TOXICOLOGICAL PROFILE FOR 

SULFUR MUSTARD 

(UPDATE)
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Agency for Toxic Substances and Disease Registry
 

September 2003 
SULFUR MUSTARD ii 

DISCLAIMER 

The use of company or product name(s) is for identification only and does not imply endorsement by the 

Agency for Toxic Substances and Disease Registry. 
SULFUR MUSTARD iii 

UPDATE STATEMENT 

A Toxicological Profile for Sulfur Mustard (previously Mustard Gas), Draft for Public Comment was released 

in September 2001. This edition supersedes any previously released draft or final profile. 

Toxicological profiles are revised and republished as necessary. For information regarding the update 

status of previously released profiles, contact ATSDR at: 

Agency for Toxic Substances and Disease Registry
 

Division of Toxicology/Toxicology Information Branch 

1600 Clifton Road NE, Mailstop E-29 

Atlanta, GA 30333 



 

 

SULFUR MUSTARD vii 

QUICK REFERENCE FOR HEALTH CARE PROVIDERS 

Toxicological Profiles are a unique compilation of toxicological information on a given hazardous 

substance. Each profile reflects a comprehensive and extensive evaluation, summary, and interpretation of 

available toxicologic and epidemiologic information on a substance. Health care providers treating 

patients potentially exposed to hazardous substances will find the following information helpful for fast 

answers to often-asked questions. 

Primary Chapters/Sections of Interest 

Chapter 1: Public Health Statement: The Public Health Statement can be a useful tool for educating 

patients about possible exposure to a hazardous substance. It explains a substance’s relevant 

toxicologic properties in a nontechnical, question-and-answer format, and it includes a review of 

the general health effects observed following exposure. 

Chapter 2: Relevance to Public Health: The Relevance to Public Health Section evaluates, interprets, 

and assesses the significance of toxicity data to human health. 

Chapter 3: Health Effects: Specific health effects of a given hazardous compound are reported by type 

of health effect (death, systemic, immunologic, reproductive), by route of exposure, and by length 

of exposure (acute, intermediate, and chronic). In addition, both human and animal studies are 

reported in this section. 

NOTE: Not all health effects reported in this section are necessarily observed in the clinical 

setting. Please refer to the Public Health Statement to identify general health effects observed 

following exposure. 

Pediatrics: Four new sections have been added to each Toxicological Profile to address child health 

issues: 

Section 1.6 How Can (Chemical X) Affect Children? 

Section 1.7 How Can Families Reduce the Risk of Exposure to (Chemical X)? 

Section 3.7 Children’s Susceptibility 

Section 6.6 Exposures of Children 

Other Sections of Interest: 

Section 3.8 Biomarkers of Exposure and Effect 

Section 3.11 Methods for Reducing Toxic Effects 

ATSDR Information Center 

Phone: 1-888-42-ATSDR or (404) 498-0110 Fax: (404) 498-0093 

E-mail: atsdric@cdc.gov Internet: http://www.atsdr.cdc.gov 

The following additional material can be ordered through the ATSDR Information Center: 

Case Studies in Environmental Medicine: Taking an Exposure History—The importance of taking an 

exposure history and how to conduct one are described, and an example of a thorough exposure 

history is provided. Other case studies of interest include Reproductive and Developmental 
 

SULFUR MUSTARD viii 

Hazards; Skin Lesions and Environmental Exposures; Cholinesterase-Inhibiting Pesticide 

Toxicity; and numerous chemical-specific case studies. 

Managing Hazardous Materials Incidents is a three-volume set of recommendations for on-scene 

(prehospital) and hospital medical management of patients exposed during a hazardous materials 

incident. Volumes I and II are planning guides to assist first responders and hospital emergency 

department personnel in planning for incidents that involve hazardous materials. Volume III— 

Medical Management Guidelines for Acute Chemical Exposures—is a guide for health care 

professionals treating patients exposed to hazardous materials. 

Fact Sheets (ToxFAQs) provide answers to frequently asked questions about toxic substances. 

Other Agencies and Organizations 

The National Center for Environmental Health (NCEH) focuses on preventing or controlling disease, 

injury, and disability related to the interactions between people and their environment outside the 

workplace. Contact: NCEH, Mailstop F-29, 4770 Buford Highway, NE, Atlanta, GA 

30341-3724 • Phone: 770-488-7000 • FAX: 770-488-7015. 

The National Institute for Occupational Safety and Health (NIOSH) conducts research on occupational 

diseases and injuries, responds to requests for assistance by investigating problems of health and 

safety in the workplace, recommends standards to the Occupational Safety and Health 

Administration (OSHA) and the Mine Safety and Health Administration (MSHA), and trains 

professionals in occupational safety and health. Contact: NIOSH, 200 Independence Avenue, 

SW, Washington, DC 20201 • Phone: 800-356-4674 or NIOSH Technical Information Branch, 

Robert A. Taft Laboratory, Mailstop C-19, 4676 Columbia Parkway, Cincinnati, OH 45226-1998 

• Phone: 800-35-NIOSH. 

The National Institute of Environmental Health Sciences (NIEHS) is the principal federal agency for 

biomedical research on the effects of chemical, physical, and biologic environmental agents on 

human health and well-being. Contact: NIEHS, PO Box 12233, 104 T.W. Alexander Drive, 

Research Triangle Park, NC 27709 • Phone: 919-541-3212. 

Referrals 

The Association of Occupational and Environmental Clinics (AOEC) has developed a network of clinics 

in the United States to provide expertise in occupational and environmental issues. Contact: 

AOEC, 1010 Vermont Avenue, NW, #513, Washington, DC 20005 • Phone: 202-347-4976 • 

FAX: 202-347-4950 • e-mail: AOEC@AOEC.ORG • Web Page: http://www.aoec.org/. 

The American College of Occupational and Environmental Medicine (ACOEM) is an association of 

physicians and other health care providers specializing in the field of occupational and 

environmental medicine. Contact: ACOEM, 55 West Seegers Road, Arlington Heights, IL 

60005 • Phone: 847-818-1800 • FAX: 847-818-9266. 
SULFUR MUSTARD ix 

CONTRIBUTORS 

CHEMICAL MANAGER(S)/AUTHOR(S): 

Zemoria A. Rosemond, B.A. 

ATSDR, Division of Toxicology, Atlanta, GA 

Dolores A. Beblo, Ph.D. 

Syracuse Research Corporation, North Syracuse, NY 

Richard Amata, Ph.D. 

Syracuse Research Corporation, North Syracuse, NY 

THE PROFILE HAS UNDERGONE THE FOLLOWING ATSDR INTERNAL REVIEWS: 

1. Health Effects Review. The Health Effects Review Committee examines the health effects 

chapter of each profile for consistency and accuracy in interpreting health effects and classifying 

end points. 

2.	 Minimal Risk Level Review. The Minimal Risk Level Workgroup considers issues relevant to 

substance-specific minimal risk levels (MRLs), reviews the health effects database of each 

profile, and makes recommendations for derivation of MRLs. 

3. Data Needs Review. The Research Implementation Branch reviews data needs sections to assure 

consistency across profiles and adherence to instructions in the Guidance. 

SULFUR MUSTARD xi 

PEER REVIEW 

A peer review panel was assembled for sulfur mustard. The panel consisted of the following members: 

1.	 Dr. Vincent Garry, M.D. D.A.B.T., Director, Laboratory of Environmental Medicine and 

Pathology, University of Minnesota Medical School, Minneapolis, Minnesota; 

2. Dr. Shane Que Hee, Ph.D., Professor, Center for Occupational and Environmental Health, UCLA 

School of Public Health, Los Angeles, California; and 

3. Dr. James Withey, Ph.D., Retired Senior Research Scientist, Environmental Health Science 

Center, Ontario, Canada, Ottawa, Ontario. 

These experts collectively have knowledge of sulfur mustard's physical and chemical properties, 

toxicokinetics, key health end points, mechanisms of action, human and animal exposure, and 

quantification of risk to humans. All reviewers were selected in conformity with the conditions for peer 

review specified in Section 104(I)(13) of the Comprehensive Environmental Response, Compensation, 

and Liability Act, as amended. 

Scientists from the Agency for Toxic Substances and Disease Registry (ATSDR) have reviewed the peer 

reviewers' comments and determined which comments will be included in the profile. A listing of the 

peer reviewers' comments not incorporated in the profile, with a brief explanation of the rationale for their 

exclusion, exists as part of the administrative record for this compound. A list of databases reviewed and 

a list of unpublished documents cited are also included in the administrative record. 

The citation of the peer review panel should not be understood to imply its approval of the profile's final 

content. The responsibility for the content of this profile lies with the ATSDR. 

SULFUR MUSTARD xiii 

CONTENTS 

DISCLAIMER ..............................................................................................................................................ii
 

UPDATE STATEMENT .............................................................................................................................iii
 

FOREWORD ................................................................................................................................................v
 

QUICK REFERENCE FOR HEALTH CARE PROVIDERS....................................................................vii
 

CONTRIBUTORS.......................................................................................................................................ix
 

PEER REVIEW ...........................................................................................................................................xi
 

CONTENTS...............................................................................................................................................xiii
 

LIST OF FIGURES ..................................................................................................................................xvii
 

LIST OF TABLES.....................................................................................................................................xix
 

1. PUBLIC HEALTH STATEMENT..........................................................................................................1
 

1.1	 WHAT IS SULFUR MUSTARD? ..............................................................................................1
 

1.2	 WHAT HAPPENS TO SULFUR MUSTARD WHEN IT ENTERS THE 

 ENVIRONMENT? ......................................................................................................................2
 

1.3	 HOW MIGHT I BE EXPOSED TO SULFUR MUSTARD? .....................................................3
 

1.4	 HOW CAN SULFUR MUSTARD ENTER AND LEAVE MY BODY? ..................................3
 

1.5	 HOW CAN SULFUR MUSTARD AFFECT MY HEALTH? ...................................................4
 

1.6	 HOW CAN SULFUR MUSTARD AFFECT CHILDREN?.......................................................5
 

1.7	 HOW CAN FAMILIES REDUCE THE RISK OF EXPOSURE TO SULFUR 

MUSTARD?................................................................................................................................5
 

1.8	 IS THERE A MEDICAL TEST TO DETERMINE WHETHER I HAVE BEEN EXPOSED 

TO SULFUR MUSTARD? .........................................................................................................6
 

1.9	 WHAT RECOMMENDATIONS HAS THE FEDERAL GOVERNMENT MADE TO 

PROTECT HUMAN HEALTH?.................................................................................................6
 

1.10	 WHERE CAN I GET MORE INFORMATION? .......................................................................7
 

2. RELEVANCE TO PUBLIC HEALTH ...................................................................................................9
 

2.1	 BACKGROUND AND ENVIRONMENTAL EXPOSURES TO SULFUR MUSTARD IN 

THE UNITED STATES..............................................................................................................9
 

2.2	 SUMMARY OF HEALTH EFFECTS......................................................................................11
 

2.3	 MINIMAL RISK LEVELS .......................................................................................................15
 

3. HEALTH EFFECTS..............................................................................................................................21
 

3.1 INTRODUCTION.....................................................................................................................21
 

3.2 DISCUSSION OF HEALTH EFFECTS BY ROUTE OF EXPOSURE ..................................22
 

3.2.1 Inhalation Exposure ..............................................................................................................24
 

3.2.1.1 Death ............................................................................................................................24
 

3.2.1.2 Systemic Effects...........................................................................................................26
 

3.2.1.3 Immunological and Lymphoreticular Effects...............................................................41
 

3.2.1.4 Neurological Effects.....................................................................................................41
 

3.2.1.5 Reproductive Effects....................................................................................................42
 

3.2.1.6 Developmental Effects .................................................................................................43
 

3.2.1.7 Cancer...........................................................................................................................43
 

3.2.2 Oral Exposure........................................................................................................................47
 

3.2.2.1 Death ............................................................................................................................47
 

3.2.2.2 Systemic Effects...........................................................................................................48
 

3.2.2.3 Immunological and Lymphoreticular Effects...............................................................57
 
SULFUR MUSTARD xiv 

3.2.2.3 Neurological Effects.....................................................................................................57
 

3.2.2.4 Reproductive Effects....................................................................................................58
 

3.2.2.5 Developmental Effects .................................................................................................59
 

3.2.2.7 Cancer...........................................................................................................................60
 

3.2.3 Dermal Exposure...................................................................................................................60
 

3.2.3.1 Death ............................................................................................................................60
 

3.2.3.2 Systemic Effects...........................................................................................................60
 

3.2.3.3 Immunological and Lymphoreticular Effects...............................................................64
 

3.2.3.4 Neurological Effects.....................................................................................................65
 

3.2.3.5 Reproductive Effects....................................................................................................65
 

3.2.3.6 Developmental Effects .................................................................................................65
 

3.2.3.7 Cancer...........................................................................................................................65
 

3.2.4 Other Routes of Exposure .....................................................................................................66
 

3.3 GENOTOXICITY .....................................................................................................................67
 

3.4 TOXICOKINETICS..................................................................................................................70
 

3.4.1 Absorption.............................................................................................................................70
 

3.4.1.1 Inhalation Exposure......................................................................................................70
 

3.4.1.2 Oral Exposure...............................................................................................................71
 

3.4.1.3 Dermal Exposure ..........................................................................................................71
 

3.4.2 Distribution ...........................................................................................................................72
 

3.4.2.1 Inhalation Exposure......................................................................................................72
 

3.4.2.2 Oral Exposure...............................................................................................................72
 

3.4.2.3 Dermal Exposure ..........................................................................................................72
 

3.4.2.4 Other Routes of Exposure ............................................................................................73
 

3.4.3 Metabolism............................................................................................................................74
 

3.4.3.1 Inhalation Exposure......................................................................................................75
 

3.4.3.2 Oral Exposure...............................................................................................................75
 

3.4.3.3 Dermal Exposure ..........................................................................................................75
 

3.4.3.4 Other Routes of Exposure ............................................................................................76
 

3.4.4 Elimination and Excretion.....................................................................................................77
 

3.4.4.1 Inhalation Exposure......................................................................................................77
 

3.4.4.2 Oral Exposure...............................................................................................................77
 

3.4.4.3 Dermal Exposure ..........................................................................................................78
 

3.4.4.4 Other Routes of Exposure ............................................................................................78
 

3.4.5 Physiologically Based Pharmacokinetic (PBPK)/Pharmacodynamic (PD) Models .............79
 

3.5 MECHANISMS OF ACTION ..................................................................................................82
 

3.5.1 Pharmacokinetic Mechanisms...............................................................................................82
 

3.5.2 Mechanisms of Toxicity........................................................................................................82
 

3.5.3 Animal-to-Human Extrapolations.........................................................................................89
 

3.6 TOXICITIES MEDIATED THROUGH THE NEUROENDOCRINE AXIS ..........................91
 

3.7 CHILDREN’S SUSCEPTIBILITY...........................................................................................94
 

3.8 BIOMARKERS OF EXPOSURE AND EFFECT ....................................................................96
 

3.8.1 Biomarkers Used to Identify or Quantify Exposure to Sulfur mustard.................................97
 

3.8.2 Biomarkers Used to Characterize Effects Caused by Sulfur mustard...................................99
 

3.9 INTERACTIONS WITH OTHER CHEMICALS ..................................................................100
 

3.10 POPULATIONS THAT ARE UNUSUALLY SUSCEPTIBLE.............................................100
 

3.11 METHODS FOR REDUCING TOXIC EFFECTS.................................................................100
 

3.11.1 Reducing Peak Absorption Following Exposure ................................................................101
 

3.11.2 Reducing Body Burden .......................................................................................................102
 

3.11.3 Interfering with the Mechanism of Action for Toxic Effects..............................................105
 

3.12 ADEQUACY OF THE DATABASE......................................................................................107
 
SULFUR MUSTARD xv 

3.12.1 Existing Information on Health Effects of Sulfur Mustard.................................................109
 

3.12.2 Identification of Data Needs ...............................................................................................109
 

3.12.3 Ongoing Studies ..................................................................................................................116
 

4. CHEMICAL AND PHYSICAL INFORMATION..............................................................................119
 

4.1 CHEMICAL IDENTITY.........................................................................................................119
 

4.2 PHYSICAL AND CHEMICAL PROPERTIES......................................................................119
 

5. PRODUCTION, IMPORT/EXPORT, USE, AND DISPOSAL..........................................................125
 

5.1 PRODUCTION .......................................................................................................................125
 

5.2 IMPORT/EXPORT .................................................................................................................127
 

5.3 USE..........................................................................................................................................127
 

5.4 DISPOSAL..............................................................................................................................127
 

6. POTENTIAL FOR HUMAN EXPOSURE .........................................................................................131
 

6.1 OVERVIEW............................................................................................................................131
 

6.2 RELEASES TO THE ENVIRONMENT................................................................................131
 

6.2.1 Air .......................................................................................................................................133
 

6.2.2 Water...................................................................................................................................133
 

6.2.3 Soil ......................................................................................................................................134
 

6.3 ENVIRONMENTAL FATE....................................................................................................134
 

6.3.1 Transport and Partitioning...................................................................................................134
 

6.3.2 Transformation and Degradation ........................................................................................137
 

6.3.2.1 Air...............................................................................................................................137
 

6.3.2.2 Water ..........................................................................................................................137
 

6.3.2.3 Sediment and Soil.......................................................................................................139
 

6.3.2.4 Other Media................................................................................................................140
 

6.4 LEVELS MONITORED OR ESTIMATED IN THE ENVIRONMENT...............................140
 

6.4.1 Air .......................................................................................................................................140
 

6.4.2 Water...................................................................................................................................141
 

6.4.3 Sediment and Soil ...............................................................................................................141
 

6.4.4 Other Environmental Media................................................................................................141
 

6.5 GENERAL POPULATION AND OCCUPATIONAL EXPOSURE .....................................142
 

6.6 EXPOSURES OF CHILDREN...............................................................................................142
 

6.7 POPULATIONS WITH POTENTIALLY HIGH EXPOSURES ........................................... 143
 

6.8 ADEQUACY OF THE DATABASE......................................................................................143
 

6.8.1 Identification of Data Needs ...............................................................................................144
 

6.8.2 Ongoing Studies ..................................................................................................................146
 

7. ANALYTICAL METHODS ...............................................................................................................149
 

7.1 BIOLOGICAL MATERIALS.................................................................................................149
 

7.2 ENVIRONMENTAL SAMPLES............................................................................................152
 

7.3 ADEQUACY OF THE DATABASE......................................................................................156
 

7.3.1 Identification of Data Needs ...............................................................................................157
 

7.3.2 Ongoing Studies ..................................................................................................................158
 

8. REGULATIONS AND ADVISORIES ...............................................................................................159
 

9. REFERENCES ....................................................................................................................................167
 

10. GLOSSARY ......................................................................................................................................211
 
 

SULFUR MUSTARD xvi 

APPENDIX A. ATSDR MINIMAL RISK LEVELS AND WORKSHEETS.........................................A-1
 

APPENDIX B. USER'S GUIDE..............................................................................................................B-1
 

APPENDIX C. ACRONYMS, ABBREVIATIONS, AND SYMBOLS.................................................C-1 

APPENDIX D. ACUTE EXPOSURE GUIDELINE LEVELS (AEGLS) FOR 

 SULFUR MUSTARD.......................................................................................D-1 
SULFUR MUSTARD xvii 

LIST OF FIGURES 

3-1. Levels of Significant Exposure to Sulfur Mustard -Inhalation ...................................................... 29 

3-2. Levels of Significant Exposure to Sulfur Mustard -Oral ............................................................... 53 

3-3. Conceptual Representation of a Physiologically Based Pharmacokinetic (PBPK) Model for a 

Hypothetical Chemical Substance .................................................................................................81
 

3-4. Existing Information on Health Effects of Sulfur Mustard..........................................................110
 

5-1. Locations of Sulfur Mustard Stockpile and Non-stockpile Sites in the United States.................126
 

6-1. Frequency of NPL Sites with Sulfur Mustard Contamination.....................................................132
 

6-2. Primary Hydrolysis Pathways of Sulfur Mustard in the Environment ........................................138
 

SULFUR MUSTARD xix 

LIST OF TABLES 

3-1. Levels of Significant Exposure to Sulfur Mustard-Inhalation ....................................................... 27 

3-2. Levels of Significant Exposure to Sulfur Mustard-Oral ................................................................ 49 

3-3. Genotoxicity of Sulfur Mustard In Vitro........................................................................................69
 

3-4. Ongoing Studies on Health Effects of Sulfur Mustard ................................................................117
 

4-1. Chemical Identity of Sulfur Mustard ...........................................................................................120
 

4-2. Typical Composition of Sulfur Mustard (H) from an Old Chemical Munition...........................121
 

4-3. Typical Composition of Sulfur Mustard (HD) in 1-Ton Storage Containers (Aberdeen, 

 Maryland).....................................................................................................................................122
 

4-4. Physical and Chemical Properties of Sulfur Mustard ..................................................................123
 

5-1. Original Stockpile Quantities of Sulfur Mustard as Munitions and Bulk Agent .........................128
 

6-1. Location of Historical Dumping Areas for Sulfur Mustard (H) in Coastal Waters of the 

 United States................................................................................................................................135
 

6-2. Ongoing Studies on the Environmental Fate of Sulfur Mustard..................................................147
 

7-1. Analytical Methods for Determining Sulfur Mustard in Biological Samples..............................150
 

7-2. Analytical Methods for Determining Sulfur Mustard in Environmental Samples.......................153
 

8-1. Regulations and Guidelines Applicable to Sulfur Mustard..........................................................160
 

8-2. Acute Exposure Guideline Level (AEGL) Values for Sulfur Mustard (ppm [mg/m3

])...............164
 

8-3. U.S. Army Toxicity Values for Sulfur Mustard...........................................................................165
 
SULFUR MUSTARD xx 
SULFUR MUSTARD 1 

1. PUBLIC HEALTH STATEMENT 

This public health statement tells you about sulfur mustard and the effects of exposure. 

The Environmental Protection Agency (EPA) identifies the most serious hazardous waste sites in 

the nation. These sites make up the National Priorities List (NPL) and are the sites targeted for 

long-term federal cleanup activities. Sulfur mustard has been found in at least 3 of the 

1,636 current or former NPL sites. However, the total number of NPL sites evaluated for this 

substance is not known. As more sites are evaluated, the sites at which sulfur mustard is found 

may increase. This information is important because exposure to this substance may harm you 

and because these sites may be sources of exposure. 

When a substance is released from a large area, such as an industrial plant, or from a container, 

such as a drum or bottle, it enters the environment. This release does not always lead to 

exposure. You are exposed to a substance only when you come in contact with it. You may be 

exposed by breathing, eating, or drinking the substance, or by skin contact. 

If you are exposed to sulfur mustard, many factors determine whether you'll be harmed. These 

factors include the dose (how much), the duration (how long), and how you come in contact with 

it. You must also consider the other chemicals you're exposed to and your age, sex, diet, family 

traits, lifestyle, and state of health. 

1.1 WHAT IS SULFUR MUSTARD? 

Sulfur mustard is a thick liquid, which was made for use as a chemical weapon. Presently, the 

chemical is found at a few Army facilities in large quantities and at several locations in smaller 

quantities. It is often called by its common name, ‘mustard gas.’ However, the term ‘mustard 

gas’ can be confusing, since it is stored as a liquid and is not likely to change into a vapor 

immediately if it is released at ordinary temperatures. As a liquid, it is colorless when pure and it 

is brown when mixed with other chemicals. It is odorless when pure, but can have a slight garlic 
SULFUR MUSTARD 2 

1. PUBLIC HEALTH STATEMENT 

smell when mixed with other chemicals. It dissolves easily in fats, oils, alcohol, and gasoline. 

Sulfur mustard dissolves slowly in unstirred water, but within minutes in stirred water. When it 

does dissolve, it reacts with water and turns into different chemicals. It was used in 

chemical warfare as early as World War I and as late as the Iran-Iraq War in 1980– 

1988. It is not used in the United States, except for laboratory testing of health effects and 

antidotes. More information on the physical and chemical properties of sulfur mustard can be 

found in Chapters 4 and 5. Information about mustard agents other than sulfur mustard, such as 

nitrogen mustard, thickened mustard, and lewisite, is not included in this document. 

1.2 WHAT HAPPENS TO SULFUR MUSTARD WHEN IT ENTERS THE 

ENVIRONMENT? 

Sulfur mustard is not found naturally in the environment in any amount. If sulfur mustard is 

accidentally spilled at an Army base where it is stored, it could be released into the environment. 

Currently, all of the sulfur mustard at these Army bases is being destroyed by burning or 

neutralization. U.S. law requires that the Department of Defense destroy all sulfur mustard by 

2004. However, complete destruction of sulfur mustard may continue beyond this date. Once all 

of the sulfur mustard is destroyed, it will no longer be dangerous. If sulfur mustard is put on soil, 

it will remain there for at least a day, but may remain for several days or longer. The time it 

takes for sulfur mustard to disappear from soil depends on how hot it is outside and how strongly 

the wind is blowing. If it is hot and the wind is strong, then sulfur mustard will disappear faster. 

When sulfur mustard disappears from soil, it becomes a vapor or changes into other compounds 

if the soil is wet. If sulfur mustard is buried underground, it may not disappear for several years. 

Sulfur mustard will not move through soil to underground water. If sulfur mustard is put in 

water, it dissolves within minutes if the water is stirred, and slowly if is not. When it does 

dissolve, it reacts with water and changes to other compounds. The time necessary for a quantity 

of sulfur mustard that is dissolved in water to decrease by half is about 2 minutes at 40 °C 

(104 °F). If large amounts of sulfur mustard are spilled into water, most of the sulfur mustard 

will change to other compounds very slowly or not at all. If sulfur mustard is released into air, it 

will react with components in the air to form other compounds. The time necessary for a 

quantity of sulfur mustard in air to decrease by half is about 2 days at 25 °C (77 °F). Because 
SULFUR MUSTARD 3 

1. PUBLIC HEALTH STATEMENT 

sulfur mustard changes to other chemicals in the environment, it will not concentrate in plants or 

animals. For more information on what happens when sulfur mustard enters the environment, 

see Chapter 6. 

1.3 HOW MIGHT I BE EXPOSED TO SULFUR MUSTARD? 

Sulfur mustard is not currently being produced in the United States. The general public might be 

exposed through accidental release from the Army bases where it is stored. These storage areas 

are heavily guarded, and storage buildings are sealed. People who work at Army bases that store 

sulfur mustard are more likely to be exposed than the general public. However, the Army has 

taken many precautions to protect the public from exposure to sulfur mustard. The general 

public may be exposed to sulfur mustard at hazardous waste sites that contain sulfur mustard. In 

addition, the use of sulfur mustard by terrorists is of concern. Persons involved in the transport 

or disposal of sulfur mustard may be exposed to mustard agents generated unintentionally 

through mishap. Spouses, children, and others may be exposed if workers unknowingly bring 

the mustard agents out of the factory on their skin or clothing. Sulfur mustard readily passes 

through ordinary clothing. Mixed in water, sulfur mustard changes its form within minutes, so it 

is very unlikely that you would drink it. The likelihood of the general population being exposed 

by way of water (drinking, cooking, bathing, and swimming) is therefore very small. Sulfur 

mustard does not occur naturally; therefore, there are no background levels in the soil, air, water, 

or food. If it is accidentally released, it will stay in the air or on the ground for 1–3 days. Under 

certain conditions, it may remain on the ground or in water for long periods. For more 

information on possible exposures, see Chapter 6. 

1.4 HOW CAN SULFUR MUSTARD ENTER AND LEAVE MY BODY? 

Sulfur mustard can enter your body easily and quickly if it gets in your eyes or on your skin, or if 

you breathe sulfur mustard vapors. It can easily pass through your clothing to get onto your skin. 

It is possible that you could come into contact with sulfur mustard at hazardous waste sites that 

contain this material. Sulfur mustard changes into other chemicals in your body, and these 
SULFUR MUSTARD 4 

1. PUBLIC HEALTH STATEMENT 

chemicals mostly leave your body in the urine within a few weeks. For more information, see 

Chapter 3. 

1.5 HOW CAN SULFUR MUSTARD AFFECT MY HEALTH? 

To protect the public from the harmful effects of toxic chemicals and to find ways to treat people 

who have been harmed, scientists use many tests. 

One way to see if a chemical will hurt people is to learn how the chemical is absorbed, used, and 

released by the body; for some chemicals, animal testing may be necessary. Animal testing may 

also be used to identify health effects such as cancer or birth defects. Without laboratory 

animals, scientists would lose a basic method to get information needed to make wise decisions 

to protect public health. Scientists have the responsibility to treat research animals with care and 

compassion. Laws today protect the welfare of research animals, and scientists must comply 

with strict animal care guidelines. 

