Fax (510) 540–2673. cAdditional information on curriculum development in pulmonology can be found in the reports: Preventive Pulmonary Academic Award Program. 1993. Guidelines for Curriculum Development for Undergraduate Medical Education in the Prevention of Pulmonary Diseases. Bethesda, MD: Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, November. Preventive Pulmonary Academic Award Program. 1994. Knowledge Bases and Sample Curricula. Bethesda, MD: Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, March. |
INDEX 3: Selected Case Studies Related to Sentinel Pathophysiological Conditions for Environmental/Occupational Evaluation
Sentinel Pathophysiological Conditions |
Agent or Exposure Discussed |
Selected Case Studies |
|
CARDIOVASCULAR |
Bradycardia |
Pesticide |
30, 33 |
Chest Pain |
Methylene Chloride |
24, 25 |
|
DERMATOLOGIC |
Acne |
Dioxin |
13 |
Acne |
Polychlorinated Biphenyl (PCB) |
36 |
|
Acrodynia |
Mercury |
22 |
|
Contact Dermatitis |
Chromium |
11 |
|
Contact Dermatitis |
Methylmethacrylate |
49 |
|
Hyperkeratosis |
Arsenic |
1, 2 |
|
ENDOCRINOLOGIC |
Thyrotoxicosis |
Lead |
18 |
GASTROINTESTINAL |
Abdominal Pain |
Lead |
18 |
Abdominal Pain, Nausea, and Vomiting |
Carbon Tetrachloride |
8 |
|
Diarrhea |
Nitrates |
27 |
|
Diarrhea |
Pesticides |
30, 31, 33, 34 |
|
Vomiting |
Pesticides |
30, 31, 33, 34 |
|
HEMATOLOGIC/ ONCOLOGIC |
Hypochronic Anemia |
Lead |
19 |
Leukemia |
Benzene |
4 |
|
Liver Cancer |
Vinyl Chloride |
47 |
|
Lung Cancer |
Asbestos |
3 |
|
Lung Cancer |
Polynuclear Aromatic Hydrocarbon (PAH) |
35 |
|
Lung Cancer |
Radon |
39 |
Sentinel Pathophysiological Conditions |
Agent or Exposure Discussed |
Selected Case Studies |
|
HEMATOLOGIC/ ONCOLOGIC |
Methemoglobinemia |
Nitrate |
26 |
HEPATIC |
Cancer |
Vinyl Chloride |
47 |
Hepatitis |
Carbon Tetrachloride |
8 |
|
Hepatitis |
Polychlorinated Biphenyl (PCB) |
36 |
|
INFECTIOUS |
Respiratory |
Hantavirus |
17 |
Respiratory |
Legionella |
20 |
|
NEUROLOGIC |
Ataxia |
Mercury |
21 |
Carpel Tunnel Syndrome (CTS) |
Repetitive Motion |
48 |
|
Dysarthria |
Mercury |
21 |
|
Encephalopathy |
Trimethyltin |
45 |
|
Headache |
Carbon Tetrachloride |
8 |
|
Headache |
Methanol |
23 |
|
Headache |
Methylene Chloride |
24 |
|
Headache |
Tetrachloroethylene |
41 |
|
Headache |
Toluene |
42 |
|
Hearing Loss |
Lead |
19 |
|
Hyperactive |
Lead |
19 |
|
Peripheral Neuropathy |
Arsenic |
1, 2 |
|
Tremor |
Mercury |
21 |
Sentinel Pathophysiological Conditions |
Agent or Exposure Discussed |
Selected Case Studies |
|
OBSTETRIC/GYNECOLOGIC |
Miscarriage and Fetal Death |
Carbon Monoxide |
7 |
ORTHOPEDIC |
Carpel Tunnel Syndrome (CTS) |
Repetitive Motion |
48 |
Osteomalacia Syndrome (CTS) |
Cadmium |
6 |
|
RENAL |
Acute Renal Failure |
Carbon Tetrachloride |
8 |
Acute Renal Failure |
Ethylene/Propylene Glycol |
14 |
|
Acute Renal Failure |
Methanol |
23 |
|
Chronic Renal Failure |
Cadmium |
6 |
|
Chronic Renal Failure |
Mercury |
21, 22 |
|
Chronic Renal Failure |
Lead |
18, 19 |
|
REPRODUCTIVE AND DEVELOPMENTAL |
Birth Defects |
Various |
53 |
Birth Defects |
Mercury |
22 |
|
Birth Defects |
Radiation |
37 |
|
