# Presentation: 264499

## 1-BromopropaneA Private Neurological Practice Experience in 2000

- J. Keith Miller, MD, FAAN
- Johnson Neurological Clinic
- High Point, NC

## Case Reports

- NC cushion company begins using
- 	1-BP in July, 1999
- 3 F workers, ages 35, 30 & 50 years
- sprayed 1-BP with solvent gun
- Wore thin latex gloves, no respirators
- Glue splattered on face
- Ventilation 15 mins Q hour summer, 2000
- Patient 3 worked with no ventilation

- Ichihara G. J Occup Health 2002;44:1-7

## 1-Bromopropane Glue

- MSDS
- 55% - 1-BP
- 8% Ethyl acetate
- 2% Aliphatic petroleum distillates

- Ichihara G. J Occup Health 2002;44:1-7

## Patient 1 6/30/2000

- 35 yo white female
- CC:  Weak, tingling, numb burning from waist down, some pain in lower back and difficulty swallowing. PMHx:  asthma, bronchitis, “Arthritis”
- PSHx:  Tonsillectomy, bunionectomy, cholecystectomy, tubal ligation
- Smoke:  1 ppd
- EtOH:  none

## Patient 1 (continued)

- Current meds on presentation:
- Etodolac, Cetirizine, Nasonex® (mometasone furoate), sulfamethoxazole
- 2 children
- Family Hx:  DM, Heart disease, migraines
- Allergies to PCN and codeine

## Patient 1 (continued)

- HPI:  3 weeks of tingling, numbness and burning sensations primarily in thighs (anterior, worse with touch), but also present in legs (posterior).  Lower extremities ache.  Feeling of something stuck in her throat as well.
- 1 wk prior to initial visit felt dizzy and appeared to stagger.  Antibiotic Rx by PCP.  No improvement
- Over last week worsening with pain in feet
- Fell at home night before evaluation

## Case 1

- April to June 2000
- Sore throat
- Earache
- Sinus irritation
- Hoarseness
- Urinary incontinence
- Headaches

- Ichihara G. J Occup Health 2002;44:1-7

## Patient 1 (continued)

- No Lhermitte’s phenomenon
- No difficulty with bowel or bladder sensation or control
- No diplopia, loss of vision, no difficulty with chewing or speech
- No weakness in extremities
- Romberg negative
- Plantar reflexes, DTRs, cerebellar tests normal

## Patient 1 Exam (continued)

- Normal except
- Left pupil slightly larger than right
- Sensory level at T6 bilaterally to pin prick but not to vibration
- Unsteady, wide spread gait with patient needing to hold onto the wall

- Patient was felt to have a possible myelopathy related to transverse myelitis or multiple sclerosis

## Testing completed

- MRI Head – WNL
- MRI T spine – WNL
- MRI C spine – WNL
- ESR – WNL
- ANA – WNL

## 7/3/2000

- Four days after initial evaluation patient was feeling improved BUT exam was still demonstrating dystaxia but less than prior exam.  Patient also noted numbness in her perineum.

- Further testing done
- B12 442 (WNL)
- RPR negative
- Lyme disease negative
- CSF studies negative for MS or inflammation
- EMG-NCS of LE and UE were normal
- Urinary metals negative for Pb & Hg
- As 48.3 mcg/L, 150.9 mcg/g creatinine

## 7/19/2000

- After worsening following the LP, a 12 day course of prednisone was given with improvement in dystaxia symptoms
- Patient noted that a coworker was in the office getting ready to see the examiner for her initial exam
- Patient noted that work had recently switched the glue that they were working with

- Patient noted that one of the chemicals that she was exposed to was 1-Bromopropane 55%, a component of Whisper Spray per the Material Safety Data Sheet
- Patient was referred to Occupational Medicine for further evaluation for possible environmental or toxic exposure at work.  The patient was lost to follow-up.

## Patient 2 7/11/2000

- 30 yo Hispanic female
- CC:  numbness in both lower extremities
- Worked with glue Feb.-June, 2000
- June 30, 2000 developed staggering gait
- ~ 5 kg weight loss in preceding 5 days
- PMHx:  none       PSHx:  C-section

## Patient 2 (continued)

- NKA
- Smoke:  1 pack per week   EtOH:  none
- Medications:  none
- Family Hx:  DM and heart disease

## Patient 2 - HPI

- Complained of  numbness in her lower extremities.
- RPR and ESR by PMD were normal.
- Noted difficulty feeling if she needed to defecate or void.  She would only have a vague pressure sensation in  her abdomen.