Sulfur mustard can harm you depending on how much of the chemical you were exposed to and 

for how long. Sulfur mustard may make your eyes burn, your eyelids swell, or cause you to 

blink a lot. Sulfur mustard may burn your skin and cause skin blisters within a few days. Your 

eyes and the parts of your body that are sweaty are the most likely to be harmed. If you breathe 

it, sulfur mustard can cause coughing, bronchitis, and long-term respiratory disease. Sulfur 

mustard may affect reproduction. Some men exposed to sulfur mustard during war have 

reported decreased sexual drive and have had problems with sexual function due to scarring of 

genital tissues and lower sperm counts. The International Agency for Research on Cancer has 

determined that sulfur mustard is carcinogenic to humans. The Department of Health and 

Human Services has also determined that sulfur mustard is a known carcinogen. It can cause 

cancer in your airways, lungs, skin, and maybe other areas of your body later in life. If you are 

exposed to a very large amount of sulfur mustard, you can eventually die from it. Some of the 

chemicals that are formed when sulfur mustard is burned or spilled into water can also be 

irritating to the skin. 
SULFUR MUSTARD 5 

1. PUBLIC HEALTH STATEMENT 

1.6 HOW CAN SULFUR MUSTARD AFFECT CHILDREN? 

This section discusses potential health effects from exposures during the period from conception 

to maturity at 18 years of age in humans. 

Sulfur mustard causes the eyes and skin of children to burn similarly to adults; however, the 

burns may be more severe in children. Blisters may appear sooner in children than adults, as 

early as 4 hours after sulfur mustard contacts the skin. Coughing and vomiting have been 

reported as early symptoms of exposure to sulfur mustard in children. Sulfur mustard vapors are 

heavier than air and since young children are closer to the ground or floor because of their 

height, they may be exposed to more sulfur mustard vapors than adults during accidental 

exposures. Sulfur mustard may cause birth defects or affect the development of children. An 

increased incidence of birth defects has been reported among newborn babies of sulfur mustard 

victims exposed during war. Studies in animals also indicate that sulfur mustard may affect 

development. It is not known if sulfur mustard can cross the placenta or be passed to infants in 

breast milk. 

1.7 HOW CAN FAMILIES REDUCE THE RISK OF EXPOSURE TO SULFUR 

MUSTARD? 

If your doctor finds that you have been exposed to significant amounts of sulfur mustard, ask 

whether your children might also be exposed. Your doctor might need to ask your state health 

department to investigate. 

The risk of exposure to sulfur mustard to the general public may be slightly greater for those who 

live or work near Army bases and other facilities that store it. However, the Army has instituted 

precautions to protect the public from exposure to sulfur mustard. Sulfur mustard is currently 

being destroyed at these facilities, and thus the risk of exposure due to accidents is decreasing. 
SULFUR MUSTARD 6 

1. PUBLIC HEALTH STATEMENT 

1.8 IS THERE A MEDICAL TEST TO DETERMINE WHETHER I HAVE BEEN 

EXPOSED TO SULFUR MUSTARD? 

Sulfur mustard or some of the chemicals that it makes in your body can be found by testing your 

urine or blood. However, a test for sulfur mustard exposure is not readily available at local 

physicians’ offices or hospitals. A urine or blood sample may be sent to a special laboratory for 

testing. For further assistance, see Section 1.10. 

1.9 WHAT RECOMMENDATIONS HAS THE FEDERAL GOVERNMENT MADE TO 

PROTECT HUMAN HEALTH? 

The federal government develops regulations and recommendations to protect public health. 

Regulations can be enforced by law. Federal agencies that develop regulations for toxic 

substances include the Environmental Protection Agency (EPA), the Occupational Safety and 

Health Administration (OSHA), and the Food and Drug Administration (FDA). 

Recommendations provide valuable guidelines to protect public health but cannot be enforced by 

law. Federal organizations that develop recommendations for toxic substances include the 

Agency for Toxic Substances and Disease Registry (ATSDR) and the National Institute for 

Occupational Safety and Health (NIOSH). 

Regulations and recommendations can be expressed in not-to-exceed levels in air, water, soil, or 

food that are usually based on levels that affect animals; then they are adjusted to help protect 

people. Sometimes these not-to-exceed levels differ among federal organizations because of 

different exposure times (an 8-hour workday or a 24-hour day), the use of different animal 

studies, or other factors. 

Recommendations and regulations are also periodically updated as more information becomes 

available. For the most current information, check with the federal agency or organization that 

provides it. Some regulations and recommendations for sulfur mustard include the following: 

The federal government considers sulfur mustard an extremely hazardous substance. In 1985, 

Congress directed the U.S. Army to begin destroying the stockpile of U.S. chemical agents 
 

 

 

 

SULFUR MUSTARD 7 

1. PUBLIC HEALTH STATEMENT 

including sulfur mustard. As a result, the U.S. Army's Chemical Stockpile Disposal Program 

(CSDP) was started. As part of this program, the U.S. Army has continued to study how workers 

and the general public might best be protected from harm by sulfur mustard. The U.S. Army is 

the primary source of safety recommendations for sulfur mustard. The federal government has 

recommended maximum concentrations in air to which the general public should be exposed for 

different lengths of time. The maximum concentration for long-term exposure is 

0.0001 milligrams per cubic meter of air. Higher concentrations may be tolerated for shorter 

periods. Stored quantities of 500 pounds or more must be reported to the State Emergency 

Response Commission, the fire department, and the Local Emergency Planning Committee. 

Spills of over 1 pound must be reported to the National Response Center. For more information, 

see Chapter 8. 

The National Advisory Committee has developed acute exposure guideline levels (AEGLs) to 

protect people from the harmful effects of a short-term (8 hours or less) exposure to sulfur 

mustard. Three types of AEGLs have been developed: AEGL-1, AEGL-2, and AEGL-3. For 

sulfur mustard, the AEGL-1 values range from 0.40 mg/m3

 for a 10-minute exposure to 

0.008 mg/m3

 for an 8-hour exposure; exposure to higher concentrations may result in eye 

irritation. The AEGL-2 values range from 0.60 mg/m3 for 10 minutes to 0.013 mg/m3 for 

8 hours; exposure to higher concentrations may result in swelling of the eyes, sensitivity to light, 

and eye irritation. The AEGL-3 values range from 3.9 mg/m3 for 10 minutes to 0.27 mg/m3 for 

8 hours; exposure to higher concentrations may result in death. For more information on the 

AEGLs, see Appendix D. 

1.10 WHERE CAN I GET MORE INFORMATION? 

If you have any more questions or concerns, please contact your community or state health or 

environmental quality department or 

Agency for Toxic Substances and Disease Registry 

Division of Toxicology 

1600 Clifton Road NE 

Mailstop E-29 
 

 

 

 

 

 

 

 

 

 

 

 

SULFUR MUSTARD 8 

1. PUBLIC HEALTH STATEMENT 

Atlanta, GA 30333 

Web site: http://www.atsdr.cdc.gov 

* Information line and technical assistance 

Phone: 1-888-42-ATSDR (1-888-422-8737) 

Fax: 1-404-498-0093 

As part of the Homeland Defense Program, the U.S. Army Soldier and Biological Chemical 

Command (SBCCOM) has a mission to enhance the response capabilities of military, federal, 

state, and local emergency responders to incidents involving biological and chemical agents, 

including sulfur mustard. For more information, you may go to the SBCCOM Web site: 

http://hld.sbccom.army.mil/ip/bca_qr.htm. 

The following agencies may also be contacted for assistance regarding sulfur mustard exposure: 

National Response Center: 800-424-8802 

U.S. Public Health Service: 800-USA-NDMS 

Chemical Transportation Emergency Center: 800-424-9300 

ATSDR can also tell you the location of occupational and environmental health clinics. These 

clinics specialize in recognizing, evaluating, and treating illnesses resulting from exposure to 

hazardous substances. 

* To order toxicological profiles, contact 

National Technical Information Service 

5285 Port Royal Road 

Springfield, VA 22161 

Phone: (800) 553-6847 or (703) 605-6000 

Web Site: http://www.ntis.gov/ 
SULFUR MUSTARD 9 

2. RELEVANCE TO PUBLIC HEALTH 

2.1 BACKGROUND AND ENVIRONMENTAL EXPOSURES TO SULFUR MUSTARD IN 

THE UNITED STATES 

Sulfur mustard (bis[2-chloroethyl]sulfide; C4H8Cl2S; CASRN: 505-60-2) or as it is commonly called, 

‘mustard gas’, is one of a class of vesicant chemical warfare agents with the ability to form vesicles or 

blisters on exposed skin. Sulfur mustard is a viscous liquid at ambient temperature, but becomes a solid 

at 58 °F (14 °C). It is heavier than water as a liquid and heavier than air as a vapor. Sulfur mustard is a 

component of the H-series blister agents including undistilled sulfur mustard (H; sulfur mustard with 20– 

30% impurities, also known as Levinstein mustard), distilled sulfur mustard (HD or HS; approximately 

96% pure), a mustard-lewisite mixture (HL), an HD/agent T mixture (HT; a mixture of HD and 

nonvolatile agent T), and an HD/agent Q mixture (HQ; a mixture of HD and nonvolatile agent Q; agent Q 

is also known as sesqui-mustard). 

Sulfur mustard was first manufactured in 1822. It was utilized as early as the late 1880s, when it was 

used as a pesticide and to treat minor tumors. It was first used as a war gas in 1917, during World War I 

by the Germans on the British at Ypres. For this reason, sulfur mustard is also called yperite. Sulfur 

mustard was used in the Iran-Iraq War of 1980–1988, and there are reports of sulfur mustard being 

utilized in other conflicts. The production of sulfur mustard in the United States was discontinued in 

1968. Sulfur mustard does not naturally occur, and, therefore, there are no background levels in the soil, 

air, water, or food. The major possibilities of exposure of the general public are through accidental 

release from the Army bases where it is stored. Occupational exposures in the United States are expected 

when handling, disposing and treating hazardous wastes containing sulfur mustard. It is also possible that 

workers involved in plastics manufacturing may be exposed to mustard agents inadvertently, resulting 

from process contamination with sulfur or nitrogen impurities, as occurred in a vinyl chloride monomer 

manufacturing facility in Plaquemine, Louisiana in 1996. If sulfur mustard was released into the air, the 

primary routes of exposure would be contact with eyes and skin or inhalation. Children are expected to 

be exposed to sulfur mustard by the same routes as adults. 

The U.S. stockpile of sulfur mustard is currently stored at seven sites in the continental United States, and 

formerly at one site located on Johnston Island in the Pacific Ocean. All of these locations are heavily 
 

 

SULFUR MUSTARD 10 

2. RELEVANCE TO PUBLIC HEALTH 

guarded, and storage buildings are sealed. Sulfur mustard may also be found in non-stockpile locations at 

current and former military base sites and testing sites across the United States. Non-stockpile sites 

include locations that may contain buried chemical munitions or contaminated sites formerly used in 

production and storage of sulfur mustard. The Army has taken many precautions to protect the public 

from exposure to sulfur mustard. People who work at Army bases that store sulfur mustard are more 

likely to be exposed than the general public. Currently, all of the sulfur mustard at these Army bases will 

be destroyed by either incineration or neutralization. U.S. law requires that the Department of Defense 

destroy all sulfur mustard by 2004. However, complete destruction of the entire stockpile of sulfur 

mustard may continue beyond this date. The United States also ratified the international Chemical 

Weapons Convention treaty, according to which, the United States must destroy its stockpile of mustard 

agents by April 2007. Sulfur mustard has been found in at least 3 of the 1,636 current or former NPL 

sites, the EPA’s listing of the most serious hazardous waste sites in the nation. At hazardous waste sites, 

exposure to sulfur mustard is also possible by dermal contact with contaminated soil or containers. 

The National Advisory Committee for the Acute Exposure Guideline Levels for Hazardous Substances 

has developed acute exposure guideline levels (AEGLs) for sulfur mustard. The AEGLs are threshold 

exposure limit values for the general public applicable to emergency exposure periods ranging from 

10 minutes to 8 hours. For each chemical, three levels of AEGLs, distinguished by varying degrees of 

severity of toxic effects, are developed: at exposure levels above the AEGL-1, the general population 

could experience notable discomfort, irritation, or asymptomatic, nonsensory effects; above AEGL-2, the 

general population could experience irreversible or other serious, long-lasting health effects or impaired 

ability to escape; and above AEGL-3, the general population could experience life-threatening health 

effects or death. At each AEGL level, values are developed for five exposure periods: 10 minutes, 

30 minutes, 1 hour, 4 hours, and 8 hours. The AEGLs for sulfur mustard are summarized below. For 

sulfur mustard, the AEGL-1 values are based on human data for conjunctivitis; the AEGL-2 values are 

based on human data for conjunctivitis, edema, photophobia, and eye irritation, and the AEGL-3 values 

are for lethality in mice. For a more detailed description of the derivation of the sulfur mustard AEGLs, 

see Appendix D. 

Acute Exposure Guideline Level (AEGL) Values for Sulfur Mustard (mg/m3

) 

AEGL Level 10-minute 30-minute 1-hour 4-hour 8-hour 

AEGL-1 0.40 mg/m3

 0.13 mg/m3 0.067 mg/m3 0.017 mg/m3 0.008 mg/m3 

AEGL-2 0.60 mg/m3

 0.20 mg/m3 0.10 mg/m3 0.025 mg/m3 0.013 mg/m3 

AEGL-3 3.9 mg/m3

 2.7 mg/m3 2.1 mg/m3 0.53 mg/m3 0.27 mg/m3 
SULFUR MUSTARD 11 

2. RELEVANCE TO PUBLIC HEALTH 

Information about mustard agents other than sulfur mustard, such as nitrogen mustard and thickened 

mustard is not included in this document (see Chapter 4). 

2.2 SUMMARY OF HEALTH EFFECTS 

Sulfur mustard or other chemical warfare agents containing sulfur mustard are no longer produced or used 

commercially in the United States and general population exposures are expected to be low. People 

whose work is connected with chemical weapons or who work at military sites where these compounds 

are stored have the potential of being exposed. The primary adverse health effects of sulfur mustard 

exposure are ocular, respiratory and dermal direct contact effects, reproductive effects and cancer 

following inhalation, oral, and dermal exposure. Numerous reports of battlefield exposures provide 

strong evidence of the toxic potential of sulfur mustard; however, combat sulfur mustard exposure levels 

have not been quantified, and blast effects may be present concurrently. Additional information on the 

acute health effects of sulfur mustard is available from studies of sulfur mustard testing of volunteer 

subjects. Clinical studies of mustard agent filling plant workers provide evidence of health effects 

following chronic exposure to sulfur mustard; however, these studies are complicated by possible 

concurrent exposure to other toxic agents because factories generally produced multiple chemical warfare 

agents. Some evidence has also surfaced regarding delayed toxic effects several years after acute sulfur 

mustard exposure during battlefield operations or occupational exposure. The following symptoms have 

appeared from 2 months to several years after exposure to sulfur mustard: cough, chest pain, shortness of 

breath, fatigue, wheezing, insomnia, fever, relapsing keratitis (inflammation of the cornea), marked 

sensitivity to pulmonary irritants, and increased susceptibility to respiratory infections. Animal studies 

have shown that sulfur mustard induces similar toxic effects in animals and humans, with the exception of 

blistering of animals that have fur. 

Ocular Effects. The eye is one of the organs that is most sensitive to the acute effects of sulfur 

mustard vapor. Studies with volunteer soldiers wearing respirators indicated conjunctivitis (inflammation 

of the conjunctiva), manifested as early as 30 minutes after exposure, as the first sign of exposure to 

sulfur mustard. The ocular effects are due to direct contact of sulfur mustard with the corneal/ 

conjunctival epithelium. This is supported by experiments in animals that have shown little involvement 

of the eye when sulfur mustard was administered parenterally at dose levels known to be systemically 

toxic and lethal. The severity of ocular injury is a function of dose/concentration, duration, and 
 

SULFUR MUSTARD 12 

2. RELEVANCE TO PUBLIC HEALTH 

temperature. Respiratory tract and skin irritations have occurred at about the same threshold vapor 

concentration, but the latency periods were generally longer (≥12 hours). Other signs and symptoms of 

acute exposure include ocular irritation, redness, lacrimation, burning pain, swelling of the eyelids, 

photophobia (sensitivity of the eyes to light), blepharospasm (spasm of eyelid muscle), and corneal 

damage. When the severity of the injury was such that corneal damage occurred, necrotic ulcers, with or 

without bacterial infection, have developed. It has been reported that normal corneal epithelial 

regeneration occurred rapidly if the underlying stroma was intact, but if damaged, regeneration could be 

incomplete with continued erosion and neovascularization. A range of ocular effects, including 

conjunctivitis, chronic keratitis, and corneal ulcerations, have been reported in dogs and rabbits following 

acute exposure to sulfur mustard depending on the concentration and duration of exposures. 

Follow-up studies of battlefield exposures and long-term animal studies indicate that delayed or recurrent 

keratitis and/or ulceration of the cornea may result from severe burns. A sudden increase in the number 

of veterans with these signs of disease has been observed 8–25 years after the initial sulfur mustard injury. 

Long-term studies examining delayed ocular effects in rabbits acutely exposed to sulfur mustard showed 

that, similar to the human condition, migration of fatty and/or cholesterin deposits to the surface of the 

eye occurred 7–8 months after the initial injury, causing secondary ulceration. Exposure of the eye to 

liquid droplets of sulfur mustard can result in severe corneal damage, with possible perforation of the 

cornea and loss of the eye. 

There are no rigorous human studies evaluating the occurrence of ocular sensitivity to sulfur mustard. 

From early chamber tests that indicated conjunctivitis as the initial sign of toxicity, conducted with three 

groups of men, those having no previous exposure, those who were exposed to “very low”, but 

unspecified, concentrations of sulfur mustard through their work, but who experienced no symptoms or 

burns, and those with unspecified occupational exposure who experienced one or more burns at various 

times, one investigator concluded that the toxicity of sulfur mustard did not appear to increase with 

previous exposure. However, details upon which this conclusion was based were lacking. Animal data 

suggest that ocular sensitization occurs following exposures to levels in the air that produce severe 

effects. While quantitative exposure data are not available, conjunctivitis, altered corneal pigmentation, 

photophobia, lacrimation, impaired vision, and blepharospasm have been reported in studies of workers at 

sulfur mustard research laboratories and manufacturing plants with longer-than-acute (>14 days) exposure 

durations. However, these studies are limited by possible exposures to multiple toxic chemicals, 

confounding factors of age and smoking history, and comparisons to controls. Chronic keratitis has been 

observed in dogs and rats exposed to sulfur mustard vapor for ≥7.5 months. 
SULFUR MUSTARD 13 

2. RELEVANCE TO PUBLIC HEALTH 

The Agency for Toxic Substances and Disease Registry (ATSDR) has derived acute and intermediateduration inhalation Minimum Risk Levels (MRLs) based on ocular effects (see Appendix A). The 

National Advisory Committee for Acute Exposure Guideline Levels (AEGLs) for Hazardous Substances 

has established AEGLs and the Army has established an air exposure limit for the general population for 

chronic exposures (GPL) based on ocular effects (see Chapter 8). 

Respiratory Effects. Early respiratory effects of sulfur mustard exposure include hoarseness, sore 

throat, a burning sensation of the vocal cords, shortness of breath, and hemorrhagic inflammation of the 

tracheobronchial mucosa accompanied by severe erosions or membranous lesions. In children, cough 

was the first respiratory symptom. Erosions of the airway mucosa have also been reported in animals. 

Respiratory infections are often a secondary complication following sulfur-mustard-induced injury, and 

pulmonary edema and bronchopneumonia may develop. Acute exposures to sulfur mustard have resulted 

in long-term damage manifested as asthma-like conditions, emphysematous bronchitis, and increases in 

incidence of secondary respiratory infections (bronchopneumonia and tuberculosis). Epidemiological 

studies of World War I victims exposed to sulfur mustard revealed an association between acute 

respiratory exposure and the risk of developing respiratory tract cancer. Prolonged inhalation exposure, 

as experienced by workers exposed to factory ambient levels of sulfur mustard for a number of years, can 

also result in these same conditions and/or cancer. Several studies of workers occupationally exposed to 

sulfur mustard have revealed elevated risks of respiratory tract tumors after long-term exposure. 

Dermal and Other Direct Contact Effects. Data from soldiers and civilians exposed during 

combat, mustard agent factory workers, sulfur mustard testing volunteers, and people who were 

accidentally exposed to sulfur mustard provide ample evidence of the toxic potential of sulfur mustard to 

tissues coming into direct contact with sulfur mustard. Sulfur mustard exposure results in burning of the 

skin, which begins several hours after exposure. The severity of cutaneous injury is a function of dose, 

duration, temperature, humidity, and/or perspiration and is directly related to the sulfur mustard alkylation 

levels in skin. It is likely that direct contact with other tissues would have these same dependencies. 

Stomach irritation and inflammation and bleeding of the gastric mucosa were reported in victims of 

combat exposure where at least small amounts were likely ingested. Similar effects have been observed 

in animal studies. Occupational dermal exposure to sulfur mustard has produced abnormal skin 

pigmentation and Bowen's disease (precancerous dermatitis) in humans. There is also some evidence that 

former sulfur mustard factory workers may have an increased risk of developing digestive tract and skin 

tumors. 
SULFUR MUSTARD 14 

2. RELEVANCE TO PUBLIC HEALTH 

ATSDR has derived an intermediate-duration oral MRL based on gastrointestinal effects (see 

Appendix A). The U.S. Army has derived an oral reference dose (RfD) based on gastrointestinal effects 

(see Chapter 8). 

Reproductive Effects. Reduced sperm counts were reported in a follow-up study of men who were 

exposed to sulfur mustard during the Iran-Iraq War. An increased rate of fetal deaths and an altered sex 

ratio were reported in progenies of Iranian survivors of chemical attacks that included sulfur mustard. It 

is also important to note that reproductive success can be adversely affected by impaired sexual function 

caused by scarring of genital tissues resulting subsequent to blistering from direct contact with sulfur 

mustard. While the routes of exposure differ, animal reproductive toxicity data support the long-term 

effects reported in humans. Increases of early fetal resorptions and preimplantation losses and decreases 

in live embryo implants were observed in male dominant studies in which male rats, orally administered 

sulfur mustard, were mated with untreated females. An increase in the percentage of abnormal sperm was 

also detected in these treated rats. The reproductive effects appear to be male dominant as no female 

dominant lethal effects have been observed. The timing of the dominant lethal effects is consistent with 

an effect during the post-meiotic stages of spermatogenesis, possibly involving the generally sensitive 

spermatids. An altered sex ratio and a decrease in growth rate during nursing were observed in the 

offspring of parental rats that had been orally exposed to sulfur mustard during fetal and neonatal 

development, as well as premating, mating, and gestation. Sulfur mustard has also induced dominant and 

sex-linked recessive lethal mutations in Drosophila. 

Cancer. There is sufficient evidence that sulfur mustard is carcinogenic to humans. Epidemiological 

studies of World War I victims exposed to sulfur mustard revealed an association between respiratory 

exposure and the risk of developing respiratory tract cancer. Factory workers exposed to sulfur mustard 

for a number of years have been shown to develop respiratory cancer. Although most human studies have 

found an association between sulfur mustard exposure and respiratory cancer, some studies have not 

found a significant relationship, possibly due to lower exposure levels. It is also documented that 

occupational dermal exposure to sulfur mustard produces Bowen's disease (precancerous dermatitis) in 

humans. There is some evidence that former sulfur mustard factory workers may have an increased risk 

of developing digestive tract and skin tumors. Two animal studies, of low predictive quality due to 

species strain tendency to develop lung tumors, insufficient animals, and inadequate doses, have also 

shown increases in tumors from exposure to sulfur mustard in the air. Subcutaneous, intramuscular, and 

intravenous injections of sulfur mustard into mice have also produced increased tumors at the site of the 
 

SULFUR MUSTARD 15 

2. RELEVANCE TO PUBLIC HEALTH 

injection, in the mammary glands, or in the lungs. Sulfur mustard has been shown to induce a wide 

variety of genetic mutations in many types of mammalian cells in vitro in a dose-related fashion. Sulfur 

mustard has also induced genetic damage in vivo in peripheral blood lymphocytes from exposed 

individuals at low doses. This is not unexpected considering sulfur mustard is a bi-functional alkylating 

agent that can cross-link DNA strands. 

IARC has classified sulfur mustard as “carcinogenic to humans” (Group 1) based on sufficient evidence 

in humans, limited evidence in experimental animals, supporting evidence that sulfur mustard is a bifunctional alkylating agent, and positive results in a number of assays for genotoxic effects. 

The Army’s current health-based environmental screening levels (HBESLs) for sulfur mustard include an 

oral cancer potency value (slope factor), a cancer inhalation unit risk value, and an inhalation cancer 

potency value. However, ongoing evaluations of alternative approaches for quantitatively estimating 

cancer risk may result in changes to these values (see Chapter 8). 

2.3 MINIMAL RISK LEVELS 

Inhalation MRLs 

•	 An MRL of 0.0007 mg/m3

 has been derived for acute-duration inhalation exposure (14 days or 

less) to sulfur mustard. 

The acute-duration inhalation MRL was based on a concentration of sulfur mustard vapors of 0.06 mg/m3 

at which minimal ocular effects occurred in men who underwent a 3-day chamber test with sulfur mustard 

(Guild et al. 1941). The corresponding time-weighted average (TWA) concentration of 0.02 mg/m3

 was 

considered a minimal lowest-observed-adverse-effect level (LOAEL) for the MRL derivation. An 

uncertainty factor of 30 (3 for use of a minimal LOAEL and 10 for human variability) was applied to 

derive the MRL. Male soldiers wearing respirators (2–6 men/group) were exposed to sulfur mustard 

vapor concentrations ranging from 0.06 to 320 mg/m3

. Continuous exposure durations ranged from 

15 seconds to 10 hours, yielding concentration time (Ct) products in the range of 42–144 mg-minute/m3

. 

Two repeated-exposure tests were also conducted; a group of four men was exposed to 0.22 mg/m3

, 

2.5 hours/day for 2 days, and another group of four men was exposed to 0.06 mg/m3

, 8 hours/day, for 

3 days (intermittent Cts of 66 and 86 mg-minute/m3

, respectively). At the lowest continuous Ct of 42 mgminute/m3

 (1.4 mg/m3 for 30 minutes), four of four soldiers showed a slight generalized conjunctival 
SULFUR MUSTARD 16 

2. RELEVANCE TO PUBLIC HEALTH 

reaction. Slight to moderate degree of conjunctival congestion was reported for the Ct range of 80– 

90 mg-minute/m3

. Photophobia occurred at Cts ≥99 mg-minute/m3. A scarcely discernable generalized 

conjunctival reaction (incidence unspecified) was reported in subjects undergoing the 3-day repeated 

exposure. The severity of conjunctivitis for the 3-day intermittent exposure was described as far slighter 

than the moderate degree of conjunctivitis observed from continuous exposures with Cts 

≥80 mg-minute/m3

. 

Support for ocular effects as a critical detection of effect end point comes from other chamber tests with 

human subjects (Anderson 1942; Reed 1918) and numerous reports of eye injuries in humans following 

combat exposure to sulfur mustard (Hughes 1942; Pechura and Rall, 1993; Philips 1940). A range of 

ocular effects, including conjunctivitis, chronic keratitis, and corneal ulcerations, has been reported in 

dogs and rabbits following acute exposure to sulfur mustard depending on the concentration and duration 

of exposures (Balali-Mood 1986; Gates and Moore 1946; Laughlin 1944a; Maumenee and Scholts 1948; 

Reed 1918; Warthin and Weller 1919). 

•	 An MRL of 0.00002 mg/m3

 has been derived for intermediate-duration inhalation exposure (15– 

364 days) to sulfur mustard. 

The intermediate-duration inhalation MRL was based on a no-observed-adverse-effect level (NOAEL) of 

0.001 mg/m3

 for ocular effects (conjunctivitis and chronic keratitis) in dogs (McNamara et al. 1975). 

Male and female beagle dogs were exposed to sulfur mustard vapor at a concentration of 0.001 mg/m3

 for 

24 hours/day, or to 0.1 mg/m3

 for 6.5 hours followed by exposure to 0.0025 mg/m3 for the remaining 

17.5 hours of the day, 5 days/week (TWAs of 0.0007 and 0.0206 mg/m3

, respectively), for durations up to 

1 year. No dogs died during the study. No clinical signs of toxicity were observed in the dogs at the low 

concentration. Ocular effects at the high concentration first appeared after 16 weeks of exposure and 

included corneal opacity, pannus, chronic keratitis, vascularization, pigmentation, and granulation. The 

TWA concentration of 0.0007 mg/m3

 was used in the MRL derivation. 