Developmental Defects |
Polychlorinated Biphenyl (PCB) |
36 |
|
Developmental Defects |
Lead |
18, 19 |
|
Infertility |
1,2-Dibromo-3-Chloropropane (DBCP) |
32 |
|
RESPIRATORY |
Asthma |
Formalin |
15 |
Asthma |
Indoor Environment |
54 |
Sentinel Pathophysiological Conditions |
Agent or Exposure Discussed |
Selected Case Studies |
|
RESPIRATORY |
Chronic Upper Airway |
Chromium |
11 |
Cyanosis |
Nitrate |
27 |
|
Interstitial Fibrosis |
Beryllium |
5 |
|
Irritation Symptoms |
Chromium |
11 |
|
SOURCE: Kipen, HM and Craner, J. 1992. Sentinel pathophysiologic conditions: An adjunct to teaching occupational and environmental disease recognition and history-taking. Environmental Research 59:93–100. |
INDEX 4: Selected Case Studies Related to Clinical Signs, Symptoms, and Presenting Complaints
Clinical Signs, Symptoms, and Presenting Complaints |
Agent or Exposure Discussed |
Selected Case Studies |
ABDOMINAL PAIN |
Carbon Tetrachloride |
8 |
Lead |
18, 19 |
|
Pesticides |
30, 31, 33, 34 |
|
ABORTIONS, SPONTANEOUS |
Chlordane |
9 |
1,1,1-Trichloroethane |
44 |
|
Various |
53 |
|
ACNE |
Polychlorinated Biphenyl (PCB) |
36 |
ALOPECIA |
Arsenic |
2 |
ALTERED MENTAL STATUS WITH UNCONSCIOUSNESS |
Arsenic |
2 |
Carbon Monoxide |
7 |
|
Cyanide |
12 |
|
Pesticides |
30, 31, 33, 34 |
|
ANOREXIA |
Chlordane |
9 |
Chromium |
11 |
|
Pentachlorophenol |
29 |
|
Vinyl Chloride |
47 |
|
ATAXIA |
Mercury |
21 |
Methanol |
23 |
|
BIRTH DEFECTS |
Reproductive and Developmental Hazards |
53 |
1,1,1-Trichloroethane |
44 |
|
BRADYCARDIA |
Pesticides |
30, 31, 33, 34 |
CHEST PAIN |
Asbestos |
3 |
Clinical Signs, Symptoms, and Presenting Conditions |
Agent or Exposure Discussed |
Selected Case Studies |
CHEST PAIN |
Methylene Chloride |
24, 25 |
Nitrogen Dioxide |
28 |
|
Toluene Diisocyanate (TDI) |
43 |
|
CONFUSION |
Carbon Tetrachloride |
8 |
Gasoline |
16 |
|
Lead |
18, 19 |
|
Methylene Chloride |
24 |
|
Pesticides |
30, 31, 33, 34 |
|
COUGH |
Beryllium |
5 |
Hantavirus |
17 |
|
Indoor Environment |
54 |
|
Legionella |
20 |
|
Nitrogen Dioxide |
28 |
|
Radon |
39 |
|
Toluene |
42 |
|
CYANOSIS |
Nitrates |
27 |
DELIRIUM |
Arsenic |
1, 2 |
Chromium |
11 |
|
Dioxin |
13 |
|
Gasoline |
16 |
|
Mercury |
21, 22 |
|
Methylmethacrylate |
49 |
|
Trimethyltin |
45 |
|
DIFFICULTY CONCENTRATING |
Lead |
18 |
Tetrachloroethylene (TCE) |
41 |
Clinical Signs, Symptoms, and Presenting Conditions |
Agent or Exposure Discussed |
Selected Case Studies |
DIAPHORESIS |
Mercury |
21, 22 |
Pentachlorophenol |
29 |
|
Pesticides |
30, 31, 33, 34 |
|
DIARRHEA |
Carbon Tetrachloride |
8 |
Hantavirus |
17 |
|
Nitrates |
26, 27 |
|
Pesticides |
30, 31, 33, 34 |
|
DYSARTHRIA |
Mercury |
21 |
DYSPNEA |
Asbestos |
3 |
Beryllium |
5 |
|
Hantavirus |
17 |
|
Indoor Environment |
54 |
|
Nitrogen Dioxide |
28 |
|
Pentachlorophenol |
29 |
|
Pesticides |
30, 31, 33, 34 |
|
Polynuclear Aromatic Hydrocarbon (PAH) |
35 |
|
Toluene |
42 |
|
Toluene Diisocyanate (TDI) |
43 |
|
EPISTAXIS, ECCHYMOSES, and PETECHIA |
Arsenic |
2 |
Benzene |
4 |
|
Chromium |
11 |
|
FATIGUE |
Arsenic |
2 |
Benzene |
4 |
|
Lead |
18 |
|
Methylene Chloride |
24 |