## Patient 2 (continued)

- Lack of sensation with intercourse and numbness in the perineum
- Initial numbness in her hands had resolved by time of visit
- Some vague low back pain
- Slight slurring of speech
- Lower extremities “feel tired”

## Patient 2 (continued)

- No Lhermitte’s phenomenon
- No diplopia
- No difficulty swallowing  or chewing
- No headaches

**Notes:**
Flexing of the neck produces electric shock-like sensations that extend down the spine and shoot into the limbs. Caused by trauma to the cervical portion of the spinal cord, multiple sclerosis, cervical cord tumour, cervical spondylosis, or even vitamin B12 deficiency. 

## Patient 2 Exam

- Normal except
- Peripheral diminution to vibration and pinprick sensation, but no sensory level noted

## Patient 2 (continued)

- Initial diagnosis of lower extremity numbness and  speech difficulties included a  parasagital lesion or multiple sclerosis.

## Patient 2 Testing

- MRI Head – WNL
- MRI C Spine – WNL
- MRI T Spine – WNL
- Thyroid studies – WNL
- CK – WNL
- SPEP - WNL

## 7/19/2000

- Fellow worker (patient 1) and patient 2 see each other in the office.
- Patient 2 symptoms are less, but not resolved.
- No evidence on repeat exam of a polyneuropathy

## Patient 2

- August, 2000
- Some symptom improvement
- Still having paresthesias lower extremities
- No focal motor weakness
- Dysphagia

## Patient 2

- August, 2000
- Alternating hot-cold sensations in feet
- Repeated diarrhea, nausea & vomiting
- Bifrontal headache & low back pain
- Exam “normal”

## 10/5/2000

- No improvement or worsening noted in prior symptoms
- Complaining of bifrontal headache and low back pain.
- Normal exam

## 10/27/2000

- No change in symptoms from initial consultation
- Did not got to PT for low back pain
- Forgetting where she is driving
- Appears to be depressed

## 11/17/2000

- No change in symptoms
- Patient referred for neuromuscular consultation at a major university at patient’s request and then she was lost to follow-up

## Patient 3

- Evaluated by another physician
- 50 yo female
- CC:  weight loss and staggering gait, numbness in feet and pain in wrists, elbows and shoulders
- HPI:  symptoms noted 2 months after starting job using Whisper Spray.  They would appear each week and abated some over the July 4th holiday weekend.  Some difficulty with speaking

## Patient 3

- Also c/o URI type symptoms
- Headaches
- C/o decreased ability to concentrate

## Patient 3 Exam

- Normal except:
- Peripheral diminution to pinprick and vibration to level of the thighs bilaterally as well as in the lower back
- Could not maintain a standing position with knees bent

- Patient 1 contacted Gaku Ichihara,MD, PhD via the internet about his experience with 1-Bromopropane.  Dr. Ichihara subsequently interviewed this and the other patients involved and their experiences were reported in the _Journal of Occupational Health_ 2002;44:  1-7

## Ichihara – Case 3

- Exposure to 1-BP measured via passive sampler
- Oct 23-26, 8 hours per day
- Oct 30-31, 8 hours per day
- Daily TWA (n=11)
- 133 +/- 67 ppm
- Range 60 to 261 ppm

## Ichihara

- 3 workers interviewed using Nagoya Univ. organic solvent intoxication form
- Staggering, weakness in legs
- Paresthesias and numbness in similar distributions in hips, lower back & LE
- “Panty-hose” distribution

- Ichihara G. J Occup Health 2002;44:1-7

## Ichihara

- CNS symptoms
- Headache, dizziness, nausea
- Insomnia, anxiety, apathy, memory and concentration difficulties

- Ichihara G. J Occup Health 2002;44:1-7

## Three Cases

- Signs and symptoms developed at approximately same time
- Summer months were busiest
- Case 3 progression of symptoms while still working strongly suggested solvent intoxication

- Ichihara G. J Occup Health 2002;44:1-7