In addition to the supporting information for ocular lesions as provided for the acute-duration MRL, there 

are numerous reports of eye burns in workers accidentally exposed to large quantities of sulfur mustard 

vapor, as well as to slow leaks that were not detected by smell (Pechura and Rall 1993; Uhde and Dunphy 

1946). 

A chronic-duration (365 days or more) inhalation MRL for sulfur mustard was not derived because 

quantitative data were not available to determine NOAELs or LOAELs. However, using a different 
SULFUR MUSTARD 17 

2. RELEVANCE TO PUBLIC HEALTH 

derivation procedure than that used for chronic-duration inhalation MRLs, the Army has established an 

air exposure limit for the general population for chronic exposures (GPL) of 0.00002 mg/m3

 as a 24-hour 

time-weighted average, 7 days/week (USACHPPM 2000a). The key critical effect chosen for the GPL 

was ocular effects, as the data indicate the eyes to yield the most sensitive response to vapor exposures of 

sulfur mustard. A previously established GPL of 0.0001 mg/m3

 for sulfur mustard was promulgated by 

the Centers for Disease Control and Prevention (CDC) in 1988 (DHHS 1988). The Army has also 

derived an inhalation reference dose (RfD; an estimate of a daily ingestion exposure level for the human 

population, including sensitive subpopulations, that is likely to be without appreciable risk of deleterious 

noncancer health effects during a lifetime) of 0.00003 mg/kg/day from this GPL by assuming a human 

inhalation rate of 20 m3

/day and a body weight of 70 kg (USACHPPM 1999). 

Oral MRLs 

•	 An MRL of 0.0005 mg/kg/day (0.5 μg/kg/day) has been derived for acute-duration oral exposure 

(14 days or less) to sulfur mustard. 

The acute-duration oral MRL was based on a LOAEL of 0.5 mg/kg/day for inflamed mesenteric lymph 

nodes in rat dams administered sulfur mustard in sesame oil by gavage (DOA 1987). The dose is also a 

LOAEL for reduced ossification in the fetuses. An uncertainty factor of 1,000 (10 for use of a LOAEL, 

10 for extrapolation from animals to humans, and 10 for human variability) was applied to the LOAEL to 

derive the MRL. In the teratology study that formed the basis for the acute-duration oral MRL, there 

were no treatment-related deaths in groups of 25–27 mated Sprague-Dawley female rats (10–11 weeks 

old) that were dosed acutely on gestation days 6–15 (10 days) with 0, 0.5, 1.0, or 2.0 mg/kg/day sulfur 

mustard (95.9–96.1% purity) dissolved in sesame oil. Significant incidences of inflamed mesenteric 

lymph nodes in dams and reduced ossification in fetuses occurred with sulfur mustard doses 

≥0.5 mg/kg/day. 

There is some evidence for sulfur mustard-induced lymph system effects in humans. Lymph node 

discoloration and spleen pathology were found in autopsies of sulfur mustard victims (Alexander 1947). 

Additional animal studies also indicate sulfur mustard-induced damage to the lymph system (Cameron et 

al. 1946; Coutelier et al. 1991; Venkateswaran et al. 1994a). In other oral studies in animals in which 

sulfur mustard dissolved in sesame oil was administered by gavage, increased incidence of inflamed 

mesenteric lymph nodes occurred in rats at ≥0.4 mg/kg/day in dose-range experiments (DOA 1987) and 

another lymphoretic effect, enlarged Peyer’s patches, was observed in rabbits at 0.5 mg/kg/day in a range­
SULFUR MUSTARD 18 

2. RELEVANCE TO PUBLIC HEALTH 

finding study and at 0.4 mg/kg/day in the subsequent full-scale teratology study (incidence data not 

reported) (DOA 1987). 

•	 An MRL of 0.00007 mg/kg/day (0.07 μg/kg/day) has been derived for intermediate-duration oral 

exposure (15–364 days) to sulfur mustard. 

The intermediate-duration oral MRL was based on a LOAEL of 0.03 mg/kg/day for forestomach 

epithelium lesions in rats administered sulfur mustard in sesame oil by gavage in a 2-generation 

reproduction study (Sasser et al. 1996a). In that study, groups of 8-week-old Sprague-Dawley rats 

(27 females and 20 males/group/generation) were dosed with 0, 0.03, 0.1, or 0.4 mg/kg/day sulfur 

mustard (97.3% purity) dissolved in sesame oil. Male and female rats were dosed 5 days/week for 

13 weeks before mating and during a 2-week mating period. Females were dosed daily (7 days/week) 

throughout the 21-day gestation period and 4–5 days/week during the 21-day lactation period. Males 

were dosed 5 days/week during the 21-day gestation period and sacrificed at the birth of their pups. 

Dams were sacrificed when their pups were weaned. Male and female F1 pups were treated with sulfur 

mustard until they were mated and the females became pregnant and gave birth. The dosing of F1 dams 

continued until pup weaning, at which time, the study was terminated. Significant dose-related severity 

and incidences of forestomach squamous epithelium lesions occurred in both sexes with sulfur mustard 

doses ≥0.03 mg/kg/day. This LOAEL corresponds to a TWA LOAEL of 0.02 mg/kg/day, which was 

used for MRL derivation. An uncertainty factor of 300 (10 for use of a LOAEL, 3 for extrapolation from 

animals to humans, and 10 for human variability) was applied to the TWA LOAEL to derive the MRL. 

In support of the forestomach epithelial lesions as the key critical effect for the intermediate-duration 

MRL, gastrointestinal effects (stomach irritation and inflammation, hyperemia, epithelial loss, necrosis, 

ulceration, vomiting, nausea, bleeding, anorexia, and abdominal pain) have been reported in humans 

following combat exposure to sulfur mustard, in sulfur mustard testing volunteers, and in sulfur mustard 

factory workers (Alexander 1947; Momeni and Aminjavaheri 1994; Pierard et al. 1990; Sinclair 1948; 

Yamakido et al. 1985). Gastrointestinal effects (edema, hemorrhage or sloughing of the mucosa, and 

ulceration) were also observed in rabbits following 14-day exposures at ≥0.4 mg/kg/day (DOA 1987), in 

rats following 10-day exposures at ≥2.0 mg/kg/day (DOA 1987), and in rats following 13-week exposures 

at ≥0.1 mg/kg/day (Sasser et al. 1996b). 

A chronic-duration (365 days or more) oral MRL for sulfur mustard was not derived because a chronic 

bioassay was not located. However, using a derivation procedure different than that used for chronicduration oral MRLs, the Army has derived an oral RfD of 0.007 μg/kg/day (Oak Ridge National 
SULFUR MUSTARD 19 

2. RELEVANCE TO PUBLIC HEALTH 

Laboratory 1996; Opresko et al. 1998, 2001; USACHPPM 1999, 2000b) that has also been approved by 

the National Research Council (NRC 1999b). 

SULFUR MUSTARD 21 

3. HEALTH EFFECTS 

3.1 INTRODUCTION 

The primary purpose of this chapter is to provide public health officials, physicians, toxicologists, and 

other interested individuals and groups with an overall perspective on the toxicology of sulfur mustard. It 

contains descriptions and evaluations of toxicological studies and epidemiological investigations and 

provides conclusions, where possible, on the relevance of toxicity and toxicokinetic data to public health. 

A glossary and list of acronyms, abbreviations, and symbols can be found at the end of this profile. 

Sulfur mustard [bis(2-chloroethyl)sulfide; C4H8Cl2S; CASRN: 505-60-2] or as it is commonly called, 

‘mustard gas’, is one of a class of vesicant chemical warfare agents with the ability to form vesicles or 

blisters on exposed skin. Sulfur mustard is a component of the H-series blister agents including 

undistilled sulfur mustard (H; sulfur mustard with 20–30% impurities, also known as Levinstein mustard), 

distilled sulfur mustard (HD or HS; approximately 96% pure), a mustard-lewisite mixture (HL), an 

HD/agent T mixture (HT; a mixture of HD and nonvolatile agent T), and an HD/agent Q mixture (HQ; a 

mixture of HD and nonvolatile agent Q; agent Q is also known as sesqui-mustard) (Gates and Moore 

1946). Mustard agents, including sulfur mustard, are regulated under the Chemical Weapons Convention 

(CWC) (USCWCR1999). Three classes of chemicals are monitored under the CWC (1993), with sulfur 

mustard grouped in the highest risk class, "Schedule 1." Information about mustard agents other than 

sulfur mustard, such as nitrogen mustards, thickened mustard, or the mixtures listed above are not 

discussed in this document. 

Sulfur mustard is actually a clear, colorless, oily liquid. As a warfare or terrorist agent, sulfur mustard has 

been dispersed by spraying or by explosive blasts producing a vapor, aerosol, and/or liquid droplets, 

earning the chemical the name ‘mustard gas.’ Persons involved in the transport or disposal of sulfur 

mustard may be exposed occupationally. It is also possible that workers involved in plastics 

manufacturing may be exposed to mustard agents inadvertently, resulting from process contamination 

with sulfur or nitrogen impurities, as occurred in a vinyl chloride monomer manufacturing facility in 

Plaquemine, Louisiana in 1996 (Johnson 1998). Spouses, children, and others may be exposed if workers 
 

 

SULFUR MUSTARD 22 

3. HEALTH EFFECTS 

unknowingly bring the mustard agents out of the factory on their skin or clothing. Both liquid and vapor 

forms readily penetrate ordinary clothing. 

Sulfur mustard is slightly soluble in water, but both the liquid and vapor forms are readily soluble in 

alcohol, gasoline, kerosene, oils, fats, and organic solvents. Sulfur mustard is environmentally persistent. 

Evaporation in air increases with increasing temperatures, but at temperatures below 58 °F (14 °C), it 

freezes while retaining its vesicant properties. Both liquid and vapor forms readily penetrate ordinary 

clothing. The effects of sulfur mustard poisoning may be local, systemic, or both, depending on 

environmental conditions, exposed organs, and extent and duration of exposure. Because of the high lipid 

solubility, sulfur mustard quickly penetrates the lipid cell membrane. Although sulfur mustard may be 

lethal, it is more likely to cause extensive incapacitating injuries to the eyes, skin, and respiratory tract of 

exposed persons. Alkylation reactions (replacement of a hydrogen atom in an organic compound by an 

alkyl group [CnH2n+1]) of sulfur mustard with tissue are rapid and irreversible; however, there is a latency 

period before effects become apparent. Eye and cutaneous lesions do not become apparent for 30 minutes 

to several hours after exposure. Burns caused by sulfur mustard may require long healing periods. Local 

effects are manifested at concentrations/doses far lower than those that produce systemic effects (NRC 

1997). 

3.2 DISCUSSION OF HEALTH EFFECTS BY ROUTE OF EXPOSURE 

To help public health professionals and others address the needs of persons living or working near 

hazardous waste sites, the information in this section is organized first by route of exposure (inhalation, 

oral, and dermal) and then by health effect (death, systemic, immunological, neurological, reproductive, 

developmental, genotoxic, and carcinogenic effects). These data are discussed in terms of three exposure 

periods: acute (14 days or less), intermediate (15–364 days), and chronic (365 days or more). 

Levels of significant exposure for each route and duration are presented in tables and illustrated in 

figures. The points in the figures showing no-observed-adverse-effect levels (NOAELs) or lowestobserved-adverse-effect levels (LOAELs) reflect the actual doses (levels of exposure) used in the studies. 

LOAELs have been classified into "less serious" or "serious" effects. "Serious" effects are those that 

evoke failure in a biological system and can lead to morbidity or mortality (e.g., acute respiratory distress 

or death). "Less serious" effects are those that are not expected to cause significant dysfunction or death, 

or those whose significance to the organism is not entirely clear. ATSDR acknowledges that a 
SULFUR MUSTARD 23 

3. HEALTH EFFECTS 

considerable amount of judgment may be required in establishing whether an end point should be 

classified as a NOAEL, "less serious" LOAEL, or "serious" LOAEL, and that in some cases, there will be 

insufficient data to decide whether the effect is indicative of significant dysfunction. However, the 

Agency has established guidelines and policies that are used to classify these end points. ATSDR 

believes that there is sufficient merit in this approach to warrant an attempt at distinguishing between 

"less serious" and "serious" effects. The distinction between "less serious" effects and "serious" effects is 

considered to be important because it helps the users of the profiles to identify levels of exposure at which 

major health effects start to appear. LOAELs or NOAELs should also help in determining whether or not 

the effects vary with dose and/or duration, and place into perspective the possible significance of these 

effects to human health. 

The significance of the exposure levels shown in the Levels of Significant Exposure (LSE) tables and 

figures may differ depending on the user's perspective. Public health officials and others concerned with 

appropriate actions to take at hazardous waste sites may want information on levels of exposure 

associated with more subtle effects in humans or animals (LOAELs) or exposure levels below which no 

adverse effects (NOAELs) have been observed. Estimates of levels posing minimal risk to humans 

(Minimal Risk Levels or MRLs) may be of interest to health professionals and citizens alike. 

Estimates of exposure levels posing minimal risk to humans (Minimal Risk Levels or MRLs) have been 

made for sulfur mustard. An MRL is defined as an estimate of daily human exposure to a substance that 

is likely to be without an appreciable risk of adverse effects (noncarcinogenic) over a specified duration 

of exposure. MRLs are derived when reliable and sufficient data exist to identify the target organ(s) of 

effect or the most sensitive health effect(s) for a specific duration within a given route of exposure. 

MRLs are based on noncancerous health effects only and do not consider carcinogenic effects. MRLs can 

be derived for acute, intermediate, and chronic duration exposures for inhalation and oral routes. 

Appropriate methodology does not exist to develop MRLs for dermal exposure. 

Although methods have been established to derive these levels (Barnes and Dourson 1988; EPA 1990), 

uncertainties are associated with these techniques. Furthermore, ATSDR acknowledges additional 

uncertainties inherent in the application of the procedures to derive less than lifetime MRLs. 

A User's Guide has been provided at the end of this profile (see Appendix B). This guide should aid in 

the interpretation of the tables and figures for Levels of Significant Exposure and the MRLs. 
SULFUR MUSTARD 24 

3. HEALTH EFFECTS 

There is a considerable amount of information regarding the effects of exposure to sulfur mustard in 

humans and in animals dating from over a century ago. A substantial amount of information is derived 

from the use of sulfur mustard as a chemical weapon or from research related to this use and the original 

documents are not readily available. However, there are numerous reviews of the literature that include 

very early data as well as more recent information. The information in this Toxicological Profile is based 

both on reviews from the literature and original studies. 

3.2.1 Inhalation Exposure 

While sulfur mustard (mustard gas) is described as smelling like mustard, horseradish, garlic, or onions, it 

can be difficult to smell and may not be recognized by the general population. Olfactory fatigue, 

resulting in discontinued ability to detect the sulfur mustard odor, occurred within 3–8 minutes of initial 

exposure in subjects participating in sulfur mustard chamber tests (Reed 1918). Due to the delayed 

symptoms and difficulties associated with detection by smell, individuals may not know that they are 

being exposed, and consequently, appropriate actions may not be taken. Inhalation exposure to sulfur 

mustard can result in local, followed by systemic, effects and death depending on concentration, duration, 

temperature, humidity, and/or perspiration. Because of sulfur mustard’s ability to penetrate cell 

membranes rapidly, injury resulting from inhalation exposure is characterized initially by local effects on 

the epithelial tissues through which it is absorbed (Papirmeister et al. 1991). In environmental exposures 

to sulfur mustard, the most sensitive target tissues are primarily the eyes, skin, and respiratory tract 

(Papirmeister et al. 1991; Reed 1918). Although the local effects of sulfur mustard on these tissues are 

often of most immediate concern, only a small portion of the dose that penetrates the tissue may induce 

these. The remainder of the absorbed dose passes into the circulation, is distributed throughout the body, 

and may result in systemic effects (Papirmeister et al. 1991). Local effects are manifested at 

concentrations/doses far lower than those that produce systemic effects. 

3.2.1.1 Death 

Human deaths associated with sulfur mustard exposure occurred during World War I (Prentiss 1937; 

Pechura and Rall 1993) and during the Iran-Iraq War in 1980–1988 (D’Halluin and Roels 1984; 

Eisenmenger et al. 1991; Mandl and Frielinger 1984; Momeni et al. 1992); however, no exposure doses 

for any of these wartime cases are available. During chemical warfare, exposure to sulfur mustard 

generally occurred by multiple routes. In the case of exposure by multiple routes, it is often difficult to 
SULFUR MUSTARD 25 

3. HEALTH EFFECTS 

determine the relative importance of local and systemic effects in causing death. Heavy and painful 

coughing, vomiting, burning eyes, and shock often closely preceded death. Deaths have occurred 

immediately following exposure in the battlefield, most likely due to acute chemical-induced pulmonary 

edema (Freitag et al. 1991). Deaths, which occurred in 1–3% of the soldiers exposed during World War I, 

were largely due to secondary respiratory infections (Uhrig 1962). Battlefield air concentrations of sulfur 

mustard vapor during attacks in World War I were estimated in the range 19–33 mg/m3

 (Solberg et al. 

1997). While sulfur mustard was not used during World War II, German planes bombed cargo vessels in 

the Italian port of Bari carrying sulfur mustard and explosive munitions. In the resulting explosion, sulfur 

mustard was released into the air and water, exposing survivors to sulfur mustard vapor and to a mixture 

of sulfur mustard in oil. Sulfur mustard caused death within a few hours of exposure by inducing shock 

in victims of the Bari Harbor incident and in civilians who accidentally recovered unspent World War I 

sulfur mustard shells (Alexander 1947; Papirmeister et al. 1991). Deaths beyond the second day after the 

Bari Harbor incident were attributed to decreased leukocyte counts, which reached levels below 

100 cell/cm3

 (Dacre and Goldman 1996). Accidental death of a family of two adults and two children 

occurred in 1919 in Salaise, France after exposure to sulfur mustard, which evaporated from a leaking can 

of sulfur mustard-contaminated alcohol that was being stored in the house (Dacre and Goldman 1996). 

One death among 14 children (9 boys, aged 9 months to 14 years; 5 girls, aged 13 months to 9 years) 

admitted to a hospital in Iran 18–24 hours following exposure to sulfur mustard from air bombs during 

the Iran-Iraq War was reported (Momeni and Aminjavaheri 1994). The 13-month-old girl developed 

pancytopenia and respiratory failure, and died 8 days after exposure. Deaths have also occurred from 

delayed responses (DOA 1988; Somani and Babu 1989). Further information on delayed death due to 

inhalation of sulfur mustard by humans is discussed below in the sections on respiratory effects in 

Section 3.2.1.2 and on cancer in Section 3.2.1.7. 

As summarized by NRC (1997), the Army’s Chemical Defense Equipment Process Action Team 

(CDEPAT) estimated a lethal concentration-time product (LCt50) for humans of 900 mg-minute/m3

 for 2– 

10-minute exposures. In the absence of better data, the CDEPAT derived this value by averaging toxicity 

data from several animal species. 

Rabbits and monkeys that had undergone tracheal cannulation were exposed to nominal chamber 

concentrations of sulfur mustard ranging from 30 to 350 mg/m3

 (5–54 ppm) for 10 minutes (Cameron et 

al. 1946). While incidence data were not provided, Cameron et al. (1946) reported that sulfur mustard 

vapor produced lethal effects in rabbits and monkeys in the absence of lung damage, indicating that lethal 
 

SULFUR MUSTARD 26 

3. HEALTH EFFECTS 

doses may be absorbed through the mucous membrane of the nose. No deaths attributable to sulfur 

mustard were noted in mice, rats, guinea pigs, rabbits, or dogs exposed to 0.1 mg/m3

 (0.015 ppm) of 

sulfur mustard vapor, 6.5 hours/day, 5 days/week, for up to 1 year (McNamara et al. 1975). 

Gates and Moore (1946) reported undistilled sulfur mustard (agent H) median LCt50 for several different 

animal species exposed whole-body to sulfur mustard for a 10-minute exposure: dog (600 mgminute/m3

); cat (700 mg-minute/m3); monkey (800 mg-minute/m3); rat (800 mg-minute/m3); rabbit 

(900 mg-minute/m3

); mouse (1,200 mg-minute/m3); guinea pig (1,700 mg-minute/m3); and goat 

(1,900 mg-minute/m3

). 

3.2.1.2 Systemic Effects 

The highest NOAEL and all LOAEL values for each study for systemic effects in each species are 

recorded in Table 3-1 and plotted in Figure 3-1. 

Respiratory Effects. There is extensive evidence in humans that the respiratory tract is one of the 

primary targets of sulfur mustard toxicity following inhalation exposure. Respiratory effects have 

occurred in humans following acute and/or chronic exposures to sulfur mustard. In general, warm 

environmental conditions increased the severity of the respiratory effects of sulfur mustard. Reviews of 

the literature (Papirmeister et al 1991; Pechura and Rall 1993; Watson and Griffin 1992) indicate that 

symptoms of exposure are not immediate, but develop over a period of hours to days. Hoarseness and 

irritation of the nasal mucosa may develop 12 hours to 2 days after exposure to 12–70 mg-minute/m3

; 

recovery may occur after approximately 2 weeks. Pulmonary effects are evident after exposure to 100– 

500 mg-minute/m3

. Exposure to 200 mg-minute/m3 causes sneezing and lacrimation, rhinorrhea, sore 

throat, and nosebleed; recovery may occur after approximately 2 weeks following exposure. Exposure to 

≥1,000 mg-minute/m3 may result in injuries progressing to edema in the pharynx and tracheobronchial 

tree, followed by death due to severe edema, secondary infection, or necrotic bronchopneumonia. There 

is evidence that pulmonary injury is the leading cause of mortality in the first few days to weeks after 

sufficiently high concentrations of sulfur mustard (Case and Lea 1955; Hosseini et al. 1989; Papirmeister 

et al. 1991; Pechura and Rall 1993; Willems 1989). 

In a clinical study of soldiers exposed to sulfur mustard during the Iran-Iraq War, Momeni et al. (1992) 

reported respiratory effects in 15% of 535 patients (95% male; 3% children) examined. Respiratory 
LOAEL 

NOAEL Less Serious

(mg/m3) 

a 

System (mg/m3)

Exposure/ 

Duration/ 

Frequency 

(Specific Route)

Species 

(Strain) 

Key to 

figure 

Table 3-1 Levels of Significant Exposure to Sulfur Mustard - Inhalation 

ACUTE EXPOSURE 

Systemic 

1 

Ocular 

33 min 

1.7 M (Injection band over sclera) 

Human 

(mg/m3) 

Serious Reference 

Chemical Form 

Anderson 1942 

2 Human 8 h/d, 3 d Ocular 0.06 

b 

(Slight generalized conjunctival 

reaction) 

M 

Guild et al. 1941 

3 Human 15 min 

Ocular 0.1 M (Conjunctival injection) 

Reed 1918 

4 Human 10 min 

Ocular 0.1 M 

Reed 1918 

5 

(albino) 

Mouse 1 h 

Renal 21.3 (Increased blood and urine uric 

acid levels) 

F 

Kumar and Vijayaraghavan 1998 

6 

(albino) 

Mouse 1 h 

Resp 84.6 F (Decreased lung/Bd Wt ratio) 

Pant and Vijayaraghavan 1999 

Bd Wt 84.6 F (14% reduction) 

7 

(albino) 

Mouse 1 h 

Resp 16.9 F 21.3 (Decreased respiratory 

frequency) 

F 

Vijayaraghavan 1997 

8 

Not reported 

Gn Pig 10 min

Immuno/ Lymphoret 

Bd Wt 125 (14% reduction) 

Allon et al. 1993 

9 Mouse 1 h Pant and Vijayaraghavan 1999

84.6 F (Decreased spleen/Bd Wt ratio) (albino) 
Table 3-1 Levels of Significant Exposure to Sulfur Mustard - Inhalation (continued) 

a 

Exposure/ 

Duration/ 

Frequency 

(Specific Route)

Species 

(Strain) 

Key to 

figure 

INTERMEDIATE EXPOSURE 

System 

NOAEL 

(mg/m3) 

Less Serious 

(mg/m3) 

LOAEL 

(mg/m3) 

Serious Reference 

Chemical Form 

10 

Systemic 

(Beagle) 

Dog 6.5 h/d, 5 d/wk Ocular 0.1 (Conjunctivitis and chronic 

keratitis) 

McNamara et al. 1975 

11 

(Beagle) 

Dog 24 h/d, 5 d/wk Ocular 0.001 c McNamara et al. 1975 

a The number corresponds to entries in Figure 3-1. 

b Used to derive an acute-duration inhalation MRL of 0.0007 mg/m3; concentration adjusted to a TWA of 0.02 mg/m3 for intermittent exposure (see Appendix A) divided by an uncertainty 

factory of 30 (3 for use of a minimal LOAEL and 10 for human variability). 

c Used to derive an intermediate-duration inhalation MRL of 0.00002 mg/m3; concentration adjusted to a TWA of 0.0007 mg/m3 for intermittent exposure (see Appendix A) divided by an 

uncertainty factory of 30 (3 for extrapolation from animals to humans and 10 for human variability).
 

Bd Wt = body weight; d = day(s); F = female; H = hour(s); M = male; Min = minute(s); Resp = respiratory; wk = week(s)
 
1000 

Respiratory Renal Ocular Body Weight Immuno/Lymphor 

Figure 3-1. Levels of Significant Exposure to Sulfur Mustard - Inhalation 

Acute (≤14 days) Intermediate (15-364 da

Systemic Systemic 

mg/m3 Ocular 

8g 100 6m 6m 9m 

7m 5m 7m 

10 

1 

1 

0.1 3 4 10d

2 

0.01 

0.001 11d 

0.0001 

1E-5 

c-Cat -Humans f-Ferret n-Mink Cancer Effect Level-Animals Cancer Effect Level-Humans 

d-Dog k-Monkey j-Pigeon o-Other LOAEL, More Serious-Animals LOAEL, More Serious-Humans 

r-Rat m-Mouse e-Gerbil LOAEL, Less Serious-Animals LOAEL, Less Serious-Humans 

p-Pig h-Rabbit s-Hamster NOAEL - Animals NOAEL - Humans 

q-Cow a-Sheep g-Guinea Pig 
SULFUR MUSTARD 30 

3. HEALTH EFFECTS 

symptoms included those pertaining to the upper respiratory tract such as burning sensation in the mouth, 

pharyngodysphonia (difficulty in speaking due to disorder of the pharynx), and cough. Some exposed 

soldiers became temporarily aphonic due to an acid-like burning sensation of the vocal cords. Lower 

respiratory tract symptoms, such as shortness of breath and tachypnea, were reported less frequently. In 

children exposed to sulfur mustard during the Iran-Iraq War, cough was the first respiratory symptom; in 

a cohort of 14 children and teenagers examined 18–24 hours following exposure, cough developed in 

11 children (79%)(Momeni and Aminjavaheri 1994). Other respiratory effects included crepitation 

(57%), dyspnea (57%), wheezing (36%), and sore throat (14%). Secondary complications consisted of 

extensive stenosis of sections or the entire tracheobronchial tree, suppurative bronchitis, and chronic 

respiratory infections with Staphylococcus aureus, Hemophilus influenzae, and Pseudomonas aeruginosa 

resistant to appropriate antibiotic therapy. Scars, ulcers, strictures, and nonspecific fibrous granulation 

developed in central airways after a delay up to 15 months. Progressive deterioration of lung compliance 

and gas exchange with resulting hypoxemia and hypercapnia, were common with injury. Momeni and 

Aminjavaheri (1994) reported that children had higher occurrences and earlier onset of pulmonary 

symptoms than adults. 

The incidence of respiratory sequelae has been studied in subjects exposed to sulfur mustard in the 

battlefield, workers, and volunteers exposed under controlled conditions. In a study of 197 veterans 

admitted to the hospital in 1986 due to acute respiratory symptoms, exposed to sulfur mustard 10 years 

earlier asthma was newly diagnosed in 21 (10.7%), chronic bronchitis in 116 (58.9%), bronchiectasis in 

17 (8.6%), airway narrowing due to scarring or granulation tissue in 19 (9.6%), and pulmonary fibrosis in 

24 (12.2%)(Emad and Rezaian 1997). None of these were found in a control group of 84 subjects. A 

significant positive correlation was reported between the age of the subject and the severity of asthma, but 

not with the severity of pulmonary fibrosis. There was a significant correlation between age and 

incidence, but not the severity, of chronic bronchitis. There was a significant correlation between the 

severity of pulmonary fibrosis with the spirometry measurement of carbon monoxide diffusion capacity, 

but not the other physiological parameters of forced vital capacity (FVC) or forced expiratory volume in 

1 second (FEV1). Also, British soldiers exposed to sulfur mustard during combat in World War I had a 

significantly higher incidence of death due to bronchitis than the general population (Case and Lea 1955). 