Clinical Signs, Symptoms, and Presenting Conditions |
Agent or Exposure Discussed |
Selected Case Studies |
FATIGUE |
Pesticides |
30, 31, 33, 34 |
Vinyl Chloride |
47 |
|
FEVER |
Hantavirus |
17 |
Legionella |
20 |
|
Pentachlorophenol |
29 |
|
HEADACHE |
Arsenic |
2 |
Carbon Tetrachloride |
8 |
|
Chlordane |
9 |
|
Gasoline |
16 |
|
Methanol |
23 |
|
Methylene Chloride |
24 |
|
Nitrogen Dioxide |
28 |
|
Pesticides |
30, 31, 33, 34 |
|
Tetrachloroethylene (TCE) |
41 |
|
Toluene |
42 |
|
HEARING LOSS |
Lead |
19 |
Occupational Noise |
51, 52 |
|
HEMOPTYSIS |
Nitrogen Dioxide |
28 |
HEPATITIS |
Carbon Tetrachloride |
8 |
Chromium |
11 |
|
Polychlorinated Biphenyl (PCB) |
36 |
|
HEPATOMEGALY |
Vinyl Chloride |
47 |
HYPERTENSION |
Lead |
19 |
HYPOTENSION |
Cyanide |
12 |
Clinical Signs, Symptoms, and Presenting Complaints |
Agent or Exposure Discussed |
Selected Case Studies |
HYPOTENSION |
Pesticides |
30, 31, 33, 34 |
INCONTINENCE |
Pesticides |
30, 31, 33, 34 |
INFERTILITY |
1,2-Dibromo-3-Chloropropane (DBCP) |
32 |
Various |
53 |
|
IRRITABILITY |
Gasoline |
16 |
Mercury |
22 |
|
Methylene Chloride |
24 |
|
Nitrates |
26, 27 |
|
Tetrachloroethylene (TCE) |
41 |
|
LACRIMATION |
Pesticides |
30, 31, 33, 34 |
LOW BACK PAIN |
Cadmium |
6 |
MUSCLE TWITCHING |
Arsenic |
2 |
Pesticides |
30, 31, 33, 34 |
|
MYALGIA |
Cadmium |
6 |
Lead |
18 |
|
NASAL IRRITATION WITH RHINORRHEA |
Chromium |
11 |
NAUSEA |
Carbon Tetrachloride |
8 |
Chlordane |
9 |
|
Methanol |
23 |
|
Pesticides |
30, 31, 33, 34 |
|
PERIPHERAL NEUROPATHY |
Arsenic |
1, 2 |
Repetitive Motion |
48 |
|
PROTEINURIA |
Cadmium |
6 |
Carbon Tetrachloride |
8 |
|
Chromium |
11 |
Clinical Signs, Symptoms, and Presenting Complaints |
Agent or Exposure Discussed |
Selected Case Studies |
RALES |
Asbestos |
3 |
Pesticides |
30, 31, 33, 34 |
|
RASH |
Arsenic |
1, 2 |
Chromium |
11 |
|
Dioxin |
13 |
|
Environmental Exposures (i.e., allergens, irritants) |
50 |
|
Mercury |
21, 22 |
|
Methylmethacrylate |
49 |
|
Pentachlorophenol |
29 |
|
Polychlorinated Biphenyl (PCB) |
36 |
|
SEIZURES |
Arsenic |
2 |
Pesticides |
30, 31, 33, 34 |
|
Trimethyltin |
45 |
|
TACHYCARDIA |
Cyanide |
12 |
Hantavirus |
17 |
|
Methanol |
23 |
|
Methylene Chloride |
24 |
|
Nitrates |
26, 27 |
|
Pentachlorophenol |
29 |
|
TACHYPNEA |
Cyanide |
12 |
Ethylene/Propylene Glycol |
14 |
|
Hantavirus |
17 |
|
Nitrates |
26, 27 |
Clinical Signs, Symptoms, and Presenting Complaints |
Agent or Exposure Discussed |
Selected Case Studies |
TACHYPNEA |
Pentachlorophenol |
29 |
TINNITUS |
Methanol |
23 |
VISUAL DISTURBANCE |
Methanol |
23 |
VOMITING |
Carbon Tetrachloride |
8 |
Ethylene/Propylene Glycol |
14 |
|
Hantavirus |
17 |
|
Nitrates |
26, 27 |
|
Pesticides |
30, 31, 33, 34 |
|
WEAKNESS |
Pesticides |
30, 31, 33, 34 |
Polynuclear Aromatic Hydrocarbon (PAH) |
35 |
|
Repetitive Motion |
48 |
|
WEIGHT LOSS |
Benzene |
4 |
Chromium |
11 |
|
Pentachlorophenol |
29 |
|
Polynuclear Aromatic Hydrocarbon (PAH) |
35 |
|
Radon |
38, 39 |
|
Vinyl Chloride |
47 |
|
WHEEZING |
Formalin |
15 |
Indoor Environment |
54 |
|
Pesticides |
30, 31, 33, 34 |
|
Soybean Dust |
40 |
|
Toluene Diisocyanate (TDI) |
43 |