Workers who were apparently exposed to sulfur mustard for a few years (exact quantity and duration not 

reported) also developed acute and chronic respiratory effects. Workers in a Japanese poison gas factory 

were more likely to have chronic bronchitis, chronic cough, and decreased respiratory volume than nonexposed persons (Nishimoto et al. 1970). Manning et al. (1981) reported a significantly increased 
SULFUR MUSTARD 31 

3. HEALTH EFFECTS 

incidence of mortality from pneumonia among 428 former workers of a sulfur mustard manufacturing 

facility. Factory workers in Britain who were exposed to sulfur mustard also showed increased deaths 

due to acute and chronic nonmalignant respiratory disease, including influenza and pneumonia (Easton et 

al. 1988). 

A retrospective mortality study of 1,545 white male Navy recruits who were exposed to >120–960 mgminute/L of sulfur mustard under controlled conditions at a single site between 1944 and 1945 found no 

excess of any cause specific mortality associated with exposure to sulfur mustard relative to a control 

group of 2,663 white male Navy veterans who served at the same location and time as the exposed group, 

but did not participate in sulfur mustard chamber tests (Bullman and Kang 2000). Causes of death 

investigated included laryngeal, lung, and skin cancers, chronic obstructive pulmonary and parenchymal 

respiratory diseases, external causes, and suicide. The veterans who participated in the sulfur mustard 

chamber tests, while exposed to lower levels than estimated for combat-exposed World War I veterans, 

did have sufficient exposure to produce skin reactions of erythema and edema. 

Respiratory effects similar to those described in humans have been reported in experimental animals. 

Information summarized by Pechura and Rall (1993) indicate that inhalation exposure of rabbits to sulfur 

mustard produced concentration-related damage particularly prominent in the upper respiratory tract, 

including nasal passages, pharynx, larynx, trachea, and large bronchi. Low levels of exposure caused 

congestion of these areas without hemorrhage. An Army report noted that dogs exposed to unspecified 

levels of sulfur mustard developed irregular respiration 8 hours after exposure (Winternitz and Finney 

1920). Animals that died 1–3 days after exposure displayed destruction of the epithelial lining, the 

presence of pseudomembrane, and leukocytic infiltration in the trachea and bronchi. Evidence of 

necrotizing bronchopneunomia was present in dogs that died 2–10 days after exposure. In dogs that 

recovered and were killed 1–5 weeks later, there were ulcerations or constrictions of the trachea, but 

chronic changes in the lung were infrequent. 

More recent information is available from studies in mice. A study by Vijayaraghavan (1997) showed 

that a single 1-hour exposure, head-only, to 8.5, 16.9, 21.3, 26.8, 42.3, or 84.7 mg/m3

 sulfur mustard 

produced sensory irritation and, 15–20 minutes after the start, decreased respiratory frequency. 

characterized by a pause between inspiration and expiration. The respiratory frequency decreased 

approximately 20% at 8.5 mg/m3

 and a maximum of 64% at concentrations ≥42.3 mg/m3. The 

concentration that depressed 50% of the respiratory frequency (RD50) was calculated as 27.4 mg/m3

. 

Normal respiration pattern was recovered after inhalation exposure was terminated. While sensory 
SULFUR MUSTARD 32 

3. HEALTH EFFECTS 

irritation was reversible, delayed effects of sulfur mustard were indicated by a significant reduction in 

respiratory frequency beginning 48 hours after exposure at concentrations of ≥21.3 mg/m3

. The 

depression in respiratory frequency following exposure was related to both concentration and 

postexposure time. Airflow limitation was evidenced by a lengthening of expiration time and a decreased 

respiratory rate and is thought to occur due to the effect of sulfur mustard on the tracheal secretory cells. 

Reversible respiratory effects were also observed in similar experiments in mice by Rao et al. (1999) 

(10.6–42.3 mg/m3

) and by Pant and Vijayaraghavan (1999) (84.6 mg/m3). Pant and Vijayaraghavan 

(1999) measured a significant 13% reduction in lung-to-body weight ratio in mice exposed to 84.7 mg/m3 

for 1 hour. 

Guinea pigs were exposed by inhalation to 1,200–1,900 μg-minute/L of sulfur mustard for 10 minutes 

(120–190 mg/m3

) (Allon et al. 1993). A decrease in respiratory rate and minute volume, and an increase 

in tidal volume occurred immediately after the onset of exposure and lasted for up to 7 days after 

exposure. The changes in respiratory parameters were accompanied by a significant reduction in oxygen 

diffusion capacity in the lung. 

These reports indicate similar respiratory effects of sulfur mustard in several animal species (rabbits, 

dogs, mice, and guinea pigs) and humans, which suggests that knowledge obtained regarding respiratory 

effects in animal models can be usefully applied to humans. 

Cardiovascular Effects. In 12 of 53 (23%) autopsies of Bari Harbor victims, small sub-epithelial 

hemorrhages were noted in the hearts, but in all instances, the parietal pericardium showed no pathology 

(Alexander 1947). There was a slight increase in the pericardial fluid having normal color in four cases 

(8%). In 18 cases, the myocardium was described as pale and lacking normal firmness. 

Studies of 65 sulfur mustard casualties of the Iran-Iraq War treated in European hospitals did not indicate 

any heart abnormalities (Willems 1989). However, mild tachycardia without fever was reported in a 

group of 14 children and teenagers (9 boys, aged 9 months to 14 years; 5 girls, aged 13 months to 9 years) 

who were examined in a hospital in Iran 18–24 hours following exposure to sulfur mustard from air 

bombs during the Iran-Iraq War (incidence not reported) (Momeni and Aminjavaheri 1994). However, 

the tachycardia may have been due to stress caused by the bombing episode. In a 1996 follow-up study of 

Iran-Iraq War veterans, 10 years after hospital admission in 1986 due to acute respiratory symptoms with 

confirmed sulfur mustard exposure, only 3/212 (1.4%) had cardiovascular disease, which was not 
 

SULFUR MUSTARD 33 

3. HEALTH EFFECTS 

confirmed attributable to exposure (Emad and Rezaian 1997) (see study description under Respiratory 

Effects). 

Gastrointestinal Effects. Victims of the World War II Bari Harbor incident suffered local lesions of 

the oropharynx and upper portion of the esophagus (Alexander 1947). In a few cases, there was intense 

congestion of the first inch of the esophagus, which may or may not have been due to the blast. In 19 of 

53 (36%) cases autopsied, stomach irritation and inflammation were documented. The lesions varied 

from simple hyperemia to focal loss of epithelium, necrosis, and ulceration. Some lesions were located 

near the cardiac end, but most were in the region of the pylorus. In some cases, the hyperemia extended 

into the duodenum, and in one case, congestion of the jejunum was noted (Alexander 1947). In a review 

of the clinical manifestations of sulfur mustard exposure in Iran-Iraq War victims, Pierard et al. (1990) 

reported that endoscopy frequently revealed acute gastritis. Gastrointestinal effects of nausea and 

vomiting were reported in 10% of 535 patients (95% male; 3% children) exposed to sulfur mustard during 

the Iran-Iraq War (Momeni et al. 1992). Gastrointestinal symptoms were more frequent in children and 

teenagers, compared to adults; incidences of gastrointestinal effects of nausea (9 patients, 64%), vomiting 

(6 patients, 43%), and bleeding (2 patients, 14%) were reported in a group of 14 children and teenagers 

(9 boys, aged 9 months to 14 years; 5 girls, aged 13 months to 9 years) who were admitted to a hospital in 

Iran 18–24 hours following exposure to sulfur mustard from air bombs during the Iran-Iraq War (Momeni 

and Aminjavaheri 1994). Gastrointestinal neoplasms were reported in Japanese sulfur mustard factory 

workers who were involved with the production of chemical agents during World War II (Yamakido et al. 

1985). 

Gastrointestinal effects were not reported in rats, mice, rabbits, guinea pigs, and dogs exposed 

continuously to sulfur mustard concentrations up to 0.001 mg/m3

, 5 days/week, for ≥7.5 months 

(McNamara et al. 1975). Angelov et al. (1996a) observed changes in the intestinal muscosa consisting of 

villi necrosis, dilatation of blood vessels, and increased cellular presence in broiler chickens after 

inhalation exposure to 0.9 mg/L (900 mg/m3

, 138 ppm) of sulfur mustard for 30 minutes. 

Hematological Effects. There are reports of changes in white blood cell (WBC) counts in victims of 

sulfur mustard exposure during World War I and the Iran-Iraq War. In a group of children and teenagers 

who were admitted to a hospital in Iran 18–24 hours following exposure to sulfur mustard from air bombs 

during the Iran-Iraq War, admission WBC counts ranged from 9,500 to 11,200 cells/μL (normally 4,500– 

10,000 cells/μL), indicating mild leukocytosis (Momeni and Aminjavaheri 1994). During days 1–3 

following exposure in World War I, increases of 3–5 times normal levels in WBC counts in peripheral 
 

SULFUR MUSTARD 34 

3. HEALTH EFFECTS 

blood were measured (Marrs et al. 1996). The increase was due mainly to an increase in polymorphonuclear cells, while lymphocytes were reduced in numbers during this period. In severe cases, a 

subsequent leukopenia occurred with WBC counts falling to <200 cells/μL. Leukopenia and 

pancytopenia were also observed in casualties of sulfur mustard exposure of the World War II Bari 

Harbor incident and during the Iran-Iraq War (Dacre and Goldman 1996; Marrs et al. 1996; Momeni and 

Aminjavaheri 1994; Zakerinia et al. 1998). A 13-month-old Iranian girl developed pancytopenia and 

respiratory failure, and died 8 days after exposure (Momeni and Aminjavaheri 1994). 

In a review of the clinical manifestations of sulfur mustard exposure in the Iran-Iraq War victims, Pierard 

et al. (1990) reported that in addition to the leukocytosis followed by leukopenia and pancytopenia 

described above, the ratio of T and B lymphocytes decreases while the phagocytic function of neutrophils 

remains intact. A primary decrease in albumin and increase in α-globulin content, especially 

α1 antitrypsin, occurs. Both serum protein complement component C3 and C4 titers first increase, 

followed by a gradual decrease. Aplastic anemia or pancytopenia is not uncommon. Increases in serum 

tumor markers, α-fetoprotein, β-HCG, and CA-125, have been observed, but the relevance of these 

increases to the oncogenic potential of sulfur mustard is not yet known. Aplastic anemia was reported in 

a prospective study of Iran-Iraq War victims (Zakerinia et al. 1998). 

Dogs and rabbits exposed to 0.1 mg/m3

 of sulfur mustard in the air for 1 year showed no hematological 

changes in a study that did not report further experimental details (McNamara et al. 1975). Specific 

parameters monitored included red blood cell counts, total and differential white cell counts, hematocrit, 

and hemoglobin concentration. 

Changes in the coloring and formation of erythrocyte nuclei and fatty dystrophy of bone marrow cells 

were observed in broiler chickens after inhalation exposure to 0.9 mg/L (900 mg/m3

, 138 ppm) of sulfur 

mustard for 30 minutes (Angelov et al. 1996a). 

Musculoskeletal Effects. No evidence of sulfur mustard-related changes to the musculoskeletal 

system was reported in any of 53 autopsies of victims of the World War II Bari Harbor incident 

(Alexander 1947). 

Hepatic Effects. In 39 of 53 (74%) autopsies of Bari Harbor victims, yellow streaks and patches of 

fatty change appearing as fatty necrosis were observed throughout the liver (Alexander 1947). Several 

pale liver sections and atypical liver texture were mentioned. In 3 of 53 (6%) autopsies, small 
 

SULFUR MUSTARD 35 

3. HEALTH EFFECTS 

subcapsular hemorrhages, and in one instance, a small rupture near the diaphragmatic attachment, were 

noted. The gall bladder contained bile with a thick appearance. Microscopic examinations were 

performed on 31 of the 39 livers with gross changes. Five showed fatty change and two showed focal 

necroses. 

Renal Effects. Renal complications, consisting of acute hemorrhagic nephritis, oliguria, albuminuria, 

and casts, have been reported in near-death stages of sulfur mustard warfare victims (Papirmeister et al. 

1991). 

Microscopic examinations of kidney sections from Bari Harbor sulfur mustard casualties revealed tubules 

containing casts in 25 of 32 (78%) cases. In three cases, casts appeared to be calcified. Casts appeared to 

contain hemoglobin, as judged by their color in hematoxylin-stained sections, in eight cases. Both cast 

types were present in the remaining 14 cases (Alexander 1947). 

Blood uric acid increased significantly in a dose- and time-related manner in mice exposed nose-only to 

21.2, 42.3, or 84.6 mg/m3

 of sulfur mustard in the air for 1 hour, suggesting development of kidney 

damage (Kumar and Vijayaraghavan 1998). Blood uric acid levels peaked at 2 days after exposure, but 

were still significantly elevated above controls at 7 days postexposure. 

Endocrine Effects. No significant findings were noted grossly in the thyroid or adrenal glands in any 

of 53 autopsies of victims of the World War II Bari Harbor incident (Alexander 1947). 

The time course of changes in serum concentrations of total and free testosterone, luteinizing hormone 

(LH), dehydroepiandrosterone (DS), follicle-stimulating hormone (FSH), 17 α-OH progesterone, and 

prolactin were studied in 16 men during the first 3 months after chemically confirmed exposure in 

1987 during the Iran-Iraq War to chemical weapons containing sulfur mustard (Azizi et al. 1995). A 

group of 34 healthy unexposed men of similar age served as controls. At 1 week after exposure, total 

testosterone, free testosterone, and DS were significantly lower, 57, 72, and 53%, respectively, in exposed 

men than in controls, while levels of the remaining hormones were comparable between groups. Total 

testosterone, free testosterone, and DS levels continued to decrease during the first 5 weeks after 

exposure. Dehydroepiandrosterone mean values reached as low as 18% of the mean of control subjects. 

After the 5th week, these three hormone levels returned to normal levels at 12 weeks after injury. Small 

but significant increases in mean serum concentration of LH at the 3rd week and that of FSH and prolactin 

at the 5th week, were measured. Normal levels of LH, FSH, and prolactin were measured at 12 weeks. 
SULFUR MUSTARD 36 

3. HEALTH EFFECTS 

FSH and LH response levels to 100 μg of gonadotropin releasing hormone (GnRH) administered 

intravenously during the first week after exposure, were subnormal in four of five patients. 

In another study, the time course of changes in thyroid indices, serum T3, T4, TSH, reverse T3, 

thyroglobulin and cortisol, plasma adrenocorticotropic hormone (ACTH), and free T3 and T4 (FT3, FT4) 

were studied in 13 male soldiers, ages 21–32 years, during the first 5 weeks after chemically confirmed 

exposure in 1987 during the Iran-Iraq War to chemical weapons containing sulfur mustard (Azizi et al. 

1993). A group of 34 healthy unexposed men of similar age served as controls. T4 and FT4 were not 

consistently affected following injury; compared to controls, significantly decreased values were 

measured at 1 and 5 weeks after exposure, but values slightly above normal were measured at 3 weeks. 

T3 and FT3 were significantly lower (11–23%) than control at 1, 3, and 5 weeks after injury. Reverse T3 

concentration in injured men was significantly higher (29%) than mean control value at 1 week, but was 

normal at weeks 3 and 5. TSH and thyroglobulin levels in the injured soldiers were comparable to 

controls during the 5 postexposure weeks. Cortisol was significantly higher (40%) than normal 1 week 

after exposure, within the normal range at week 3, and significantly decreased (50%) below normal at 

week 5. ACTH was significantly increased (57–80%) above the normal control value at 1, 3, and 5 weeks 

after exposure. 

In a follow-up study of 42 men, ages 18–37, injured by sulfur mustard during the Iran-Iraq War, serum 

testosterone, LH, and prolactin concentrations were normal in all men 1–3 years following exposure 

(Azizi et al. 1995). A comparison of the mean serum FSH concentration in 13 subjects with sperm count 

below 20 million and in 20 subjects with sperm counts above 60 million, revealed a nearly 2-fold increase 

in FSH concentration in the those with the lower sperm count; the increased FSH level was 38% above 

the mean FSH concentration in a group of 34 health unexposed males. 

Dermal Effects. Since the dermal effects of sulfur mustard are due to direct contact of the airborne 

chemical with the skin, which is supported by experiments in animals that have shown little involvement 

of the skin when sulfur mustard was administered parentally at dose levels known to be systemically toxic 

and lethal (Papirmeister et al. 1991), dermal effects in humans and animals are described under Dermal 

Exposure, Section 3.2.3.2. 

Ocular Effects. There is extensive evidence in humans and animals that the eyes are one of the most 

sensitive targets of sulfur mustard toxicity following vapor exposure. This is attributed to the constant 

presence of a tear film over the eye’s surface and mucous membranes (Pechura and Rall 1993). Ocular 
SULFUR MUSTARD 37 

3. HEALTH EFFECTS 

effects are due to direct contact and absorption of sulfur mustard by ocular tissues. In studies with 

soldiers, Guild et al. (1941) and Anderson (1942) reported conjunctivitis (inflammation of the 

conjunctiva) as the first sign of exposure to sulfur mustard without symptoms. An acute inhalation MRL 

of 0.0007 mg/m3

 (see Appendix A) was derived based on a concentration of 0.06 mg/m3 at which minimal 

ocular effects (slight generalized conjunctival reaction) occurred in men who underwent a 3-day chamber 

test with sulfur mustard (Guild et al. 1941). The National Advisory Committee for Acute Exposure 

Guideline Levels (AEGLs) for Hazardous Substances has established AEGLs for sulfur mustard (see 

Chapter 8) based on ocular effects (NAC/AEGL 2001). Other acute signs and symptoms described in 

literature reviews include ocular irritation, redness, lacrimation, burning pain, swelling of the eyelids, 

photophobia, blepharospasm (spasm of eyelid muscle), and corneal damage (Papirmeister et al. 1991; 

Pechura and Rall 1993; Somani 1992; USACHPPM 2000a). As with skin and the respiratory tract, an 

asymptomatic latent period precedes the first signs of ocular injury. Both the severity of ocular effects 

and the latency period are dependent on the exposure concentration and duration (Ct, concentration-time 

product) (Eisenmenger et al. 1991; Papirmeister et al. 1991; Pechura and Rall 1993). The latency period 

is generally shorter in eye injuries than in skin (Papirmeister et al. 1991). As the concentration of sulfur 

mustard increases, the injury to the eye appears to parallel that of the respiratory tract. Varying degrees of 

humidity do not influence the degree of injury to the eye; this is attributed to the constant presence of 

fluid on the surface of the eye (Papirmeister et al. 1991). An increase in temperature appears to increase 

the severity of dermal effects to a greater extent than ocular effects. Anderson (1942) concluded, based 

on a comparison on his observations at tropical temperatures (>80 °F) with those of Guild et al. (1941) at 

cooler temperatures (≤80 °F), that an eye lesion, of any particular degree of severity, would result under 

tropical conditions from exposure to a Ct slightly lower than that required to produce the same result 

under cool conditions. Guild et al. (1941) concluded, based on experiments at gas chamber temperatures 

between 55 and 80 °F, that the degree of sulfur mustard-induced ocular lesions is less related to 

temperature than that of skin lesions. Reviews from the literature (Papirmeister et al. 1991; Pechura and 

Rall 1993; Watson and Griffin 1992) indicate that exposure to concentration-time products of 

≤12 mg-minute/m3

 produced conjunctivitis and reddening with a latency of hours to days, whereas 

exposure to 50–100 mg-minute/m3

 produced corneal edema and clouding, eyelid edema, photophobia, 

severe blepharospasm, and temporary blindness in 3–12 hours with recovery occurring in several weeks. 

Exposure to 400–800 mg-minute/m3

 may produce corneal damage in 1–4 hours accompanied by possible 

ulceration and secondary infection. Recovery in this case may take months with the possibility of 

permanent eye damage. Exposure to higher concentrations of sulfur mustard increases the severity of 

these signs and symptoms, and may produce systemic effects and incapacitation. 
SULFUR MUSTARD 38 

3. HEALTH EFFECTS 

In a clinical study of Iran-Iraq War victims exposed to sulfur mustard, Momeni et al. (1990) reported 

ocular effects including conjunctivitis, blepharokeratoconjunctivitis, a burning sensation, and lacrimation 

in 85%, photophobia in 62%, edema of the eyelids in 12%, and corneal edema and abrasion in 8% of 

535 patients (95% male; 3% children) examined. Most patients had blurred vision and a few were 

temporarily blinded. Of 14 children and teenagers (9 boys, aged 9 months to 14 years; 5 girls, aged 

13 months to 9 years), who were examined 18–24 hours following exposure to sulfur mustard during the 

Iran-Iraq War (Momeni and Aminjavaheri 1994), ocular effects of conjunctivitis and photophobia were 

most prevalent, each occurring in 93% of the children, with lower incidences of edema of the eyelids 

(57%), closure of the eyes (43%), keratitis (43%), blepharospasm (43%), subconjunctival hemorrhage 

(14%), and corneal ulcer in one child (7%). Burning sensation (71%) and pain (36%) were also noted. 

The burning sensation developed 3–4 hours after exposure and was followed by photophobia and 

conjunctivitis. While incidences of mild ocular effects were only slightly higher, Momeni and 

Aminjavaheri (1994) reported that the severity of ophthalmic manifestations was greater in children and 

teenagers than adults, so that children may be a sensitive sub-group. 

Humans who have experienced eye injury due to acute sulfur mustard exposure may continue to have 

recurrent corneal erosions and inflammatory keratitis for an indefinite number of years after the initial 

injury (Amalric et al. 1965; Dahl et al. 1985; Mann 1944; Scholz and Woods 1945). In the acute stage, 

the limbal region has been reported to present a marbled appearance in which areas of ischemia are 

surrounded by blood vessels of irregular diameter. Later, the vascularized scars of the cornea often 

contain deposits of cholesterin, calcium, and fat (Pechura and Rall 1993; Scholz and Woods 1945). 

While inflammatory keratitis has developed intermittently in veterans injured by sulfur mustard, a sudden 

increase in the number of cases with these symptoms has been observed some 8–25 years after the initial 

injury (Pechura and Rall 1993). 

There are no rigorous experimental human studies evaluating the occurrence of ocular sensitivity to sulfur 

mustard. From early chamber tests that indicated conjunctivitis as the initial sign of toxicity, conducted 

with three groups of men, those having no previous exposure, those who were exposed to very low 

concentrations of sulfur mustard through their work, but who experienced no symptoms or burns, and 

those with unspecified occupational exposure who experienced one or more burns at various times, one 

investigator concluded that the toxicity of sulfur mustard did not appear to increase with previous 

exposure (Reed 1918). However, details upon which this conclusion was based were lacking. As 

reported by USACHPPM (2000a), animal data suggest that ocular sensitization occurs following 

inhalation exposures that produce severe effects. McNamara et al. (1975) cite an earlier study in rabbits 
SULFUR MUSTARD 39 

3. HEALTH EFFECTS 

by Laughlin (1944a) in which the severity of ocular effects increased after a second exposure, subsequent 

to recovery from an initial exposure, to a sulfur mustard Ct of 400 mg-minute/m3

. 

While quantitative exposure data are not available, conjunctivitis, altered corneal pigmentation, 

photophobia, lacrimation, impaired vision, and blepharospasm have been reported in studies of workers at 

sulfur mustard research laboratories and manufacturing plants with longer-than-acute (>14 days) exposure 

durations (Laughlin 1944b; Morgenstern et al. 1947). However, these studies are limited by possible 

exposures to multiple toxic chemicals, confounding factors of age and smoking history, and lack of 

comparisons to controls. 

Scholz (1945) summarized the ocular histological changes that developed in rabbits after sulfur mustard 

exposure. Changes included corneal basal epithelial cell edema and nuclei relocation, loss of mucus and 

sloughing off of goblet cells, edema and loss of the conjunctival and corneal epithelial cells, and edema of 

the stroma as a consequence of corneal endothelial cell damage and loss. When the endothelium of the 

blood vessels was lost, an infiltrate, composed primarily of neutrophils, accumulated. The conjunctival 

epithelium began to regenerate about 2 days after injury. If the corneal and limbal epithelium had been 

lost, conjunctival epithelium was observed to cross the limbus to resurface the cornea. Conjunctival 

epithelium thickened in 1–2 weeks after injury, but the corneal epithelial layer remained thinner than 

normal, often with “skip” areas referred to as defects. When these defects were long-lasting, necrotic 

ulcers, with or without bacterial infection, often developed. Depending on the severity of the original 

injury, a scarring or “hazing” of the corneal stroma was noted. Normal corneal epithelial regeneration 

could occur rapidly if the underlying stroma was intact, but if damaged, regeneration could be incomplete 

with recurrent erosion and vascularization (Somani 1992). 

Long-term studies examining delayed ocular effects in rabbits acutely exposed to sulfur mustard showed 

that, similar to the human condition based on the lifetime of a rabbit as one-tenth that of a human, 

migration of fatty and/or cholesterin deposits to the surface of the eye occurred 7–8 months after initial 

injury, causing secondary ulceration (Mann and Pullinger 1944). 

Chronic keratitis has been observed in dogs and rats exposed to sulfur mustard vapor for ≥7.5 months; 

however, this lesion occurred only at the lower of two test concentrations in rats (McNamara et al. 1975). 

McNamara et al. (1975) reported chronic keratitis (inflammation of the cornea) in 5 of 79 of rats exposed 

to 0.001 mg/m3

 of sulfur mustard for 12 months, compared to a single occurrence in 29 control animals. 

However, in this same study (McNamara et al. 1975), no keratitis was observed in a group of 79 rats 
SULFUR MUSTARD 40 

3. HEALTH EFFECTS 

exposed to a higher concentration (0.1 mg/m3) of sulfur mustard. In dogs exposed to these same 

concentrations, 3 of 10 dogs exposed to 0.1 mg/m3 for ≥7.5 months developed ocular effects, first 

appearing after 16 weeks of exposure and including corneal opacity, pannus, chronic keratitis, 

vascularization, pigmentation, and granulation, compared to no incidences of these lesions in control or 

low-dose animals (McNamara et al. 1975). An intermediate-duration inhalation MRL of 0.00002 mg/m3 

(see Appendix A) was based on the NOAEL of 0.001 mg/m3

 for ocular effects in dogs identified in this 

study (McNamara et al. 1975). McNamara et al. (1975) reported no signs of increased ocular sensitivity 

in dogs or guinea pigs exposed for 1 year to 0.021 mg/m3

 (TWA). 

Using a different derivation procedure than that used for chronic-duration inhalation MRLs, the Army has 

established an air exposure limit for the general population for chronic exposures (GPL) of 

0.00002 mg/m3

 as a 24-hour time-weighted average, 7 days/week (USACHPPM 2000a). The key critical 

effect chosen for the GPL was ocular effects in humans. A previously established GPL of 0.0001 mg/m3 

for sulfur mustard was promulgated by the Centers for Disease Control and Prevention (CDC) in 1988 

(DHHS 1988). 

Body Weight Effects. No information was located regarding effects on body weight in humans 

following inhalation exposure to sulfur mustard. 

In female Swiss albino mice exposed head only to 0, 8.5, 16.9, 21.3, 26.8, 42.3, or 84.7 mg/m3

 sulfur 

mustard in the air for 1 hour, decreases in body weight began 24 hours after exposure, were 

concentration-related, and achieved statistical significance (p<0.05) at concentrations of ≥16.9 mg/m3 

(Vijayaraghavan 1997). Seven days postexposure, body weights were decreased by 2, 13, 28, 25, 32, and 

34% in the control, 8.5, 16.9, 21.3, 26.8, and 42.3 mg/m3

 exposure groups. In another study in female 

albino mice, in which the animals were exposed to 84.6 mg/m3

 sulfur mustard for 1 hour, a progressive 

fall in body weight was observed starting on the third post-exposure day; on post-exposure day 7, body 

weight was reduced by 14%, compared to control animals (Pant and Vijayaraghavan 1999). Food and 

water intakes were also significantly decreased. Since histopathological examination of the esophagus 

was apparently not conducted, it is not known whether the reduced food and water intake may have been 

due to discomfort produced by esophageal lesions. 

Guinea pigs administered nominal concentrations of 1,250, 1,650, or 1,750 μg-minute/L (125, 165, or 

175 mg/m3

) of sulfur mustard (head only) for 10 minutes exhibited a dose-related significant decrease in 

body weight, with no recovery evident at 6–7 days post-exposure (Allon et al. 1993). At 6–7 days post­
 

SULFUR MUSTARD 41 

3. HEALTH EFFECTS 

exposure, body weight was reduced compared to controls by ~14, ~24, and ~27% at the low-, mid-, and 

high-concentrations, respectively (data presented graphically). 

3.2.1.3 Immunological and Lymphoreticular Effects 

The spleen demonstrated evidences of gross pathology in 33 of 53 (62%) autopsies of Bari Harbor victims 

(Alexander 1947). In the majority of cases, the spleen was described as shrunken in size with pale color. 

Discoloration of the lymph nodes in the axillary, inguinal, and mesenteric glands were noted. No 

significant findings were noted grossly in the thymus in any of the autopsies. Microscopically only 2 of 

32 spleens examined showed degeneration or necrosis; pyknosis and karyorrhexis of lymphocytes in 

some corpuscles was observed in one and slight necrosis of the malpighian follicle in the other. 

Consistent with observations of the human spleen, Pant and Vijayaraghavan (1999) measured a 

significant 38% reduction in spleen-to-body weight ratio in mice exposed to 84.7 mg/m3

 for 1 hour. 

Cameron et al. (1946) provided a general description of pathological changes in rabbits and monkeys that 

had undergone tracheal cannulation and were exposed to nominal chamber concentrations of sulfur 

mustard ranging from 30 to 350 mg/m3

 (5–54 ppm). After 12 hours, damage was found in the cervical 

lymph nodes, which drain the nose and lymphoid tissue throughout the body. In experiments where the 

time sequence was studied, damage to the cervical lymph nodes could not be attributed solely to 

lymphatic absorption from nasal mucosa, since identical changes resulted from topical skin application or 

subcutaneous injection of sulfur mustard. Angelov et al. (1996a) detected atrophy of the lymphoid tissue 

in the bursa Fabricii of broiler chickens after inhalation exposure to 0.9 mg/L (900 mg/m3

, 138 ppm) of 

sulfur mustard for 30 minutes. 

No generalized hypersensitization reaction, as indicated by the lack of release of bradykinin or histamine 

in the plasma, was seen in dogs exposed to 0.029 mg/m3

 (TWA) of sulfur mustard for 6 months 

(McNamara et al. 1975). 

3.2.1.4 Neurological Effects 

No significant findings were noted grossly in the central nervous system in any of 53 autopsies of World 

War II Bari Harbor victims (Alexander 1947). 
 

 

SULFUR MUSTARD 42 

3. HEALTH EFFECTS 

Dogs exposed to unspecified levels of sulfur mustard showed no tremors or convulsions during exposure, 

but no examination of the nervous system was conducted (Winternitz and Finney 1920). 

3.2.1.5 Reproductive Effects 

In a follow-up study of 42 men, ages 18–37, conducted 1–3 years after injury by sulfur mustard during 

the Iran-Iraq War, the mean sperm count was 84 million cells per mL, ranging from 0 to 328 million cells 

per mL (Azizi et al. 1995). Thirteen (29%) had decreased sperm count below 20 million. Serum 

testosterone, LH, and prolactin concentrations in the 13 subjects with sperm count below 20 million were 

comparable to the levels in 20 subjects with sperm count above 60 million. FSH measured in these same 

groups was higher in the group with lower sperm counts. The increased FSH level was 38% above the 

mean FSH concentration in a group of 34 healthy unexposed males. Complete or relative arrest of 

spermatogenesis was evident in each testicular biopsy (100% incidence) performed on six men with 

sperm count below 20 million cells per mL. 

Pour-Jafari (1992, 1994a) reported an increased rate of fetal deaths and an increased secondary sex ratio 

(57.2 vs. 51.0% in controls, percent of males) in progenies of Iranian survivors of chemical attacks that 

included sulfur mustard. 

In a survey of 800 Iranian men who were exposed to sulfur mustard during the Iran-Iraq War, 279 men 

(34.8%) reported decreased libido, 342 (42.8%) reported no change, 6 (0.8%) reported increased libido, 

and 173 (21.6%) did not respond to this survey question (Pour-Jafari and Moushtaghi 1992). Of these 

men, 86.6% still suffered symptoms from chemical injury, namely lung and skin lesions. 

In a study available only in abstract form, exposure of male rats to 0.1 mg/m3

 sulfur mustard 6 hours/day, 

5 days/week for up to 52 weeks significantly increased the rate of dominant lethal mutations (Rozmiarek 

et al. 1973). A maximum rate of 9.4% was observed at 12–52 weeks, compared to 3.9% in controls. In 

an additional study in which unexposed female rats were mated to males exposed to 0, 0.001, or 

0.1 mg/m3

 sulfur mustard for up to 52 weeks, the percentage of fetal deaths in the high-exposure group 

appeared higher than in the low-exposure group, but no statistical analysis of the results was presented 

(McNamara et al. 1975). The percentages of fetal deaths at week 12 were 4.12, 4.24, and 21.05 for 

controls, 0.001, and 0.1 mg/m3

 exposure groups, respectively. In that same study, the investigators stated 

that the percentage of fetal deaths in rats exposed to 0.001 or 0.1 mg/m3

 sulfur mustard at various times 
SULFUR MUSTARD 43 

3. HEALTH EFFECTS 

during pregnancy was within normal limits, but no statistical analyses of the results was presented. No 

firm conclusions can be drawn from these limited reports. 

3.2.1.6 Developmental Effects 

Pour-Jafari (1994b) reported an increased incidence of congenital malformations among offspring of 

Iranian chemical victims. While sulfur mustard was a common chemical agent, the victims may have 

been exposed to other agents instead of or in addition to sulfur mustard. 

Rozmiarek et al. (1973) reported that exposure of pregnant rats to 0.1 mg/m3

 vaporized sulfur mustard did 

not produce fetal toxicity or gross teratogenic effects, but little additional detail was provided in this 

abstract. No excess fetal abnormalities were noted when female rats were mated with males exposed to 

up to 0.1 mg/m3

 for up to 52 weeks (McNamara et al. 1975), but no further details were provided. No 

conclusions regarding developmental effects of sulfur mustard can be made based on the information 

available. 

3.2.1.7 Cancer 

Human Cancer Studies. Data on cancer in humans after inhalation exposure to sulfur mustard are from 

two primary sources: inhalation for several years by sulfur mustard factory workers and inhalation as the 

result of a few or of single exposures during combat in World War I and in the Iran-Iraq War. While 

several epidemiologic studies provide sufficient evidence that sulfur mustard is carcinogenic in humans, 

particularly in the upper respiratory tract, in no case was the exposure level or duration quantified, and 

therefore, these data are inadequate for deriving dose-response relationships. Typically, factories 

produced several different poisonous gases and workers involved with sulfur mustard production were 

exposed to other toxic chemicals, confounding any study findings. 

Other studies provide epidemiological evidence that World War I veterans who were exposed to sulfur 

mustard in combat had slight, but statistically significant, increased incidences of lung cancer deaths. 

British retired veterans who were studied 15 years after their exposure to sulfur mustard in World War I 

showed twice the expected number of deaths due to lung cancer (standardized mortality ratio [SMR]=2; 

p<0.01) compared to controls and also had excessive deaths from bronchitis (SMR=10, p<0.001), as 

compared to nonexposed soldiers (Case and Lea 1955). Veterans who were not exposed to sulfur 
SULFUR MUSTARD 44 

3. HEALTH EFFECTS 

mustard, but who did have bronchitis also had excess mortality due to lung cancer (SMR=2; p<0.01), as 

compared with controls. The authors suggest that the finding of a high incidence of lung cancer in both 

sulfur-mustard-exposed veterans and in non-sulfur-mustard-exposed veterans who had bronchitis does not 

support the action of sulfur mustard as a direct carcinogen. Deaths from neoplasms other than cancer of 

the lung were not significantly increased. 

A cohort of 7,151 white male American World War I soldiers was studied 1–37 years (Beebe 1960) and 

47 years (Norman 1975) postexposure. Deaths from respiratory cancer occurred in 2.5% of those 

exposed to sulfur mustard, 1.8% of those who had had pneumonia, and in 1.9% of a control group 

(Norman 1975). The risk of death from lung cancer among men gassed relative to that for controls was 

estimated as 1.3 (95% CI=0.9–1.9), which in contrast to the findings of Case and Lea (1955), did not 

suggest a strong carcinogenic effect under the exposure conditions. In a 1996 follow-up clinical study of 

197 Iran-Iraq War veterans, 10 years after hospital admission in 1986 due to acute respiratory symptoms 

with confirmed sulfur mustard exposure, no bronchial carcinoma or other lung malignancies were found 

(Emad and Rezaian 1997) (see study description under Respiratory Effects in Section 3.2.1.2). 

Occupational studies from three countries have shown elevated incidence of cancers of the respiratory 

tract among factory workers who manufactured sulfur mustard and other chemical agents. In Japanese 

factory workers, histological examination revealed foci of moderate or severe atypical cell lesions or 

carcinoma in the bronchial epithelium (Tokuoka et al. 1986). Another study of workers from this same 

factory showed an increased number of deaths (SMR=37; 33 deaths observed vs. 0.9 deaths expected) 

from cancer of the respiratory passages (Wada et al. 1968). In another study of Japanese factory workers, 

with estimated exposure to sulfur mustard concentrations of 0.05–0.07 mg/L, of 172 worker deaths, 

48 (28%) were due to malignant tumors compared with 7.7 and 8.5% in two groups of unexposed 

residents of the same area (Nakamura 1956;Yamada 1963). Respiratory tract tumors accounted for 58% 

of all malignant tumors (16% of all deaths). In the two reference groups, the incidence of respiratory 

tumors was much lower, 0.5 and 0.3%, respectively. In the occupational cases described above, central 

lung cancers were more commonly observed than peripheral lung cancers, and the most common 

histologic types were squamous cell carcinoma and small cell carcinoma (Yamada 1963). The duration of 

sulfur mustard exposure in cases of lung cancer was 7–9 years, and the latent period for tumor induction 

was 17–20 years. 

Additional studies have been conducted to determine the comparative risk for development of cancer in 

Japanese males who worked in a poison gas factory between 1927 and 1945 that produced sulfur mustard, 
 

SULFUR MUSTARD 45 

3. HEALTH EFFECTS 

lewisite, diphenylcyanarsine, hydrocyanic acid, chloracetophenone, and phosgene (Nishimoto et al. 1983; 

Yamakido et al. 1996). In an attempt to establish a dose-relationship, the workers were divided into three 

groups according to type of work and association with sulfur mustard. Among 2,068 cases investigated, 

the number of deaths from cancer of the lungs in the two groups with the highest sulfur mustard exposure 

potential was more than 3 times the number in the local male population (SMR≥3, p<0.01) (Nishimoto et 

al. 1983). Deaths due to cancers of the gastrointestinal tract and liver or other type were not significantly 

elevated. Yamakido et al. (1996) studied 1,632 male workers from this same factory and found that the 

SMRs for lung cancer were significant (p<0.001) in the group working directly in the production of sulfur 

mustard and lewisite for >6 months (SMR=3.24 [0.5–5 years], SMR=7.35 [>5 years]). In a different 

group of workers who had less contact with sulfur mustard, the SMR for lung cancer was significant only 

in the subgroup with >5 years of employment (SMR=4.92), further supporting a dose-relationship for 

lung cancer. However, there were no data presented to weight relatively the exposure to sulfur mustard 

and lewisite. 

British sulfur mustard workers also showed increased deaths from cancers of the respiratory passages and 

from lung cancer (Manning et al. 1981). In a cohort study of 502 workers involved in sulfur mustard 

manufacturing between 1940 and 1945, a significant excess mortality was observed for carcinoma of the 

larynx and trachea (SMR=7.5, p<0.02). While not listed as cause of death, seven subjects developed 

cancer of the larynx, compared with 0.75 expected, yielding a rate ratio of 9.3 (p<0.001). Increased 

mortality due to cancers of other organs was not statistically significant. In another study of 3,354 British 

sulfur mustard workers, significant excesses were observed compared with national death rates for deaths 

from cancer of the larynx (SMR=2.7, 11 deaths observed, 4.04 deaths expected, p=0.003), pharynx 

(SMR=5.5, 15 observed, 2.73 expected, p<0.001), lung (SMR=1.4, 200 observed, 138.39 expected, 

p<0.001), upper respiratory sites combined (lip, tongue, salivary gland, mouth, and nose) (SMR=2.8, 

12 observed, 4.29 expected, p=0.002), esophagus (SMR=1.9, 20 observed, 10.72 expected, p<0.01), and 

stomach (SMR=1.4, 70 observed, 49.57 expected, p<0.001) (Easton et al. 1988). The risks of cancers of 

the pharynx and lung, but not of the esophagus and stomach, were significantly related to duration of 

employment. 

In a study of 245 German factory workers with previous occupational exposure to sulfur mustard and 

followed for over 20 years there was a statistically significant increase in malignant tumors, especially 

bronchial carcinoma, bladder carcinoma, and leukemia (Weiss and Weiss 1975). 
SULFUR MUSTARD 46 

3. HEALTH EFFECTS 

A retrospective mortality study was conducted in World War II veterans who participated in U.S. military 

experiments testing the effectiveness of various protective clothing and equipment in preventing injury 

due to sulfur mustard (Bullman and Kang 2000). The study identified 1,545 white male Navy recruits 

who were exposed to nonlethal levels (>120–960 mg-minute/L) of sulfur mustard at a single site between 

1944 and 1945. A control group consisted of 2,663 white male Navy veterans who served at the same 

location and time as the exposed, but did not participate in sulfur mustard chamber tests. Sulfur mustard 

chamber test documentation included concentration of sulfur mustard in the chamber, length of exposure, 

and subject physiological reactions, so a dose-response analysis could be conducted. The veterans who 

participated in the sulfur mustard chamber tests, while exposed to lower levels than estimated for combat 

exposed World War I veterans, did have sufficient exposure to produce skin reactions of erythema and 

edema. Causes of death investigated included laryngeal, lung, and skin cancers, chronic obstructive 

pulmonary and parenchymal respiratory diseases, external causes, and suicide. The mortality rate ratios 

for all cancer types among the total exposure group and all subgroups were less than unity. The greatest 

mortality rate ratio, 1.57 (95% CI=0.70–3.54), resulted for chronic obstructive pulmonary disease among 

veterans with exposure levels in the range of 121–960 mg-minute/L. The authors indicated that this value 

was not statistically significant and that there was no excess of any cause-specific mortality associated 

with sulfur mustard exposure or associated with the level of sulfur mustard exposure among veterans. 

The authors noted that reliance on death certificates for cause of death and lack of data on potential 

confounders (smoking, drinking habits, and occupational history/exposure to carcinogens) were potential 

study weaknesses. 

Animal Cancer Studies. Two animal studies showed tumors following inhalation exposure to sulfur 

mustard. Male and female Strain A mice exposed once for 15 minutes to an unquantified level of sulfur 

mustard had a significantly higher incidence of pulmonary tumors than did their littermate controls 

(Heston 1953b). The significance of this finding for humans is difficult to determine since these Strain A 

mice are used due to their specific genetic tendency to develop lung tumors. Guinea pigs, mice, rabbits, 

and dogs that were exposed to sulfur mustard in the air for 3–12 months did not develop tumors, although 

rats did develop squamous cell carcinoma of the skin (McNamara et al. 1975). 

IARC has classified sulfur mustard as “carcinogenic to humans” (Group 1) based on sufficient evidence 

in humans, limited evidence in experimental animals, supporting evidence that sulfur mustard is a 

bifunctional alkylating agent, and positive results in a number of assays for genotoxic effects (IARC 

1975, 1987). 
SULFUR MUSTARD 47 

3. HEALTH EFFECTS 

The Army’s current health-based environmental screening levels (HBESLs) for sulfur mustard include a 

cancer inhalation unit risk value, and an inhalation cancer potency value (USACHPPM 1999) (see 

Chapter 8). However, ongoing evaluations of alternative approaches for quantitatively estimating cancer 

risk may result in changes to these values. 

3.2.2 Oral Exposure 

Victims of battlefield exposures may have ingested small amounts of airborne sulfur mustard. Sulfur 

mustard aerosol, with aerodynamic diameters greater than 10 μm, entering the nose or mouth will be 

ingested, if not expectorated. However, no studies were located regarding the health effects in humans 

after specific oral exposure to sulfur mustard. While exposure to sulfur mustard by the oral route can 

occur, the dermal and inhalation routes of exposure are the primary routes of exposure. 

3.2.2.1 Death 

Limited information is available regarding the acute oral toxicity of sulfur mustard. Without providing 

any information on how the value was derived, an Army report indicates that an oral LD50 of 0.7 mg/kg 

has been estimated for humans (SBCCOM 1999). In a review of the literature on sulfur mustard, Opresko 

et al. (1998) stated that the oral LD50 for rats is 17 mg/kg. 

Significant maternal mortality occurred in a teratology study in which sulfur mustard in sesame oil was 

administered acutely by oral gavage to pregnant rats and rabbits on gestation days 6–15 and 6–19, 

respectively (DOA 1987). Rabbits were dosed with 0, 0.4, 0.6, or 0.8 mg/kg/day. In rabbits, maternal 

mortality was dose-related with deaths occurring at doses ≥0.8 mg/kg/day: 3/18 (17%) at 0.8 mg/kg/day, 

3/7 (43%) at 1.0 mg/kg/day, 5/8 (63%) at 2.0 mg/kg/day, and 4/6 (75%) at 2.5 mg/kg/day. Female rats 

were dosed with 0, 0.4, 0.8 1.0, 1.6, 2.0, or 2.5 mg/kg/day. One of three rats died on gestation day 12 at 

the highest dose of 2.5 mg/kg/day. No maternal deaths in rats were attributed to sulfur mustard at doses 

<2.5 mg/kg/day. 

The lethal dose levels for the rats and rabbits are recorded in Table 3-2 and plotted in Figure 3-2. 
 

SULFUR MUSTARD 48 

3. HEALTH EFFECTS 

3.2.2.2 Systemic Effects 

No studies were located regarding musculoskeletal effects in animals after oral exposure to sulfur mustard 

The respiratory, cardiovascular, gastrointestinal, hematological, hepatic, renal, endocrine, dermal, ocular, 

and body weight effects observed in animals after oral exposure to sulfur mustard are discussed below. 

Sparse animal data indicate no respiratory, cardiovascular, hepatic, renal, endocrine, dermal, or ocular 

effects following oral exposure to sulfur mustard. The highest NOAEL and all LOAEL values for each 

study for systemic effects in each species and duration category are recorded in Table 3-2 and plotted in 

Figure 3-2. 

Respiratory Effects. Gross examinations of the lungs of rats orally gavaged with 0.3 mg/kg/day of 

sulfur mustard in sesame oil, 5 days/week, for 13 weeks, did not reveal any significant treatment-related 

lesions (Sasser et al. 1996b). 

Cardiovascular Effects. Microscopic examinations of the heart of rats orally gavaged with 

0.3 mg/kg/day of sulfur mustard in sesame oil, 5 days/week, for 13 weeks, did not reveal any significant 

treatment-related lesions (Sasser et al. 1996b). 

Gastrointestinal Effects. Dose-related gastrointestinal effects (mucosal irritation and/or 

inflammation) have occurred in experimental animals following acute and subchronic oral administration 

of sulfur mustard in sesame oil (DOA 1987; Sasser et al. 1996a,1996b). 

In pregnant rats, orally gavaged acutely with 0.2–2.5 mg/kg/day of sulfur mustard on gestation days 6–15, 

gastric mucosal inflammation was observed at doses ≥2.0 mg/kg/day (DOA 1987). Inseminated female 

rabbits orally gavaged with 0.4–2.5 mg/kg/day of sulfur mustard on gestation days 6–19 incurred doserelated damage to the gastric mucosa at doses ≥0.4 mg/kg/day (DOA 1987). 

A significant increase in the incidence of epithelial hyperplasia of the forestomach was observed in rats 

treated with 0.3 mg/kg/day sulfur mustard by gavage for 13 weeks (Sasser et al. 1996b). No significant 

increase was seen at ≤0.1 mg/kg/day. The hyperplastic change was characterized by cellular 

disorganization of the basilar layer, apparent increase in mitotic activity of the basilar epithelial cells, and 

thickening of the epithelial layer. 
Table 3-2 Levels of Significant Exposure to Sulfur Mustard - Oral 

Exposure/ LOAEL 
 

Duration/ a Key to Species Frequency NOAEL Less Serious Serious Reference 

(Specific Route) figure (Strain)	 System (mg/kg/day) (mg/kg/day) (mg/kg/day) Chemical Form 

ACUTE EXPOSURE 

Death 

1 Rat 10 d DOA 1987 

Gd 6-15 2.5 F

(SpragueDawley) (GO) 

2 Rabbit	 14 d DOA 1987 

Gd 6-19 0.8 F

(NS)
 

(GO)
 

Systemic 

3 Rat 10 d DOA 1987 

Gd 6-15 Dermal 2.5 (SpragueDawley) (GO) 

Bd Wt 1 1.6	 (9.1-16.6% decrease after 7 

days of exposure) 

4 Rabbit	 14 d DOA 1987 

Gd 6-19 Hemato 0.6 0.8 (9.1% decreased hematocrit) (NS)
 

(GO)
 

Dermal 2.5 

Bd Wt 0.6 0.8 

Immuno/ Lymphoret 

5 Rat	 10 d, b DOA 1987 

Gd 6-15 0.5 F (Inflamed mesenteric lymph (Sprague­ nodes) Dawley) (GO) 

Developmental 

6 Rat	 10 d b DOA 1987 

Gd 6-15 0.5 (Reduced ossification) (SpragueDawley) (GO)
 
Table 3-2 Levels of Significant Exposure to Sulfur Mustard - Oral (continued) 

a Key to 

figure 

Species 

(Strain) 

Exposure/ 

Duration/ 

Frequency 

(Specific Route) System 

NOAEL 

(mg/kg/day) 

Less Serious 

(mg/kg/day) 

LOAEL 

(mg/kg/day) 

Serious Reference 

Chemical Form 

7 

(NS) 

(GO) 

14 d 

Gd 6-19 

Rabbit 

INTERMEDIATE EXPOSURE 

0.8 

DOA 1987 

8 

Systemic 

(SpragueDawley) 

Rat 

(GO) 

10 wk 

5 d/wk 

1 x/d 

Dermal 0.5 

Sasser et al. 1993 

Bd Wt 0.5 M 

9 

(SpragueDawley) 

Rat 

(GO) 

18-21 wk 

5 d/wk Gastro 0.03 c 

(29/47 M, 42/47 F; epithelial 

acanthosis of the forestomach) 

Sasser et al. 1996a 

Dermal 0.4 
Table 3-2 Levels of Significant Exposure to Sulfur Mustard - Oral (continued) 

Exposure/ LOAEL 
 

Duration/ a Key to Species Frequency NOAEL Less Serious Serious Reference 

figure (Strain) (Specific Route) System (mg/kg/day) (mg/kg/day) (mg/kg/day) Chemical Form 

10 Rat 13 wk Sasser et al. 1996b 

5 d/wk Resp 0.3 (Sprague­ 1 x/d Dawley)
 

(GO)
 

Cardio 0.3 

Gastro 0.1 0.3	 (epithelial hyperplasia of
 

forestomach)
 

Hemato 0.3 

Hepatic 0.3 

Renal 0.3 

Endocr 0.3 

Dermal 0.3 

Ocular 0.3 

Bd Wt 0.1 0.3	 (>10% decrease in females, 

>8% decrease in males) 

Immuno/ Lymphoret 

11 Rat 13 wk Sasser et al. 1996b 

5 d/wk 0.3 (Sprague­ 1 x/d Dawley)
 

(GO)
 
Table 3-2 Levels of Significant Exposure to Sulfur Mustard - Oral	 (continued) 

Exposure/ LOAEL 
 

Duration/ a Reference Key to Species Frequency NOAEL Less Serious Serious 

(Specific Route) figure (Strain)	 System (mg/kg/day) (mg/kg/day) (mg/kg/day) Chemical Form 

Neurological 

12 Rat 10 wk Sasser et al. 1993 

5 d/wk 0.5 (Sprague­ 1 x/d Dawley)
 

(GO)
 

Reproductive 

13 Rat 10 wk Sasser et al. 1993 

0.08 (4-fold increase in resorptions; 5 d/wk (Sprague­ increased preimplantation 1 x/d Dawley) losses; 7% decrease in live

(GO)
 fetuses) 

0.5 M (2-fold increase in abnormal 

sperm head morphology) 

14 Rat	 18-21 wk Sasser et al. 1996a 

5 d/wk 0.1 0.4 (Increased fraction of males, (Sprague­ 58%) Dawley) (GO) 

15 Rat	 13 wk Sasser et al. 1996b 

5 d/wk 0.3 (Sprague­ 1 x/d Dawley)
 

(GO)
 

Developmental 

16 Rat 18-21 wk Sasser et al. 1996a 

5 d/wk 0.4 (SpragueDawley) (GO)
 

a The number corresponds to entries in Figure 3-2. 

b Used to derive an acute oral MRL of 0.0005 mg/kg/day; dose divided by an uncertainty factory of 1000 (10 for use of a LOAEL, 10 for extrapolation from animals to humans, and 10 for 

human variability). 

c Used to derive an intermediate-duration oral MRL of 0.00007 mg/kg/day; dose adjusted to a TWA of 0.02 mg/kg/day for intermittent exposure (see Appendix A) divided by an 

uncertainty factory of 300 (10 for use of a LOAEL, 3 for extrapolation from animals to humans, and 10 for human variability). 

Bd Wt = body weight; Cardio = cardiovascular; d = day(s); Endo = endocrine; F = female; Gastro = gastrointestinal; Gd = gestational day; (GO) = gavage in oil; hemato = hematological; 

M = male; resp = respiratory; wk = week(s); x = time(s) 
10 

Death Hematological Dermal Body Weight Developmental 

Figure 3-2. Levels of Significant Exposure to Sulfur Mustard - Oral 

Acute (≤14 days) 

Systemic 

mg/kg/day Immuno/Lymphor 

1r 3r 4h 

3r 

1 3r 

2h 4h 4h 7h 

4h 4h 5r 6r 

0.1 

0.01 

0.001 

0.0001 

c-Cat -Humans f-Ferret n-Mink Cancer Effect Level-Animals Cancer Effect Level-Humans 

d-Dog k-Monkey j-Pigeon o-Other LOAEL, More Serious-Animals LOAEL, More Serious-Humans 

r-Rat m-Mouse e-Gerbil LOAEL, Less Serious-Animals LOAEL, Less Serious-Humans 

p-Pig h-Rabbit s-Hamster NOAEL - Animals NOAEL - Humans 

q-Cow a-Sheep g-Guinea Pig 
1 

Respiratory Cardiovascular Gastrointestinal Hematological Hepatic Renal Endocrine Dermal Ocular Body Weight Immuno/Lymphor Neurolo

Figure 3-2. Levels of Significant Exposure to Sulfur Mustard - Oral (Continued) 

Intermediate (15-364 days) 

Systemic 

mg/kg/day 

8r 8r 

9r 12r 

10r 10r 10r 10r 10r 10r 10r 10r 10r 10r 11r 

0.1 10r 10r 

9r 

0.01 

0.001 

0.0001 

1E-5 

c-Cat -Humans f-Ferret n-Mink Cancer Effect Level-Animals Cancer Effect Level-Humans 

d-Dog k-Monkey j-Pigeon o-Other LOAEL, More Serious-Animals LOAEL, More Serious-Humans 

r-Rat m-Mouse e-Gerbil LOAEL, Less Serious-Animals LOAEL, Less Serious-Humans 

p-Pig h-Rabbit s-Hamster NOAEL - Animals NOAEL - Humans 

q-Cow a-Sheep g-Guinea Pig 
 

SULFUR MUSTARD 55 

3. HEALTH EFFECTS 

In a 2-generation reproduction study, dose-related incidence and severity of lesions of the squamous 

epithelium of the forestomach occurred in both sexes of rats orally gavaged with 0, 0.03, 0.1, or 

0.4 mg/kg/day of sulfur mustard dissolved in sesame oil for 18–21 weeks (Sasser et al. 1996a). The 

incidences of hyperplasia [combined F0 and F1 males and females: 0/94 controls, 71/94 (76%; 

29 male/42 female) in the low-dose groups, 89/94 (95%; 37 male/ 52 female) in the mid-dose groups, and 

94/94 in the high-dose groups] were significantly increased in all treated groups, compared to controls. 

An intermediate-duration oral MRL of 0.07 μg/kg/day was derived based on the LOAEL of 0.03 

mg/kg/day, the lowest dose tested, for gastric lesions from this study (See Appendix A for details). 

Hematological Effects. In pregnant rats gavaged with 0.2, 0.4, 0.5, 0.8, 1.0, 1.6, or 2.0 mg/kg/day of 

sulfur mustard on gestation days 6–15, maternal hematocrit values were significantly reduced by 10.8% at 

0.8 mg/kg/day and 5.4% at 1.0 and 2.0 mg/kg/day (DOA 1987). While hematocrit at 1.6 mg/kg/day was 

reduced, the decrease was not significant. A dose-related decrease in maternal hematocrit was reported in 

pregnant rabbits following acute oral administration of 0.4, 0.6, or 0.8 mg/kg/day sulfur mustard on 

gestation days 6–19, with statistical significance achieved only at the highest dose (DOA 1987). No other 

hematological parameter was evaluated. The biological significance of these changes is unknown and, 

according to the investigators, may have been due to changes in plasma volume during pregnancy or to 

anorexia in some of the animals. 

Hepatic Effects. No significant hepatic effects were observed in rats treated by gavage with up to 

0.3 mg/kg/day sulfur mustard in sesame oil, 5 days/week, for 13 weeks, as judged by no significant 

changes in serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities and no 

microscopical alterations in the liver (Sasser et al. 1996b). 

Renal Effects. Neither blood urea nitrogen (BUN) nor serum creatinine levels were significantly 

altered in rats treated with up to 0.3 mg/kg/day sulfur mustard 5 days/week for 13 weeks (Sasser et al. 

1996b). In addition, microscopic examination of the kidneys did not reveal any treatment-related effects. 

Endocrine Effects. Only limited animal data exist on endocrine effects following oral exposure to 

sulfur mustard. Microscopic examination of adrenals from rats orally gavaged with 0.3 mg/kg/day of 

sulfur mustard in sesame oil, 5 days/week, for 13 weeks revealed no lesions (Sasser et al. 1996b). 

Dermal Effects. In animal studies, no systemic dermal effects were induced following acute or subchronic oral exposure to sulfur mustard in sesame oil. No dermal effects were observed in rats or rabbits 
 

SULFUR MUSTARD 56 

3. HEALTH EFFECTS 

acutely dosed with up to 2.5 mg/kg/day of sulfur mustard (DOA 1987) or following longer exposures in 

rats orally gavaged with 0.08–0.5 mg/kg/day of sulfur mustard, 5 days/week, for 10 weeks (Sasser et al. 

1993), with 0.003–0.3 mg/kg/day of sulfur mustard, 5 days/week, for 13 weeks (Sasser et al. 1996b), or 

with 0.03–0.4 mg/kg/day of sulfur mustard for 18–21 weeks (Sasser et al. 1996a). 

Ocular Effects. Animal data indicate that no systemic ocular effects result from oral exposure to 

sulfur mustard in sesame oil. Ophthalmology evaluations of rats orally gavaged with 0.003– 

0.3 mg/kg/day of sulfur mustard, 5 days/week, for 13 weeks, revealed no abnormalities (Sasser et al. 

1996b). 

Body Weight Effects. In pregnant rats gavaged with 0.2, 0.4, 0.5, 0.8, 1.0, 1.6, or 2.0 mg/kg/day of 

sulfur mustard in sesame oil on gestation days 6–15, a significant dose-related decrease in maternal body 

weight was observed by gestation day 9 at 1.0 mg/kg/day (4.7–9.1%) and 2.0 mg/kg/day (6.5–16.0%) and 

by gestation day 12 at 0.5 mg/kg/day (4.1–6.6%) and 1.6 mg/kg/day (9.1–16.6%) (DOA 1987). 

Reductions in extragestation weight gain was also dose-related with decreases of 10, 27, 25, 29, 38, 53, 

and 57% measured in 0.2, 0.4, 0.5, 0.8, 1.0, 1.6, and 2.0 mg/kg/day groups, respectively, compared to 

concurrent controls, with statistical significance achieved at ≥0.4 mg/kg/day. 

Inseminated female rabbits orally gavaged with 0.4–2.5 mg/kg/day of sulfur mustard in sesame oil on 

gestation days 6–19, showed a significantly decreased maternal body weight at 0.8 mg/kg/day (7.9–10.5% 

decrease after gestation day 10, 5 days of exposure) and 2.0 mg/kg/day (12.0–18.3% decrease after 

gestation day 14, 9 days of exposure), but not at 1.0 mg/kg/day (DOA 1987). 

Females in the highest-dose group of rats orally gavaged with 0.003–0.3 mg/kg/day sulfur mustard in 

sesame oil, 5 days/week, for 13 weeks, weighed significantly less than controls at week 4 and during the 

last 5 weeks of exposure (reduced >10%) (Sasser et al. 1996b). Males in the highest-dose group weighed 

significantly less than controls during 6 of the weeks in the weeks 3–12 of the study period (reduced by 

>8%). There was no indication of a dose response in body weight in lower dose groups. 

In a two-generation reproductive study of sulfur mustard in sesame oil administered intragastrically at 

doses of 0.03–0.4 mg/kg/day, the body weights of the F0 exposed rats were not significantly different 

from controls; however, the growth rate of the high-dose males tended to decline after about 7 weeks of 

exposure (Sasser et al. 1996a). Body weight gain beginning 1 or 2 weeks after treatment was started 

(approximately 20% for males and 15–24% for females) was significantly lower (p <0.05) than control 
SULFUR MUSTARD 57 

3. HEALTH EFFECTS 

values in F1 rats of both sexes born to high-dose parents. No significant dose-response in body weight 

occurred at the lower doses. 

Body weights of female rats treated by gavage with 0.5 mg/kg/day sulfur mustard for 10 weeks were 

slightly lower than controls during most of the study, but at 10 weeks, it appeared no different than 

controls in the figure from the study (Sasser et al. 1993). In males, body weight was lower than in 

controls beginning at week 2, and final body was reduced approximately 9% relative to controls. 

3.2.2.3 Immunological and Lymphoreticular Effects 

No studies were located regarding immunological effects in humans following oral exposure to sulfur 

mustard. 

In a range-finding teratology study in pregnant rats in which sulfur mustard was administered by gavage 

in oil (0.2, 0.4, 0.8, 1.6, 2.0, and 2.5 mg/kg/day), a significant increased incidence of inflamed mesenteric 

lymph nodes was found in all treated groups except the lowest dose group (DOA 1987). In the final 

study, inflamed mesenteric lymph nodes were found in 11/25 (44%), 16/25 (64%), and 15/27 (56%) 

animals at 0.5, 1.0, and 2.0 mg/kg/day, respectively, compared to no occurrences in a group of 25 control 

animals (DOA 1987). Also, enlarged Peyer’s patches (flat patches of lymphatic tissue located in the 

small intestine) were found in inseminated female rabbits orally gavaged with 0.4–2.5 mg/kg/day of 

sulfur mustard in sesame oil on gestation days 6–19; however, incidences were not reported (DOA 1987). 

The teratology study (DOA 1987) was selected as the key study for acute oral MRL derivation. An acute 

oral MRL of 0.5 μg/kg/day was derived based on the LOAEL of 0.5 mg/kg/day, the lowest dose tested, 

for inflamed mesenteric lymph nodes in the rat dams. An uncertainty factor of 1,000 (10 for use of a 

LOAEL, 10 for extrapolation from animals to humans, and 10 for human variability) was applied to the 

LOAEL to derive the MRL. 

3.2.2.3 Neurological Effects 

No studies were located regarding neurological effects in humans following oral exposure to sulfur 

mustard. 
 

SULFUR MUSTARD 58 

3. HEALTH EFFECTS 

In rats, orally gavaged with 0.08, 0.2, or 0.5 mg/kg/day sulfur mustard in sesame oil, 5 days/week, for 

10 weeks, excessive salivation (drooling) following dosing was observed in the highest dose group 

(Sasser et al. 1993). No further relevant information was located. 

3.2.2.4 Reproductive Effects 

No information was located regarding reproductive effects in humans following oral exposure to sulfur 

mustard. 

In a teratology study (DOA 1987), pregnant rats were treated by gavage with 0, 0.5, 1.0, or 2.0 mg/kg/day 

of sulfur mustard in sesame oil on gestation days 6–15. A significant decrease in gravid uteri weight 

(16%) was measured in dams at the highest dose of 2.0 mg/kg/day. The number of corpora lutea and 

implantation sites, and the incidence of pre-implantation failure and intrauterine mortality were 

unaffected by sulfur mustard treatment. 

In a study in rats, oral exposure to sulfur mustard resulted in significant dominant lethal effects in male 

rats mated to untreated females, whereas female dominant lethal effects were not observed (Sasser et al. 

1993). In that study, rats were treated by gavage with 0.08, 0.2, or 0.5 mg/kg/day sulfur mustard in 

sesame oil, 5 days/week, for 10 weeks (Sasser et al. 1993). In female dominant lethality experiments 

(treated or untreated males were mated with treated females), the overall mean pregnancy rate in treated 

groups was 86% with a range from 70 to 100%, and with no significant differences between treatment 

groups. Reproductive performance indicators (number of live or dead implants, resorptions, and 

preimplantation losses) in treated female rats mated to treated or nontreated males were not significantly 

different from controls. In male dominant lethality experiments (treated males were mated with untreated 

females), the overall mean pregnancy rate in treatment groups was 91%; treatment means ranged from 

65 to 100%, with no significant differences between treatment groups. There was no indication of a dose 

relationship with the number of live implants. In the highest exposure group, the mean number of total 

and early resorptions per litter was significantly greater than control during the 2nd and 3rd postexposure 

weeks. The number of total and late resorptions in the mid-dose group was also significantly greater than 

controls during the 3rd postexposure week. Preimplantation losses in the mid- and high-dose groups were 

significantly elevated during the 2nd postexposure week. High-dose male sperm morphology data at all 

postexposure sampling times (0, 5, and 12 weeks) showed a statistically significant decrease in the 

percentage of normal sperm. Blunthook and banana-shaped sperm heads were observed at 0, 5, and 

12 weeks, whereas amorphous and short head abnormalities were observed only at 5 and 12 weeks. 
SULFUR MUSTARD 59 

3. HEALTH EFFECTS 

Overall, there was a total 2-fold increase in abnormal sperm heads in high-dose sulfur mustard-treated 

males. Sperm morphology and motility were not examined in the low- and mid-dose groups. In 

summary, female fertility was not affected by these sulfur mustard exposures; however, a male dominant 

lethal effect was demonstrated at the mid and high doses of sulfur mustard. 

In a two-generation study in rats, reproductive performance was not adversely affected following 

exposure to sulfur mustard administered by gavage at levels of 0.03–0.4 mg/kg/day, 5 days/week, for 

13 weeks prior to mating and through gestation, parturition, and lactation (Sasser et al. 1996a). 

Reproductive performance was measured by assessing the number of matings, pregnant females and 

females delivering live pups, fertility index, and mating index. The only significant birth measurement 

was an altered sex ratio (58% males) in the high-dose F0 offspring (Sasser et al. 1996a). Futhermore, 

microscopic examination of the reproductive organs revealed no evidence of treatment-related effects. 

Microscopic examinations of the testes from rats orally gavaged with up to 0.3 mg/kg/day of sulfur 

mustard in sesame oil, 5 days/week, for 13 weeks also revealed no lesions (Sasser et al. 1996b). 

3.2.2.5 Developmental Effects 

No information was located regarding developmental effects in humans following oral exposure to sulfur 

mustard. 

In a study in which rats were treated by gavage with 0, 0.5, 1.0, or 2.0 mg/kg/day sulfur mustard, the 

numbers of live fetuses per litter were comparable between dose groups. Fetal body weights were 

significantly decreased in litters exposed to doses ≥1.0 mg/kg/day; however, the depressed fetal weights 

were not accompanied by a corresponding decrease in crown-rump length. Sex ratio was significantly 

different from control only at the high-dose. Placental weights were significantly lower in the high-dose 

group, compared to control. The number of minor skeletal anomalies, mostly commonly misaligned 

sternebrae, was significantly increased in the high-dose group. The incidences of reduced ossification of 

the vertebrae and/or sternebrae in all treated groups were significantly increased, compared to controls 

(DOA 1987). In the companion study in rabbits with doses of 0, 0.4, 0.6, or 0.8 mg/kg/day, no adverse 

effects to fetal body weight or skeletal morphology were observed. However, in the preliminary doserange study in rabbits, fetal body weight was significantly reduced at 2.0 mg/kg/day (DOA 1987). 

See Table 3-4 for ongoing studies of developmental effects of sulfur mustard. 
SULFUR MUSTARD 60 

3. HEALTH EFFECTS 

3.2.2.7 Cancer 

No studies were located regarding cancer in humans or animals after oral exposure to sulfur mustard. 

The Army’s current health-based environmental screening levels (HBESLs) for sulfur mustard include an 

oral cancer potency value (slope factor) (USACHPPM 1999). In the absence of a chronic bioassay for 

sulfur mustard, the oral cancer potency value was estimated as the geometric mean of slope factors 

developed using various data sets (potency relative to benzo(a)pyrene, forestomach hyperplasia incidence, 

and maximum tolerated dose). However, ongoing evaluations of alternative approaches for quantitatively 

estimating cancer risk may result in changes to this value (see Chapter 8). 

3.2.3 Dermal Exposure 

3.2.3.1 Death 

There are reports of human deaths from skin contact with liquid sulfur mustard from old deteriorating 

artillery shells (Aasted et al. 1985; Heully et al. 1956; Jorgensen et al. 1985). In France, two children died 

after a 40-year-old sulfur mustard shell accidentally exploded spraying the liquid onto their skin and 

clothing (Heully et al. 1956). Two fishermen died from handling sulfur mustard bombs disposed of in the 

Baltic Sea, which became caught in their nets (Aasted et al. 1985; Jorgensen et al. 1985). Dermal dose 

estimates are not available for these accidental exposures. Other surviving fishermen suffered skin 

lesions, erythema, blistering, and eye lesions. Without providing any further details, SBCCOM (1999) 

indicates that in humans the LD50 for skin exposure is 100 mg/kg. LD50 values in animals for sulfur 

mustard administered topically range from 9 to 100 mg/kg (Dacre et al. 1995). Of the species studied 

(rat, mouse, dog, rabbit, guinea pig, and goat), the rat was the most sensitive to acute lethal effects, with a 

dermal LD50 of 9 mg/kg. 

3.2.3.2 Systemic Effects 

No studies were located regarding respiratory, cardiovascular, musculoskeletal, renal, or body weight 

effects in humans or animals after dermal exposure to sulfur mustard. 
 

SULFUR MUSTARD 61 

3. HEALTH EFFECTS 

Gastrointestinal Effects. Volunteers who were wearing respirators and who were exposed to 

unspecified levels of sulfur mustard vapors and liquids not only had skin burns, but also complained of 

nausea, vomiting, anorexia, abdominal pain, diarrhea, headache, and lassitude (Sinclair 1948). These 

signs could have been primary effects of the sulfur mustard on the rapidly dividing cells of the 

gastrointestinal epithelium, secondary effects from the skin burns, or psychological effects not related to 

the sulfur mustard exposure at all. 

In a study designed to determine lethal dermal doses, rats stopped eating and drinking, had diarrhea, and 

lost weight prior to death (Young 1947). 

Hematological Effects. Intense skin exposure to sulfur mustard sufficient to cause severe 

vesiculation and skin necrosis may result in systemic effects to bone marrow. Absorbed sulfur mustard 

may destroy or diminish bone marrow activity denoted by reduced numbers of or destruction of 

replicating marrow stem cells (Pechura and Rall 1993). Sulfur mustard-induced reduction of granulocyte 

and other marrow-derived cells in peripheral blood cause a diminished protective effect from 

polymorphonuclear leukocytes, macrophages, monocytes, and other cell types that are active in the 

destruction and scavenging of organisms that invade and impede wound healing. 

A reduction in lymphocytes was noted in mice whose shaved backs were topically treated a single time 

with 3.88–15.5 mg/kg of sulfur mustard diluted in olive oil (Venkateswaran et al. 1994a); hematology 

revealed a significant dose-related increase in packed cell volume (10–16%). The increase in hemoglobin 

concentration was also dose-related and significantly increased (13–19%) at 7.75–15.5 mg/kg of sulfur 

mustard. 

Hepatic Effects. Topical application of a single dose of 3.88, 7.75, or 15.5 mg/kg sulfur mustard to 

the shaved backs of Balb/c mice induce a dose-related decrease in liver weight was observed, with a 

significant reduction of 14% measured at the high dose (Venkateswaran et al. 1994a). 

Twenty-four hours after application of a single dose of 51.3 mg/kg (1 LD50) of neat sulfur mustard to the 

hair-clipped backs of male guinea pigs the liver showed fatty degeneration accompanied by infiltration 

with red blood cells, lipidolysis, and distortion of cell structure (Chauhan and Murty 1997). Three days 

after dosing, infiltration with macrophages was observed in addition to the above alterations. Liver injury 

was also indicated by increases in serum AST and ALT activities. Both enzymes increased after 
 

 

 

SULFUR MUSTARD 62 

3. HEALTH EFFECTS 

exposure, reaching maximum levels of nearly twice control values at 3 days, and returned toward normal 

levels at 6 days postexposure. The AST recovery was slower than ALT as the 6-day level, while 

submaximal, was still significantly elevated (33%) above control. 

Endocrine Effects. Adrenal weight was significantly increased in a dose-related manner in mice 

whose shaved backs were treated topically with sulfur mustard doses of 7.8–15.5 mg/kg once 

(Venkateswaran et al. 1994a). 

Dermal Effects. When sulfur mustard gets on human skin, it causes itching, erythema, and/or blister 

formation (Pechura and Rall 1993). Australian soldiers, who were wearing respirators, volunteered to be 

exposed to skin contact with sulfur mustard during World War I. They had erythema on the exposed 

areas, and skin burns on the genitalia (Sinclair 1948, 1950). Men who were exposed to sulfur mustard 

from leaking artillery shells picked up by fishing vessels off the coast of Denmark showed inflamed skin, 

blisters, eye irritation, and transient blindness (Wulf et al. 1985). These reactions are usually delayed by 

at least several hours, up to 48 hours after initial exposure (Jakubowski et al. 2000; Renshaw 1946; Smith 

et al. 1919). 

A review of the literature prior to 1950 indicates that drops containing 0.1% or more sulfur mustard can 

cause skin blisters on humans (Sulzberger et al. 1947). Tissue injury does not develop when low, 

therapeutically effective doses of sulfur mustard are used to control the hyperproliferation of psoratic 

keratinocytes. The severity of cutaneous injury is dependent on dose, exposure duration, temperature, 

humidity, and/or perspiration and is directly related to the sulfur mustard alkylation levels in skin 

(Papirmeister 1993). Sulfur mustard is more harmful to the skin on hot, humid days or in tropical 

climates (Papirmeister et al. 1991; Sulzberger et al. 1947). 

Humans show varying degrees of sensitivity to sulfur mustard (Renshaw 1946; Sulzberger et al. 1947). 

In particular, people with fair skin are more sensitive than those with dark skin. Affected skin usually 

changes color in response to stimulation of melanogenesis (Pechura and Rall 1993). Increased darkening 

of the skin at the periphery of sulfur mustard-induced blisters is characteristically observed. There may 

be variations in the skin’s response to the same sulfur mustard dose and exposure duration depending on 

the contacted dermal site (Pechura and Rall 1993). For a given dose and duration of exposure, loose 

tissue, as around the eyes and on the genitalia, may respond with edema without blistering, while tissue 

sites having a very dense dermis, such as on the back, may respond with erythema and blister formation 

without edema (Pechura and Rall 1993). Scar formation following sulfur mustard injury may be 
SULFUR MUSTARD 63 

3. HEALTH EFFECTS 

disabling. Individuals with previous exposure are more sensitive to the dermal effects of sulfur mustard 

(Renshaw 1946; Sulzberger et al. 1947). SBCCOM (1999) reports a maximum safe Ct of 5 mgminute/m3

 for human skin exposure to sulfur mustard vapor. 

A group of patients, including a subgroup of 14 children and teenagers (9 boys, aged 9 months to 

14 years; 5 girls, aged 13 months to 9 years), were examined in a hospital in Iran 18–24 hours following 

exposure to sulfur mustard from air bombs during the Iran-Iraq War (Momeni and Aminjavaheri 1994). 

Cutaneous effects included erythema (in 94% of patients), itching (71%), bulla (71%), ulceration (64%), 

hyperpigmentation (50%), and hypopigmentation (21%). Burning sensation (in 71% of patients) and pain 

(36%) were also noted. Skin lesions first appeared 4–18 hours after exposure, and were accompanied by 

an itching and burning sensation, especially over the face and neck. Thereafter, the patients developed 

erythema and gradually, after 20–30 hours, blisters. Most of the lesions in children developed of the face 

(79%), followed by genital (43%), thoracic (21%), trunkal (14%), and axillar lesions (14%). No direct 

relation was found between sex of the individual and the site of the lesions. The time of onset of sulfur 

mustard manifestations in children was shorter (4–18 hours) and the severity of the lesions higher than in 

adults (8–24 hours), possibly due to more delicate skin and epithelial tissues. Genital lesions were less 

frequent in children and teenagers (42%) than adults (70%); however, even within the group of children, 

the incidence and severity of genital lesions increased with age. Other skin lesions had no apparent agerelation. 

Sulfur mustard applied to the skin of rats produced local edema, which subsided after 3 days (Young 

1947). In mice, rabbits, and guinea pigs, sulfur mustard produced vascular leakage, leukocytic 

infiltration, and slow death of basal epidermal cells; this damage reached its peak 1–3 days after 

application (Chauhan et al. 1993a, 1993b, 1995, 1996; Vogt et al. 1984). Healing occurred within 

10 days. Suckling rats (which had not yet grown hair) developed inflammatory changes and epidermal 

thickening after dermal exposure to sulfur mustard for 1–15 minutes (McAdams 1956). This damage was 

evident 1–7 days postexposure. Blisters did not develop, but the basal cells were destroyed. 

Application of single doses of 3.88, 7.75, or 15.5 mg/kg sulfur mustard to the shaved backs of Balb/c 

mice resulted in mild skin lesions, first appearing on postexposure day 4 (Venkateswaran et al. 1994a). 

The lesions progressed to severe, with fluid loss, on postexposure day 7. 

Ocular Effects. Ocular effects that occur during or following exposure to sulfur mustard in the air are 

due to direct contact of sulfur mustard with the eye. This is supported by experiments in animals that 
 

SULFUR MUSTARD 64 

3. HEALTH EFFECTS 

have shown little involvement of the eyes when sulfur mustard was administered parentally at dose levels 

known to be systemically toxic and lethal (Papirmeister et al. 1991). Ocular effects due to exposure to 

sulfur mustard in the air are summarized in Section 3.2.1.2. 

Body Weight Effects. Application of a single dose of 3.88, 7.75, or 15.5 mg/kg sulfur mustard to the 

shaved backs of Balb/c mice resulted in a progressive dose-dependent fall in body weight beginning 3– 

5 days after exposure (Venkateswaran et al. 1994a). The decrease was significant at the mid and high 

doses, 11 and 27%, respectively. Reduced food consumption was noted only in the high-dose group. 

Guinea pigs treated with a single dose of 51.3 mg/kg (1 LD50) of neat sulfur mustard applied to their hairclipped backs showed a gradual loss of weight up to 35% on postexposure day 6 (Chauhan and Murty 

1997). 

3.2.3.3 Immunological and Lymphoreticular Effects 

Sulfur mustard was topically applied a single time at doses of 3.88, 7.75, or 15.5 mg/kg to the shaved 

backs of Balb/c mice (16/group/dose) (Venkateswaran et al. 1994a). Sulfur mustard produced a 

significant dose-related decrease in the weight of the spleen (12–59%), and peripheral (12–44%) and 

mesenteric lymph nodes (significant only at high dose, 18%). Incidence and severity of histological 

changes in the thymus and spleen were also dose-related. Spleen histopathology included hypocellularity, 

atrophy of the lymphoid follicles, degeneration of germinal centers, and red pulp infiltrated with 

macrophages. The cortex and medulla regions of the thymus showed atrophy and hypocellularity. Red 

blood cells replaced cortical thymocytes with severe atrophy. A significant dose-related decrease in the 

cellularity of the spleen (24–45%) was measured. A dose-related decrease in the cellularity of the thymus 

was also found, significant at the mid and high doses (36–42%). 

Cameron et al. (1946), after observing damage to the cervical lymph nodes and lymphoid tissue 

throughout the body in rabbits and monkeys that had undergone tracheal cannulation and were exposed to 

nominal chamber concentrations of sulfur mustard ranging from 30 to 350 mg/m3

 (5–54 ppm), 

administered sulfur mustard to animal skin and found identical changes to the lymph tissue, suggesting 

that lymphoid tissue damage may be due to systemic absorption. Only a general discussion, lacking 

experimental details, was reported. 
SULFUR MUSTARD 65 

3. HEALTH EFFECTS 

3.2.3.4 Neurological Effects 

Chronic and/or late neurological symptoms of abnormal skin sensation after exposure to sulfur mustard 

were studied in five patients exposed to sulfur mustard during battlefield operations in the Middle East 

and five fishermen accidentally exposed to sulfur mustard by pulling shells leaking the chemical agent 

aboard their fishing vessels. All 10 patients (100%) suffered from neuropathic pain or other 

deafferentation symptoms, suggesting persistent damage to the afferent nerve system as a frequent 

complication in persons exposed to sulfur mustard (Thomsen et al. 1998). 

Guinea pigs treated with a single dose of 51.3 mg/kg (1 LD50) of neat sulfur mustard applied to their hairclipped backs became sedated 1 day after exposure (Chauhan and Murty 1997). 

3.2.3.5 Reproductive Effects 

No studies were located regarding reproductive effects in humans after dermal exposure to sulfur 

mustard. However, it is likely that dermal exposure contributed to the effects observed in subjects 

exposed to sulfur mustard in the air described in Section 3.2.1.5. 

3.2.3.6 Developmental Effects 

No studies were located regarding developmental effects in humans or animals after dermal exposure to 

sulfur mustard. 

3.2.3.7 Cancer 

Five cases of Bowen's disease (a type of skin cancer) were studied among 488 former workers of a 

Japanese poison gas factory (Inada et al. 1978). Workers were involved in manufacturing sulfur mustard 

for 3–15 years and the diagnosis was made 31–41 years after exposure. These workers also suffered from 

acute dermatitis, conjunctivitis, bronchitis, and hyperkeratotic skin eruptions. The occurrence of Bowen's 

disease, Bowen's carcinoma, basal cell carcinomas, and spinocellular carcinoma has also been reported in 

survivors of the dismantling of the "Heeres-Munitionsanstalt St. Georgen" who were exposed to 

poisonous gases including sulfur mustard by skin contact and inhalation (Klehr 1984). 
 

SULFUR MUSTARD 66 

3. HEALTH EFFECTS 

No studies were located regarding cancer in animals after dermal exposure to sulfur mustard, although 

animals exposed to sulfur mustard in the air could have also had skin exposure. Cancer in these animals 

is discussed in Section 3.2.1.7. 

3.2.4 Other Routes of Exposure 

Several animal studies indicate effects of sulfur mustard on the hemopoietic system following intravenous 

or subcutaneous administration of sulfur mustard. Single intravenous injection of 0.5 mg/kg of sulfur 

mustard dissolved in thiodiglycol in young male rats caused degenerative damage to the spleen, thymus, 

and bone marrow (Kindred 1947). This was also observed in rats, mice, rabbits, and dogs following a 

subcutaneous injection of 3 mg/kg of sulfur mustard (Graef et al. 1948). Within 12 hours of injection, 

granulocytosis was observed, followed by leukopenia. In addition to hemopoietic tissue damage, injury 

to the testes with inhibition of spermatogenesis were also observed. An intraperitoneal injection of 

15 mg/kg of sulfur mustard in olive oil depressed the activity of bone marrow cells of the femur in mice 

(Friedberg et al. 1983). Parenteral administration of sulfur mustard to laboratory animals resulted in 

death due to systemic intoxication, with little or no involvement of the eyes or skin. Damage to the lungs 

was seen with intravenous administration of neat sulfur mustard or a solution of sulfur mustard in either 

propylene glycol or thiodiglycol, but not other parenteral routes (Anslow and Houck 1946). 

A significant dose-related reduction in spleen cell number was measured in mice 7 days after 

intraperitoneal injection of sulfur mustard (23% at 5 mg/kg and 49% at 10 mg/kg) (Coutelier et al. 1991). 

Sv female mice (5–9/group) were injected intraperitoneally with a single dose of 2, 5, or 10 mg/kg sulfur 

mustard (>90% purity) in a 1% isopropanol solution in saline. A 26% increase in spleen T-lymphocytes 

and a 44% decrease in B-lymphocytes was measured 7 days following injection with 10 mg/kg of sulfur 

mustard. B- and T-lymphocyte function, as assayed by in vitro thymidine incorporation and/or 

immunoglobulin secretion, was not significantly affected by sulfur mustard. 

The retinas of rats sacrificed 24 hours after subcutaneous injection in the dorsal area with 10 μL of 

undiluted radiolabeled sulfur mustard showed edematous swelling of the inner layers. Cell degenerative 

changes included dense cytoplasm, enlarged mitochondria, and Golgi apparatus. Rats sacrificed at 

48 hours after injection had highly disorganized and vacuolated outer segment membranes and the 

choroid vessels contained large clusters of activated platelets (Klain et al. 1991). 
 

SULFUR MUSTARD 67 

3. HEALTH EFFECTS 

Sulfur mustard, administered to guinea pigs by intratracheal injection, induced a 3-fold increase in 

respiratory system resistance, accompanied by a significant decrease in compliance (Calvet et al. 1993). 

Capsaicin-sensitive nerves do not have primary involvement in the acute respiratory effects of sulfur 

mustard as pretreatment with capsaicin did not prevent acute effects. Fourteen days after exposure, 

substance P induced concentration-dependent bronchoconstriction in guinea pigs, and tracheal epithelium 

neutral endopeptidase (NEP), the main enzyme that degrades tachykinins, was reduced significantly 

(40%) from the control level. While hyper-responsiveness to substance P has been attributed to a 

decrease in the tracheal activity of NEP and corresponding increase in tachykinins, this hypothesis was 

not upheld, as pretreatment with phosphoramidon, a NEP inhibitor, only increased sulfur mustard-induced 

hypersensitivity to substance P. Phosphoramidon administered prior to vehicle control ethanol also 

increased sensitivity to substance P. 

3.3 GENOTOXICITY 

Low doses of sulfur mustard can inhibit cell division due to its ability to cross-link complementary 

strands of DNA or produce mutagenesis, which may be caused by replication or repair errors 

(Papirmeister 1993). DNA is the most functionally sensitive target of sulfur mustard in cells. Men who 

were exposed to sulfur mustard from leaking shells picked up by fishing vessels showed increased sister 

chromatid exchanges in their lymphocytes (Wulf et al. 1985). However, the offspring of workers exposed 

to sulfur mustard in a Japanese factory showed no increases in diseases that would be indicative of 

genetic damage (Yamakido et al. 1985). 

Sulfur mustard induced dose-related interstrand cross-links in the DNA of rat epidermal keratinocytes in 

primary monolayer cultures (Lin et al. 1996a), thus affecting the cell cycle and DNA synthesis (Lin et al. 

1996b). Similar effects on DNA from rat cutaneous keratinocytes were reported by Ribeiro et al. (1991). 

Sulfur mustard has also been shown to affect the repair of mismatched bases in the DNA in African green 

monkey kidneys cells (Fan and Bernstein 1991). 

DNA extracted from white blood cells of human blood and exposed to [14C]-labeled sulfur mustard in 

vitro was shown to contain the DNA adduct 7-(2-hydroxyethylthioethyl)guanine (Ludlum et al. 1994). 

Sulfur mustard alkylation has also been shown to affect transcriptional processes by leading to the 

production of truncated transcripts (Masta et al. 1996). This occurs when the RNA polymerase remains 
 

SULFUR MUSTARD 68 

3. HEALTH EFFECTS 

associated with an alkylated promoter. Analysis of truncated transcripts revealed that sulfur mustard 

alkylates DNA preferentially at 5'-AA, 5'-GG, and 5'-GNC sequences on the DNA template strand. 

Sulfur mustard at concentrations of 0.5 and 0.1 mM produced single strand breaks in bacteriophage 

lambda DNA (Venkateswaran et al. 1994b), which were prevented by the presence of magnesium ions in 

the reaction mixture. The authors proposed that the degradation of lambda DNA by its interaction with 

sulfur mustard may be caused by the breakage of phosphodiester backbone of DNA via the formation of 

an intermediate phosphotriester bond. 

A variety of in vitro assays, summarized in Table 3-3, provide positive genotoxicity results. These data 

support the few human data on in vivo exposures to this compound. The in vitro data from both 

prokaryotic organisms (Salmonella typhimurium and Escherichia coli) and eukaryotic organisms (HeLa 

cells, mouse lymphoma, mouse L cells, rat lymphosarcoma) all support a mechanism of DNA alkylation 

leading to cross-link formation, inhibition of DNA synthesis and repair, point mutation, and chromosome 

and chromatid aberration formation. 

There are also data from Drosophila experiments in which sulfur mustard was injected into male flies, 

leading to sex-linked lethal mutations and point mutations at one of the loci affecting bristle formation 

(Auerbach 1947; Fahmy and Fahmy 1971, 1972). Sulfur mustard has also been shown to be a 

micronucleus-inducing agent to the mouse bone marrow (Ashby et al. 1991). All of these data are 

consistent with this agent being a powerful genotoxicant, which supports the recognized carcinogenicity 

of sulfur mustard. 

Transcription, translation, and enzyme catalysis, cellular activities that are dependent on biological 

entities of much lower molecular size than chromosomal DNA, are much less sensitive to sulfur mustard 

(Papirmeister 1993). Thus, cells that are prevented from synthesizing DNA continue to generate energy 

and synthesize RNA and protein. As a result of this unbalanced metabolism, cells may enlarge, 

differentiate, or be induced to synthesize high levels of certain proteins. While some of these proteins 

may protect cells, others may hasten cell death. 

Vesicant and acute tissue injury only occur at sulfur mustard alkylation levels much higher than those 

needed to produce genotoxic effects. Tissue injury does not develop when low, therapeutically effective 

doses of sulfur mustard are used to control the hyperproliferation of psoratic keratinocytes. Therefore, it 
 

 

 

 

 

 

 

 

 

SULFUR MUSTARD 69 

3. HEALTH EFFECTS 

Table 3-3. Genotoxicity of Sulfur Mustard In Vitro 

Results 

Species (test system) End point 

With 

activation 

Without 

activation Reference 

Prokaryotic organisms: 

Escherichia coli DNA interstrand crosslinks + No data Venitt 1968 

E. coli DNA recombination repair 

inhibition 

+ + Ichinotsubo et al. 1977 

Salmonella 

typhimurium 

Gene mutation + + Ichinotsubo et al. 1977 

S. typhimurium Gene mutation + + Ashby et al. 1991 

Eukaryotic organisms: 

Fungi: 

Saccharomyces 

cerevisiae 

DNA alkylation + No data Kircher and Brendel 

1983 

Human HeLa cells in 

culture 

DNA crosslinking + No data Ball and Roberts 

1971/72 

Mouse lymphoma 

cells 

Gene mutation + No data Capizzi et al. 1974 

Mouse lymphoma 

cells 

Chromosomal and chromatid 

aberrations 

+ No data Scott et al. 1974 

Rat lymphosarcoma 

cells 

Chromosomal and chromatid 

aberrations 

+ No data Scott et al. 1974 

Rat lymphosarcoma 

cells 

DNA replication repair 

inhibition 

+ No data Scott et al. 1974 

Mouse fibroblasts, Lstrain Inhibition of DNA synthesis + No data Walker and Thatcher 

1968 

+ = positive result; DNA = deoxyribonucleic acid 
 

 

SULFUR MUSTARD 70 

3. HEALTH EFFECTS 

 is likely that additional mechanisms other those related to genotoxicity are responsible for acute toxicity 

of sulfur mustard. 

3.4 TOXICOKINETICS 

There is a substantial toxicokinetic database for intravenous and intraperitoneal routes of sulfur mustard 

exposure in animals. While these data are useful, there is evidence to suggest that this information does 

not mimic the scenario resulting from field or accidental conditions that expose humans to sulfur mustard 

by absorption from the skin, or by the lung or eyes. Sulfur mustard tissue distribution data from an 

Iranian soldier who died 7 days after inhalation and/or dermal exposure to sulfur mustard indicated 

distribution: brain > kidney > liver > spleen > lung (Drasch et al. 1987), whereas radiolabel concentration 

data in rats 4 days after an intravenous injection of radiolabeled sulfur mustard indicate a different 

distribution pattern to these organs: kidney > lung > liver > spleen > brain (Maisonneuve et al. 1994). 

While the difference could be due to measurement methods, species variations, or postexposure time, the 

route of exposure appears to be a significant toxicokinetic factor. 

3.4.1 Absorption 

3.4.1.1 Inhalation Exposure 

Since sulfur mustard can be found in human tissues following exposure through the air, it can apparently 

be absorbed through the lungs or skin (Drasch et al. 1987). Analyses of the blood of hairless guinea pigs 

after 8-minute nose-only exposure to 300 mg/m3

 (46 ppm) of sulfur mustard indicated that the 

concentration of sulfur mustard in blood peaked within 5 minutes after inhalation exposure (Langenberg 

et al. 1998). 

In rabbits and monkeys that had undergone tracheal cannulation and were exposed to nominal chamber 

concentrations of 40, 100, and 500 mg/m3

 of sulfur mustard, about 15% of the dose was recovered, 

indicating that 85% was absorbed through the mucous membrane of the nose (Cameron et al. 1946). 

The absorption of sulfur mustard through the cornea was demonstrated in guinea pigs (Klain et al. 1991). 

Following 30 minutes after a single topical application of 5 μL of radiolabeled sulfur mustard to the 
 

 

SULFUR MUSTARD 71 

3. HEALTH EFFECTS 

cornea of guinea pigs, radioactivity was detected in kidney, liver, lung, adipose tissue, adrenals, plasma, 

and muscle. 

3.4.1.2 Oral Exposure 

No studies were located regarding absorption in humans or animals after oral exposure to sulfur mustard. 

Absorption via the oral route has been demonstrated in animal studies in which sulfur mustard dissolved 

in sesame oil was administered by gavage to rats (DOA 1987; Sasser et al. 1993, 1996a, 1996b) and 

rabbits (DOA 1987). 

3.4.1.3 Dermal Exposure 

Sulfur mustard is readily absorbed through the skin. When applied to human skin, most of the sulfur 

mustard evaporates (Smith et al. 1919). Some of the absorbed sulfur mustard remains in the skin, 

whereas the majority passes into the blood stream (Cullumbine 1946, 1947; Nagy et al. 1946; Renshaw 

1946). Renshaw (1946) reported that 80% of unoccluded, topically-applied sulfur mustard evaporates 

from the skin and the remaining fraction penetrates the skin. This finding has been confirmed in studies 

of human foreskin grafted onto athymic mice (Papirmeister et al. 1984a, 1984b). 

The absorption of sulfur mustard through the cornea was demonstrated in guinea pigs (Klain et al. 1991). 

Following 30 minutes after a single topical application of 5 μL of radiolabeled sulfur mustard to the 

cornea of guinea pigs, radioactivity was detected in kidney, liver, lung, adipose tissue, adrenals, plasma, 

and muscle. 

Hambrook et al. (1993) reported that after a 6-hour cutaneous exposure with occlusion, >90% of the 

applied dose was absorbed in rat skin. The initial rate of uptake, within 60 minutes of loading, increased 

linearly with applied dosage in the range of 3–605 μg/cm2

 (0.2–3.8 μmol/cm2), and reached a maximum 

of approximately 7 μg/cm2

/minute (0.044 μmol/cm2/minute) at a dosage of 955 μg/cm2 (6 μmol/cm2) 

(Hambrook et al. 1993). A range of skin-retention fractions from 10 to 50% has been reported 

(Cullumbine 1947; Hambrook et al. 1992; Renshaw 1946), while the remaining sulfur mustard is 

absorbed systemically. The rate of penetration of sulfur mustard into human skin was estimated in the 

range of 1–4 μg/cm2

/minute (0.006–0.025 μmol/cm2/minute) (Renshaw 1946). Skin penetration of sulfur 

mustard is proportional to its temperature (Nagy et al. 1946). 
 

SULFUR MUSTARD 72 

3. HEALTH EFFECTS 

3.4.2 Distribution 

3.4.2.1 Inhalation Exposure 

Analyses of body fluids and tissues of an Iranian soldier who died 7 days after exposure to sulfur mustard 

(by inhalation and/or dermal routes) indicated that sulfur mustard was distributed to cerebrospinal fluid 

and, in order of decreasing concentrations, fat (from thigh), brain, abdominal skin, kidney, muscle, liver, 

spleen, and lung (Drasch et al. 1987). Analyses of the blood of hairless guinea pigs after 8-minute noseonly exposure to 300 mg/m3

 (46 ppm; 2,400 mg-minute/m3) of sulfur mustard indicated that the 

concentration of sulfur mustard in blood peaked within 5 minutes after exposure, dropped to about 50% 

of peak at 30 minutes, and gradually increased again to about 60% of peak concentration at 4 hours after 

exposure (Langenberg et al. 1998). Evidence of tissue sulfur mustard DNA adducts in hairless guinea 

pigs at 4 hours after 5-minute nose-only exposure to 160 mg/m3

 (25 ppm; 800 mg-minute/m3) of sulfur 

mustard indicates absorption and/or distribution to nasal epithelium, nasopharynx, larynx, carina, and 

lung (Langenberg et al. 1998). Sulfur mustard DNA adducts found in the lung, spleen, and bone marrow 

in the same species after 8-minute nose-only exposure to 300 mg/m3

 (46 ppm; 2,400 mg-minute/m3) of 

sulfur mustard indicates distribution to these tissues (Langenberg et al. 1998). 

3.4.2.2 Oral Exposure 

No studies were located regarding distribution in humans or animals after oral exposure to sulfur mustard. 

3.4.2.3 Dermal Exposure 

As reported in Section 3.4.2.1, analyses of body fluids and tissues of an Iranian soldier exposed to 

airborne sulfur mustard indicated sulfur mustard distribution to most major organs (Drasch et al. 1987), 

consistent with older reports (Cullumbine 1947). Hambrook et al. (1993) reported that after a 6-hour 

cutaneous exposure to radiolabeled sulfur mustard with occlusion, 10–23% of absorbed radiolabel dose 

was retained in rat skin, with 3–7% detected in blood. At the end of the 6-hour application, when the 

level of radiolabel in the blood reached a maximum, greater than 90% of the red cell radiolabel activity 

was found within the cell, and the rest in the red cell membrane. 
SULFUR MUSTARD 73 

3. HEALTH EFFECTS 

In guinea pigs, following a single topical application of 5 μL of radiolabeled sulfur mustard to the cornea, 

radioactivity at 30 minutes after application, as expressed per unit weight, was greatest in the kidney 

followed by liver, lung, adipose tissue, adrenals, plasma, and muscle (Klain et al. 1991). At 2 and 5 hours 

postadministration, the greatest radioactivity per unit weight was again measured in the kidney, whereas 

the level in the plasma increased and that in the liver and lung decreased with postadministration time. 

Expressed per organ, the liver contained the highest level of radioactivity, followed by the kidney and 

lung. At 30 minutes postapplication, radioactivity was widely distributed in the guinea pig eye; the 

choroid/sclera portion contained the highest level followed by cornea, retina, and lens. Low levels were 

also detected in the aqueous and vitreous humors. At 5 hours, the only eye compartment in which the 

radioactivity level had decreased significantly from the 30-minute value was the choroid/sclera portion. 

3.4.2.4 Other Routes of Exposure 

Boursnell et al. (1946) observed significant radioactivity levels in the kidney, lung, and liver of rabbits 

after intravenous injection of 5 mg/kg of radiolabeled sulfur mustard. Lower levels of radioactivity were 

also detected in bone marrow, spleen, stomach wall, duodenal wall, brain, heart, muscle, skin, and 

thyroid. Six hours after intravenous injection of 8.2 mg/kg of radiolabeled sulfur mustard into male 

hairless guinea pigs, radiolabel was distributed in decreasing concentrations to the bone marrow, liver, 

spleen, blood, and lung (Langenberg et al. 1998). In the rat, sulfur mustard is quickly and widely 

distributed (Maisonneuve et al. 1993, 1994; Zhang and Wu 1987). Maisonneuve et al. (1993) reported a 

distribution volume of 74.4 L/kg and a half-life of 5.6 minutes following intravenous bolus administration 

of 10 mg/kg (3 LD50) of sulfur mustard in the rat. The concentration of unchanged sulfur mustard in the 

blood decreased quickly in the first half hour, but low levels were detectable up to 8 hours after 

administration. The large volume of distribution, greater than the volume of body water, suggests a wide 

distribution of sulfur mustard throughout the animal. A quantitative distribution analysis was performed 

by Maisonneuve et al. (1994) in rats intravenously injected with radiolabeled sulfur mustard. 

Radioactivity was detected in blood, plasma, kidney, liver, intestine and stomach, heart, lung, brain, 

spleen, eyes, testicle, and adrenal gland. From 10 minutes to 6 hours after administration, the liver and 

kidney had higher radiolabel concentrations than the blood. The organs with the lowest levels of 

radioactivity were the brain, spleen, eye, and testicle. Maximum radioactivity levels in the organs were 

reached between 2 and 3 hours after injection. Total radioactivity in any organ did not exceed 4% of the 

administered dose. Most of the administered radioactivity was recovered in the muscle; 51% measured in 
SULFUR MUSTARD 74 

3. HEALTH EFFECTS 

muscle at 5 minutes, 36% in muscle at 3 hours, 3% in fat at 35 minutes, and 10% in skin at 35 minutes 

(radioactivity peaked in fat and skin at 35 minutes). 

In vitro studies of plasma and red blood cells treated with radiolabeled sulfur mustard indicate a high 

affinity of sulfur mustard toward red blood cells (Maisonneuve et al. 1993). The mean equilibrium red 

blood cell/plasma radiolabel concentration ratios for treatments with 4 and 400 μg/mL radiolabeled sulfur 

mustard were 2.12 and 4.15, respectively. 

Radiolabeled sulfur mustard administered in rats to the femoral or jugular veins resulted in different organ 

distribution patterns. Subsequent to femoral vein injection, the injected leg was a site of significant sulfur 

mustard distribution, whereas jugular vein injection did not result in significant accumulation in the lung 

(Maisonneuve et al. 1994). The heart, lung, brain, and spleen received greater proportionate shares of 

radioactivity 35 minutes after jugular vein injection compared to femoral vein administration. 

In rats subcutaneously injected with 10 μL of undiluted radiolabeled sulfur mustard, examination of the 

eyes 4 hours after treatment revealed the highest level of radioactivity in the pooled aqueous and vitreous 

humors (70%), followed by retina (12%), choroid/sclera (8%), lens (6%), and cornea (3%) (Klain et al. 

1991). 

3.4.3 Metabolism 

The metabolism of sulfur mustard has not been studied extensively. Sulfur mustard tends to undergo 

intramolecular cyclization to create a hyperactive compound (see Section 6.3.2). Conversion to this 

derivative is facilitated in aqueous solution (Somani and Babu 1989), which accounts for the sensitivity of 

mucosal tissues, such as the eye, to its action (Solberg et al. 1997). Sulfur mustard cyclic intermediates 

react with and alkylate electron-rich molecular structures, such as the sulfhydryl (-SH) and amino (-NH2) 

groups of proteins and nucleic acids (Solberg et al. 1997). Metabolic pathways, including direct 

alkylation reactions, glutathione reactions, hydrolysis, and oxidation, are presumed based on the finding 

of sulfur mustard DNA adducts in tissues (Fidder et al. 1994, 1996a; Niu et al. 1996; Somani and Babu 

1989; Van der Schans et al. 1994) and the identification of urinary products (Jakubowski et al. 2000; Wils 

et al. 1985, 1988). 
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3.4.3.1 Inhalation Exposure 

Jakubowski et al. (2000) measured elevated levels of thiodiglycol, the major sulfur mustard hydrolysis 

product, in human urine following an accidental exposure to sulfur mustard vapor and aerosol. Thiodiglycol was also found in the urine of people exposed to airborne sulfur mustard during the Iran-Iraq 

War (Wils et al. 1985, 1988). 

A sulfur mustard adduct in DNA, the 2′-deoxyguanosine derivative of N7-HETE-guanine, 

N7-(2-hydroxyethylthioethyl)-2′-deoxyguanosine, as well as albumin- and hemoglobin-sulfur mustard 

adducts, have been detected in the blood of two sulfur mustard poisoning victims of the Iran-Iraq War 

(Benschop et al. 1997; Noort et al. 1999). Sulfur mustard DNA adducts were found in the nasal 

epithelium, nasopharynx, larynx, carina, lung, spleen, and bone marrow of hairless guinea pigs after noseonly exposure to sulfur mustard (Langenberg et al. 1998). 

3.4.3.2 Oral Exposure 

No studies were located regarding metabolism in humans or animals after specific oral exposure to sulfur 

mustard. 

3.4.3.3 Dermal Exposure 

Studies of casualties of the Iran-Iraq War with obvious signs of sulfur mustard-induced cutaneous injuries 

have identified significant amounts of the sulfur mustard metabolite, thiodiglycol, in human urine for up 

to 2 weeks after sulfur mustard exposure (Wils et al. 1985, 1988). As reported in Section 3.4.3.1, DNA-, 

hemoglobin- and albumin-sulfur mustard adducts have been detected in the blood of sulfur mustard 

poisoning victims (Benschop et al. 1997; Noort et al. 1999). In two subjects following an accidental 

predominantly cutaneous exposure to sulfur mustard, thiodiglycol, thiodiglycol sulphoxide, and closely 

related metabolites, 1,1'-sulphonylbis[2-(methylsulphinyl)ethane] and 1-methylsulphinyl-2-[2-methylthio)ethylsulphonyl]ethane, derived from the action of β-lyase on cysteine conjugates, were detected in 

the urine (Black and Read 1995a). Thiodiglycol sulphoxide concentrations were 20–35 times thiodiglycol 

concentrations. The β-lyase metabolites were detected at concentrations comparable with those of 

thiodiglycol sulphoxide (Black and Read 1995a). The presence of urinary biotransformation product 

thiodiglycol sulphoxide is consistent with findings in animal studies discussed below in which sulfur 
 

 

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mustard was administered by alternate routes (Black et al. 1992a). Sandelowsky et al. (1992) reported the 

detection of sulfur mustard metabolite, 4-met-1-imid-thiodiglycol, in plasma and urine following dermal 

exposure of sulfur mustard in pigs. 

3.4.3.4 Other Routes of Exposure 

In a metabolic study, radiolabeled sulfur mustard dissolved in ethanol was administered intravenously to 

rats, mice, and two terminal cancer patients (Davison et al. 1961). Several minutes after administration, 

80–90% of the radioactivity was cleared from human blood. The residual level remained constant in both 

plasma and cells for at least 2 days, suggesting binding to some blood constituent. Chromatographic 

analyses of urine yielded similar eluant patterns for rats and mice, whereas those of the human subjects 

showed somewhat lower peaks at pH 2.8 and 2.3. The metabolism of sulfur mustard is apparently largely 

due to glutathione reactions, hydrolysis, and oxidation, since the major urinary metabolites identified in 

the rat were glutathione-bis-2-chloroethyl sulfide conjugates (45% of total), thiodiglycol and conjugates 

(14%), and sulfone products (20%). Unchanged sulfur mustard in excess of the 5 μg assay detection limit 

was not detected in rat urine. 

Slightly different results were reported by Roberts and Warwick (1963), who found that at least 50% of 

the urinary metabolites in rats were conjugated forms of bis-cysteinyl-ethylsulphone. Thiodiglycol 

accounted for 15–20% of the urinary radioactivity, and 10–15% was a sulfide. Black et al. (1992b) 

similarly investigated the metabolism of sulfur mustard in the rat and identified urinary metabolites 

thiodglycol sulphoxide, 1,1'-sulphonylbis[2-(methylsulphinyl)ethane], 1-[S-(N-acetylcysteinyl)]­

2-(ethenylsulphonyl)ethane, 1-methylsulphinyl-2-[2-(methylthio)ethylsulphonyl]ethane, two 

diastereoisomers of 1-[S-(N-acetylcysteinyl)]-2-(2-chloroethylsulphinyl)ethane, 1,1'-sulphinylbis­

[2-chloroethane], 1,1'-sulphonylbis[2-S(N-acetylcysteinyl)ethane], and 1-[S-(N-acetylcysteinyl)]­

2-(2-chloroethylsulphonyl)ethane. Black et al. (1992b), while confirming the major metabolic 

transformations of Davison et al. (1961), identified thiodiglycol sulphoxide as the major urinary excretion 

product and not the initial hydrolysis product thiodiglycol. The finding of metabolites 1,1'-sulphonylbis­

[2-(methylsulphinyl)ethane] and 1-methylsulphinyl-2-[2-(methylthio)ethylsulphonyl]ethane revealed a 

pathway for the degradation of glutathione conjugates formed via the action of enzyme β-lyase on 

cysteine conjugates. Renal β-lyase metabolism has also been implicated in the formation of nephrotoxic 

intermediates from halogenated alkenes. 
SULFUR MUSTARD 77 

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A comparison of unchanged radiolabeled sulfur mustard and total radiolabel concentrations in the blood 

following intravenous bolus administration of radiolabeled sulfur mustard in rats indicated that much of 

the sulfur mustard is metabolized within a half-hour after administration (Maisonneuve et al. 1993). 

Metabolites N7-HETE-guanine (Fidder et al. 1996b), derived from sulfur mustard DNA alkylation, and 

N7-HETE-valine (Fidder et al. 1996a), derived from sulfur mustard hemoglobin alkylation, have been 

detected in the urine of guinea pigs intravenously injected with sulfur mustard. 

3.4.4 Elimination and Excretion 

Urinary excretion is the primary route of elimination for sulfur mustard and/or its metabolites (Boursnell 

et al. 1946; Davison et al. 1961; Hambrook et al. 1992; Maisonneuve et al. 1993). 

3.4.4.1 Inhalation Exposure 

People who were exposed to sulfur mustard during the Iran-Iraq War could have absorbed the material 

through the lungs or through the skin. One of the breakdown products of sulfur mustard, thiodiglycol, 

was detected in the urine of these people (Wils et al. 1985). These authors also report that thiodiglycol 

was found in unexposed persons and could not be used to determine the exact level of sulfur mustard 

exposure, although it could possibly be used to show exposures to high levels. Unmetabolized sulfur 

mustard was also found in urine and feces samples from two Iran-Iraq War victims (Heyndrickx and 

Heyndrickx 1984; Mandl and Freilinger 1984; Pauser et al. 1984; Vycudilik 1985). No studies regarding 

animal excretion data from inhalation exposure are available. 

3.4.4.2 Oral Exposure 

No studies were located regarding excretion in humans or animals after specific oral exposure to sulfur 

mustard. 
 

SULFUR MUSTARD 78 

3. HEALTH EFFECTS 

3.4.4.3 Dermal Exposure 

Jakubowski et al. (2000) measured the excretion of thiodiglycol in human urine following an accidental 

exposure to sulfur mustard vapor and aerosol. Detectable levels of thiodiglycol in urine were measured 

for 13 days after exposure to an undetermined level. The patient’s urine was randomly sampled for 

6 months after exposure and no further thiodiglycol elimination was detected. Maximum thiodiglycol 

excretion was seen on postexposure day 4. First-order elimination kinetics was observed, and the half-life 

of thiodiglycol elimination was estimated to be 1.2 days. 

Hambrook et al. (1992) reported that in the rat, following a 6-hour cutaneous exposure to radiolabeled 

sulfur mustard with occlusion, the urinary excretion of radiolabel had a half-life of 1.4 days; the half-life 

of excretion in feces, which varied slightly with dose, was approximately 1.6 days. Most of the 

radioactivity was found in the urine. Most of the dose was eliminated by 3 days; however, measurable 

urinary excretion of radiolabel continued for >3 months. 

3.4.4.4 Other Routes of Exposure 

Two terminal cancer patients were injected intravenously with radiolabeled sulfur mustard dissolved in 

ethanol (Davison et al. 1961). Several minutes after administration, 80–90% of the radioactivity was 

cleared from the blood. The residual level remained constant in both plasma and cells for at least 2 days, 

suggesting binding to some blood constituent. Excretion of 21% of the radioactivity in the urine occurred 

within 3 days. 

The major route of elimination of radioactivity in the rat, after intravenous injection of radiolabeled sulfur 

mustard is by the kidney (Boursnell et al. 1946; Davison et al. 1961; Hambrook et al. 1992; Maisonneuve 

et al. 1993). Maisonneuve et al. (1993) reported a blood clearance of 21 L/hours-kg, indicating rapid 

excretion from the body, and elimination half-life of 3.59 hours from blood concentration data following 

intravenous bolus administration of 10 mg/kg (3 LD50) of radiolabeled sulfur mustard in the rat. 

Maximum blood radioactivity was observed 1 hour after sulfur mustard administration and, similarly to 

that found in humans (Davidson et al. 1961), a residual constant level of radioactivity (approaching 70% 

of maximum) was found in blood 2 days after exposure; a second peak approaching the maximum level 

was observed between 2 and 4 days. The largest overall recovery of radioactivity was in urine, with about 

65% of the administered dose excreted during 24 hours and 80% during 96 hours, a much higher 
 

SULFUR MUSTARD 79 

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percentage than that reported for humans (Davison et al. 1961). Fecal excretion accounted for <3% of the 

administered dose during 96 hours (Maisonneuve et al. 1993). 

Rats and mice that were injected intraperitoneally with radiolabeled sulfur mustard excreted 50–78% of 

the radioactivity within 1 day and 90% within 3–5 days in the urine (Black et al. 1992a; Davison et al. 

1961; Roberts and Warwick 1963; Smith et al. 1958). Twelve hours after intraperitoneal injection, 6% 

was excreted in the feces and 0.05% in the expired air (Davison et al. 1961). 

Hambrook et al. (1992) measured the excretion of radiolabel in urine and feces in the rat following 

intravenous or intraperitoneal injection of radiolabeled sulfur mustard. The half-life varied little with 

dose, route, or excretion type and an average value of 1.4 days was reported. The pattern of excretion 

was similar after intraperitoneal and intravenous injections. Most of the dose was eliminated by 3 days; 

however, urinary excretion of radiolabel continued for greater than 3 months. About 65% of absorbed 

radiolabel was found in the urine and 11% in feces within 24 hours after administration. 

3.4.5 Physiologically Based Pharmacokinetic (PBPK)/Pharmacodynamic (PD) Models 

Physiologically based pharmacokinetic (PBPK) models use mathematical descriptions of the uptake and 

disposition of chemical substances to quantitatively describe the relationships among critical biological 

processes (Krishnan et al. 1994). PBPK models are also called biologically based tissue dosimetry 

models. PBPK models are increasingly used in risk assessments, primarily to predict the concentration of 

potentially toxic moieties of a chemical that will be delivered to any given target tissue following various 

combinations of route, dose level, and test species (Clewell and Andersen 1985). Physiologically based 

pharmacodynamic (PBPD) models use mathematical descriptions of the dose-response function to 

quantitatively describe the relationship between target tissue dose and toxic end points. 

PBPK/PD models refine our understanding of complex quantitative dose behaviors by helping to 

delineate and characterize the relationships between: (1) the external/exposure concentration and target 

tissue dose of the toxic moiety, and (2) the target tissue dose and observed responses (Andersen et al. 

1987; Andersen and Krishnan 1994). These models are biologically and mechanistically based and can 

be used to extrapolate the pharmacokinetic behavior of chemical substances from high to low dose, from 

route to route, between species, and between subpopulations within a species. The biological basis of 

PBPK models results in more meaningful extrapolations than those generated with the more conventional 

use of uncertainty factors. 
SULFUR MUSTARD 80 

3. HEALTH EFFECTS 

The PBPK model for a chemical substance is developed in four interconnected steps: (1) model 

representation, (2) model parametrization, (3) model simulation, and (4) model validation (Krishnan and 

Andersen 1994). In the early 1990s, validated PBPK models were developed for a number of 

toxicologically important chemical substances, both volatile and nonvolatile (Krishnan and Andersen 

1994; Leung 1993). PBPK models for a particular substance require estimates of the chemical substancespecific physicochemical parameters, and species-specific physiological and biological parameters. The 

numerical estimates of these model parameters are incorporated within a set of differential and algebraic 

equations that describe the pharmacokinetic processes. Solving these differential and algebraic equations 

provides the predictions of tissue dose. Computers then provide process simulations based on these 

solutions. 

The structure and mathematical expressions used in PBPK models significantly simplify the true 

complexities of biological systems. If the uptake and disposition of the chemical substance(s) is 

adequately described, however, this simplification is desirable because data are often unavailable for 

many biological processes. A simplified scheme reduces the magnitude of cumulative uncertainty. The 

adequacy of the model is, therefore, of great importance, and model validation is essential to the use of 

PBPK models in risk assessment. 

PBPK models improve the pharmacokinetic extrapolations used in risk assessments that identify the 

maximal (i.e., the safe) levels for human exposure to chemical substances (Andersen and Krishnan 1994). 

PBPK models provide a scientifically sound means to predict the target tissue dose of chemicals in 

humans who are exposed to environmental levels (for example, levels that might occur at hazardous waste 

sites) based on the results of studies where doses were higher or were administered in different species. 

Figure 3-3 shows a conceptualized representation of a PBPK model. 

No PBPK models exist for sulfur mustard. Toxicokinetic information is insufficient for modeling. 
 

SULFUR MUSTARD 81 

3. HEALTH EFFECTS 

Figure 3-3. Conceptual Representation of a Physiologically Based 

Pharmacokinetic (PBPK) Model for a 

Hypothetical Chemical Substance 

Source: Adapted from Krishnan et al. 1994 

Note: This is a conceptual representation of a physicologically based pharmacokinetic (PBPK) model for a 

hypothetical chemical substance. The chemical substance is shown to be absorbed via the skin, by inhalation, or by 

ingestion, metabolized in the liver, and excreted in the urine or by exhalation. 
 

SULFUR MUSTARD 82 

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3.5 MECHANISMS OF ACTION 

3.5.1 Pharmacokinetic Mechanisms 

Absorption. Sulfur mustard is slightly soluble in water, but both the liquid and vapor forms are 

readily soluble in oils, fats, alcohol, and organic solvents. Because of its high lipid solubility, sulfur 

mustard quickly penetrates the lipid cell membrane. 

Distribution. It has been estimated that about 12% of dermally absorbed sulfur mustard reacts with 

components in skin and the remainder is distributed in greatest proportion to the kidney and fairly evenly 

throughout the rest of the body as unreacted sulfur mustard or hydrolyzed sulfur mustard. In studies with 

radiolabeled sulfur mustard, tissue radioactivity levels increased as early as 5 minutes after intravenous 

injection and 15 minutes after percutaneous administration. 

Metabolism. Sulfur mustard is presumed to be biotransformed by direct alkylation reactions, 

glutathione reactions, hydrolysis, and oxidation based on the finding of sulfur mustard DNA adducts in 

tissues and the identification of urinary products. 

Excretion. Urinary excretion is the primary route of elimination for sulfur mustard and/or its 

metabolites. In humans, elimination follows first-order kinetics and the half-life of thiodiglycol 

elimination is estimated to be 1.2 days (Jakubowski et al. 2000). 

3.5.2 Mechanisms of Toxicity 

Several studies have shown that sulfur mustard applied topically can diffuse and produce biochemical 

alterations consistent with free-radical-mediated oxidative stress, including increased lipid peroxidation 

and antioxidant enzyme activities, depletion of glutathione content, and increased glutathione content in 

eye, kidney, brain, lungs, and liver of rats and mice (Arroyo et al. 2000). Compounds containing reactive 

chlorine, preferably a chloroamide group, have been demonstrated as useful neutralizers of sulfur mustard 

(Arroyo et al. 2000). Sulfur mustard undergoes nucleophilic substitution reactions to form a sulfonium 

ring (Yang et al, 1992) that, in the presence of oxygen, generates a non-toxic sulfoxide reactive 

intermediate (Arroyo et al. 2000). More extensive oxidation results in a toxic sulfone species (Arroyo et 

al. 2000). 
SULFUR MUSTARD 83 

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At the cellular level, sulfur mustard interacts with nucleophiles on the cell membrane, at intracellular 

sites, and with nucleic acids (Papirmeister et al. 1991). While sulfur mustard is able to alkylate DNA, 

RNA, and proteins affecting a variety of cell functions, including altering proteins that have been coded 

by alkylated RNA and structurally altering cell membranes, DNA is the most functionally sensitive target 

of sulfur mustard in cells. Low doses of sulfur mustard can inhibit cell division due to its ability to crosslink complementary strands of DNA (Papirmeister 1993). Transcription, translation, and enzyme 

catalysis, cellular activities that are dependent on biological entities of much lower molecular size than 

chromosomal DNA, are much less sensitive to sulfur mustard. Thus, cells that are prevented from 

synthesizing DNA continue to generate energy and synthesize RNA and proteins. As a result of this 

unbalanced metabolism, cells may enlarge, differentiate, or be induced to synthesize high levels of certain 

proteins. While some of these proteins may protect cells, others may hasten cell death. 

Mechanisms of the toxicity of sulfur mustard have been postulated, but none have been demonstrated 

with certainty (Papirmeister 1993; Somani and Babu 1989; Whitfield 1987). As discussed in Section 3.3, 

it appears that different mechanisms are responsible for the acute and delayed effects of sulfur mustard 

and that additional mechanisms besides genotoxicity mechanisms are responsible for sulfur mustard 

vesication since acute skin injury develops at a time much earlier than expected from genotoxic effects. 

Also, tissue injury does not develop when low, therapeutically effective doses of sulfur mustard are used 

to control the hyperproliferation of psoratic keratinocytes. 

While the mechanisms of sulfur mustard toxicity are not currently fully understood, one hypothesis for 

sulfur mustard cytotoxicity involves poly(ADP-ribose) polymerase (PARP). The following mechanism 

for skin damage has been proposed: sulfur mustard alkylates DNA, which causes DNA breaks; numerous 

sulfur mustard-induced DNA strand breaks cause activation of nuclear repair enzyme PARP. This causes 

cellular depletion of nicotinamide adenine dinucleotide (NAD+

), which decreases glycolysis, which leads 

to protease release and cellular injury. Dermal-epidermal separation and blister formation may involve 

the fragmentation of anchoring filaments by protease released from moribund or dead cells (Papirmeister 

1993). Clark and Smith (1993) showed that sulfur mustard treatment of HeLa cells produces a rapid 

stimulation of PARP activity, followed 2 hours later by a decline in NAD+

 levels. Several other studies 

provide partial support for the hypothesis, but hint that additional pathways may be involved. The 

hypothesis is almost fully validated in a study by Meier and Kelly (1993), in which PADPRP inhibitors 

prevent the sulfur mustard-induced losses of ATP, NAD+

, and viability in human peripheral blood 
SULFUR MUSTARD 84 

3. HEALTH EFFECTS 

lymphocytes. However, their observation that ATP levels decline before NAD+ deviates from the 

expected response. 

Niacinamide, an inhibitor of PARP and a substrate for NAD synthesis reduced sulfur mustard-induced 

loss in NAD (Meier et al. 1987; Mol et al. 1989, 1991; Papirmeister et al. 1985; Smith et al. 1990a) and 

ATP (Meier et al. 1996). 3-Aminobenzamide, an inhibitor of PADPRP but not a substrate for NAD 

synthesis, also reduced sulfur mustard-induced loss in ATP (Meier et al. 1996). Niacin, a substrate for 

NAD synthesis, which does not effect PADPRP, failed to prevent sulfur mustard-induced loss of ATP 

(Meier et al. 1996). These findings support the hypothesis that PARP plays a substantial role in sulfur 

mustard-initiated biochemical changes. Cowan et al. (1993) observed that although niacinamideattenuated sulfur mustard-induced increases in protease activity in vitro and in vivo, it did not eliminate 

them, suggesting that pathways other than the one involving PADPRP may contribute to the increase in 

protease activity. Yourick et al. (1991, 1993) noted that while pretreatment with niacinamide reduced the 

incidence of sulfur mustard-induced microvesiculation in hairless guinea pig skin, the prediction of the 

PARP hypothesis, that the loss of NAD+ precedes tissue injury, was not upheld. Martens and Smith 

(1993) demonstrated that whereas sulfur mustard treatment of human epidermal keratinocytes (HEK) 

produces a dose-related depletion of NAD+

 and inhibition of glucose metabolism, preceding cell death, 

niacinamide did not prevent the inhibition of glycolysis, suggesting that in HEK, other energy-depleting 

mechanisms may be involved in sulfur mustard cytotoxicity. In contradiction to the hypothesis, results in 

rat keratinocytes exposed to sulfur mustard indicate that depletion of NAD is not a prerequisite for cell 

death (Lin et al. 1994). At doses lower than 50 μM, DNA content, viable cell number, and the 

proliferative capacity of the culture, as assessed by thymidine incorporation, were all reduced, whereas 

the total NAD level (NAD+

 plus NADH) was not changed. Also supplementing the culture with 

nicotinamide after exposure to sulfur mustard did not reverse the decrease in DNA content. 

As another hypothesis for sulfur mustard-induced cytotoxicity, Whitfield (1987) suggested that sulfur 

mustard alkylation of glutathione (GSH) removes one of the major cellular defense mechanisms against 

electrophilic compounds and oxidants. Once GSH is depleted, electrophiles such as sulfur mustard or 

endogenously-generated reactive oxygen species eventually inactivate critical sulfhydryl proteins 

involved in calcium homeostasis and/or modify cytoskeletal elements. The subsequent inability of cells 

to maintain the low intracellular calcium concentration causes activation of catabolic processes leading to 

cell damage and death. In partial support of this hypothesis, Ray et al. (1993) demonstrated that treatment 

of neuroblastoma cells and HEKs with sulfur mustard causes depletion of GSH, raises the level of 

intracellular calcium, and stimulates phospholipase A2, processes that precede and ultimately lead to 
 

 

SULFUR MUSTARD 85 

3. HEALTH EFFECTS 

membrane damage and cell death. Also, increasing cellular GSH levels decreased the toxic effects of 

sulfur mustard in human peripheral blood lymphocytes (Gross and Smith 1993). 

Apoptosis may be a mechanism by which sulfur mustard exerts its cytotoxic effects. In keratinocytes 

incubated with sulfur mustard, p53 (a promoter of apoptosis) levels increases, while levels of bcl-2 (a 

suppressor of apoptosis) decreased (Rosenthal et al. 1998). The immunostaining pattern of these two 

markers in sulfur mustard treated skin excised from weanling pigs also suggests the involvement of 

apoptosis in cell death secondary to sulfur mustard exposure (Smith et al. 1997a). Thymocytes, isolated 

from rats, and incubated with sulfur mustard showed an increase in the production of DNA fragments 

characteristic of apoptosis (Michaelson 2000). It is possible that sulfur mustard toxicity involves several 

independent or interacting pathways, some aspects of the various hypotheses. 

Lundy et al. (1998) proposed that sulfur mustard-induced cytotoxicity results from activation of 

purinergic P2 receptors. P2 antagonists were shown to reduce sulfur mustard-induced cytotoxicity, 

providing support for this hypothesis (Doebler 2002). 

Cell cycle kinetics are involved in the cytotoxic processes following sulfur mustard exposure. Sulfur 

mustard-induced damage at subvesicating concentrations (<50 μM) to genomic DNA in cultured HEK 

resulted in a dose-related reversible block at the G2/M phase of the cell cycle (Smith et al. 1993a). 

Okadaic acid and calyculin A, inhibitors of protein phosphatase 2A (PP2A), completely reversed the 

sulfur mustard-induced G2/M block, whereas tautomycin, an inhibitor of protein phosphatase 1, was 

ineffective at reversing the block (Hart and Schlager 1997). As total cellular PP2A was not affected by 

sulfur mustard treatment; these results suggest that PP2A is involved in the G2/M block produced by 

exposure of HEK to low concentrations of sulfur mustard. Exposure of human peripheral blood 

lymphocytes (PBL) to vesicating equivalent concentrations of sulfur mustard (≥50 μM) resulted in 

irreversible blockage at the G1/S interface (Smith et al. 1998). DNA became terminally fragmented. 

Theories have been proposed that blistering induced by sulfur mustard may involve cytokine production 

and a secondary inflammatory response (Dannenberg and Tsuruta 1993; Graham et al. 1994; Papirmeister 

et al. 1991). In the trachea as in the skin, sulfur mustard appears to preferentially damage the cells that 

are the most active in regeneration after aggression, basal cells located above the dermal papillae in skin 

(Papirmeister et al. 1991), and epithelial secretory cells in the trachea (Calvet et al. 1996). In the cell, 

DNA and proteins are the main targets for sulfur mustard alkylation; therefore, it is not unexpected that 

the most severe lesions affect cells with the greatest progenitorial and metabolic capacity. Eosinophils, 
SULFUR MUSTARD 86 

3. HEALTH EFFECTS 

known to produce growth factor and cytokines, were reduced in guinea pigs at 2 weeks postexposure, 

which may influence epithelial regeneration and result in the characteristic slow lesion repair or recovery 

(Calvet et al. 1996). The literature contains conflicting reports of sulfur mustard effects on cytokines. In 

cultured HEK treated with 1–100 μM sulfur mustard, Pu et al. (1995) observed a dose-related increase in 

IL-1α at 72 hours after exposure. Zhang et al. (1995) also measured an increase in IL-1α in isolated 

perfused porcine skin treated with sulfur mustard at 5 hours after exposure. In contrast, Kurt et al. (1998) 

who tested the effects of sulfur mustard on both adult and neonatal HEK, reported a dose-related decrease 

in IL-1α in cultured adult HEK treated with 0.5 and 1.0 mM sulfur mustard; however, only a minimal 

change in IL-1α was seen in neonatal HEK. Sulfur mustard applied to the mouse ear resulted in an 

increase in IL-6 levels at 6 and 18 hours postexposure, whereas IL-1β and TNF-α levels were unchanged 

(Casillas et al. 1996). Kurt et al. (1998) reported that in both neonatal and adult HEK, TNF-α was 

increased at 0.5 mM and decreased at 1.0 mM sulfur mustard, whereas IL-1β, IL-6, and IL-8 were 

increased at both concentrations. While IL-1α and IL-1β share the same biological activity and recognize 

the same receptors on target cells, Kurt et al. (1998) suggest that the differences in the amount of each 

cytokine released relative to the distribution in HEK support different mechanisms of action for sulfur 

mustard with IL-1α and IL-1β. Since the decrease in IL-1β was the only cytokine of those studied with 

significant decreases in both neonatal and adult cell types and at both concentrations, Kurt et al. (1998) 

hypothesized a direct effect of sulfur mustard on IL-1β and indirect actions on the other cytokines. 

In order to investigate possible mechanisms of blistering, urokinase, one of two mammalian activators for 

converting plasminogen into active plasmin, was investigated in vitro in cultured 3T3 fibroblasts exposed 

to 100 μM sulfur mustard (Detheux et al. 1997). Plasmin is a wide-spectrum serine protease, which is 

capable of degrading most extracellular and basement membrane proteins. Twenty-four hours after 

exposure, urokinase activity was increased 20-fold compared to control cells. The significance of this 

proteolytic response in the pathogenesis of blistering is not yet understood. 

There have been several studies of protein alkylation by sulfur mustard with possible relevance to blister 

formation. A potential target for sulfur mustard alykation is uncein, an anchoring filament-associated 

antigen thought to play a role in maintaining the integrity of the dermal-epidermal basement membrane 

zone. Fractionation by SDS-PAGE and immonofluorescent staining of uncein treated with sulfur mustard 

indicated that sulfur mustard chemically modified uncein (Zhang et al. 1998). Male Yorkshire cross 

weanling pigs were exposed dermally to two vesicating doses, estimated at 21,000 and 42,000 mgminute/m3

, of sulfur mustard (Smith et al. 1997a). Immunostaining of excised treated skin revealed a 

progressive decrease with eventual loss of expression of GB3, an antibody to basement membrane 
SULFUR MUSTARD 87 

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protein, laminin 5, during the time of vesiculation at both doses. Desmosomal proteins, cellular 

fibronectin, laminin 1, collagen IV, and collagen VII showed no change or inconsistent changes during 

the same period. The laminins are cystein-rich proteins with multiple thiol groups available for alkylation 

by sulfur mustard. The pattern of immunostaining for laminin 5 was consistent with electron microscopy 

findings showing fragmentation of anchoring filaments at the time of vesication and suggests that 

disruption of laminin 5 may be a factor in sulfur mustard-induced blistering. Laminin 5 regeneration 

occurs early after injury, whereas cutaneous lesions are slow-healing with no evidence of reepithelialization at 7 days after exposure in a hairless guinea pig model. The authors suggested that 

residual alkylated laminin 5 and laminin 1 fragments could inhibit the functioning of the newly formed 

laminin 5. 

DNA arrays were used to study the differential gene expression changes that occur within human 

epidermal keratinocytes after exposure to sulfur mustard (Platteborze 2000). Several genes were 

identified that exhibited significant transcriptional upregulation that could have roles in early sulfur 

mustard injury. Transmembrane serine protease hepsin, which is thought to be involved in cell growth, 

differentiation, and maintenance of morphology, was upregulated about 8-fold at 10–30 minutes after 

exposure. Heparin sulfate proteoglycan 2 (HSPG2) was upregulated about 13-fold at 10 minutes and 

about 8-fold at 30 minutes after exposure. HSPG2 is an integral component of basement membranes and 

is proposed to be involved in cell binding, basement membrane assembly, calcium binding, LDL 

metabolism, activation of serine protease inhibitors, and the anchorage of acetylcholinesterase (AChE) to 

the extracellular matrix of the neuromuscular junction. In addition, heparin sulfate chains carry a fixed 

negative charge, which is thought to participate in the selective permeability of basement membranes. 

Human periodic tryptophan protein 2 (yeast) homolog (PWP2H) was also significantly overexpressed, 

about 7-fold at 10 minutes and about 14-fold at 30 minutes. At present, little is known about the function 

of PWP2H. A notable absence of upregulation of nucleotide repair genes, ERCC1 (Excision Repair 

Cross-Complementing repair deficiency group 1) and ERCC2, and enzyme PARP at 10 and 30 minutes 

postexposure suggests that the recognition or response of human epidermal keratinocytes to sulfur 

mustard genotoxicity is delayed, since PARP) activation was observed at 4 hours after exposure. 

A dose-dependent inhibitory effect of sulfur mustard on the heat shock response (temperature-related 

synthesis of heat-shock proteins enabling an adaptive response) was found in mononuclear human cells 

(Sterri 1993). The effect was fully developed at subvesicating doses and was strongly dependent on the 

order of the exposures to sulfur mustard and stress effector. Heat shock protein expression was inhibited 

in cells exposed to sulfur mustard and subsequently heat shocked, whereas cells that were heat shocked 
 

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first and then exposed to sulfur mustard continued with the normal heat shock response. These results 

point to both transcriptional and translational sites of effect. The mechanistic coupling between the stress 

response and sulfur mustard remains to be understood. 

Sawyer et al. (1996) examined the possibility that the toxicity of sulfur mustard is due to the induction or 

activation of nitric oxide synthase (NOS). L-nitroarginine methyl ester (L-NAME), an arginine analog 

inhibitor of NOS, was found to confer protection to mature primary cultures of chick embryo forebrain 

neurons against the toxicity of sulfur mustard when administered as a pretreatment or up to 3 hours 

postexposure. No protection was evident in immature (1-day-old) cultures. While NOS requires 

L-arginine as a substrate, sulfur mustard toxicity and L-NAME protection were independent of L-arginine 

concentration. In contrast to L-NAME, L-thiocitrulline (L-TC), another arginine analog NOS inhibitor, 

was found to protect immature cultures of neurons against sulfur mustard, as well as mature cultures 

(Sawyer et al. 1998). L-TC increased the LC50 of sulfur mustard by approximately 800 and 1,500% with 

1- and 24-hour pretreatments, respectively. The protection conferred by L-TC was persistent, unlike 

L-NAME whose protection was dependent on its continued presence, suggesting that these closely related 

arginine analogs act at different sites to exert their effects (Sawyer et al. 1996, 1998). A synergistic 

protective effect was found in mature neuron cultures pretreated with both L-NAME and L-TC (Sawyer 

1998). Whereas 1-hour pretreatment with L-NAME and L-TC increased the LC50 of sulfur mustard by 

approximately 200 and 800%, respectively, together up to 1,500% protection was conferred in mature 

cultures. Based on these findings, Sawyer (1998) proposed that sulfur mustard initiates its toxicity 

rapidly through a cell-surface mediated event, that can be blocked by L-TC, followed by signal 

transduction into the cell with an additional event manifested several hours later. The role of NOS in 

sulfur mustard toxicity remains unclear; however, these arginine analog NOS inhibitors provide 

protective effects, apparently not mediated through inhibition of NOS. 

A study by Zhang et al. (1995) of the protective effects of four pharmacological agents in sulfur mustardtreated isolated perfuse porcine skin flap (IPPSF) suggests that different mechanisms are involved in the 

production of sulfur mustard-induced dark basal cells, microvesicles, and vascular response. Reduction 

of sulfur mustard-induced dark basal cells was observed with sulfur mustard scavengers, sodium 

thiosulfate and cysteine, with niacinamide, an inhibitor of poly(adenosine diphosphoribose) polymerase 

(PADPRP) and a substrate for NAD synthesis, and with cyclooxygenase inhibitor indomethacin. 

Treatments with niacinamide and indomethacin, but not sodium thiosulfate or cysteine, resulted in an 

inhibition of the vascular response in IPPSF exposed to sulfur mustard. Of the four agents, microvesicles 

were only partially prevented in the indomethacin-perfused IPPSF. 
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The toxic effects of sulfur mustard have been attributed to DNA modification with the formation of 

7-hydroxyethylthioethyl guanine, 3-hydroxyethylthioethyl adenine, and the cross-link, di-(2-guanin-7-ylethyl)sulfide. Bacterial 3-methyladenine DNA glycosylase II (Gly II) was found to release both 

3-hydroxyethylthioethyl adenine and 7-hydroxyethylthioethyl guanine from calf thymus DNA was 

modified with [14C]sulfur mustard, suggesting that glycosylase action may play a role in protecting cells 

from the toxic effects of sulfur mustard (Matijasevic et al. 1996). 

Sulfur mustard was found to inhibit blood cell and tissue antioxidant enzyme activities in rats following 

topical application, which could impair cytoprotective defense mechanisms (Husain et al. 1996). Enzyme 

activities were measured at 24 hours after dermal treatment with 98 mg/mg (0.5 LD50) of sulfur mustard. 

Superoxide dismutase (SOD) activity decreased significantly, 70% in white blood cells, 65% in platelets, 

72% in the spleen, and 29% in brain. SOD activity in red blood cells, liver, and kidney did not change 

significantly following treatment. Catalase activity decreased significantly (54% in white blood cells, 

23% in red blood cells, and 51% in spleen); activity levels in platelets, liver, kidney, and brain were not 

significantly altered. Glutathione peroxidase (GSH-Px) activity, as a consequence of glutathione and 

NADPH depletion, decreased significantly in white blood cells (42%), spleen (43%), and liver (22%). 

Glutathione activities in red blood cells, platelets, kidney, and brain were within 10% of control values. 

A significant depletion of GSH of blood and liver was also observed in mice following dermal application 

of 38.7 or 77.4 mg/kg of sulfur mustard (Vijayaraghavan et al. 1991). 

3.5.3 Animal-to-Human Extrapolations 

Various models consisting of human peripheral blood lymphocytes, human skin grafts, porcine skin flaps 

in explant culture, human epidermal keratinocytes in culture, human eyes, hairless guinea pigs, nude 

mice, and stratified rat epidermal cultures have been developed to study the biochemical events in sulfur 

mustard toxicity. However, an appropriate animal model is lacking, as there have been no animals in 

which it has been possible to reproduce, in its entirety, the effects of sulfur mustard on human skin 

(Pechura and Rall 1993). Laboratory animals with fur, lacking sweat glands on most of their body, do not 

provide optimal models for dermal exposure. For a given dose, higher dermal concentrations are 

achieved in nonhuman mammalian skin, compared to human skin, and more severe tissue damage is 

noted in the dermis than the epidermis (Pechura and Rall 1993). Injuries to animal skin develop and heal 

more quickly than same-degree-of-severity injuries to human skin (Pechura and Rall 1993). Blister 
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character differs between humans and animals. Microblisters, rather than macroblisters, develop in the 

skin of laboratory species at effective dose levels. 

An intermediate-duration inhalation MRL was derived based on ocular effects of conjunctivitis and 

chronic keratitis in dogs (McNamara et al. 1975). Gates and Moore (1946) reported that the human eye is 

about 4 times more sensitive to sulfur mustard than the rabbit eye based on the observation of corneal 

ulceration produced in rabbits at a Ct of 4 times the value at which this effect occurred in humans. Gates 

and Moore (1946) also reported the observation of sulfur mustard-induced corneal ulceration in dogs at a 

Ct of twice the value at which this effect occurred in humans, which is consistent with the observation by 

McNamara et al. (1975) of ocular effects in dogs. Thus, an uncertainty factor of 3 for extrapolation of 

ocular effects data from dogs to humans, which is closer to the observed Ct difference factor of 2 than a 

default value of 10, is considered appropriate for derivation of the intermediate-duration inhalation MRL. 

An intermediate-duration oral MRL was derived based on mild epithelial acanthosis of the forestomach in 

rats (Sasser et al. 1996a). Although humans do not have forestomachs, the primary mechanism of toxicity 

of sulfur mustard is epithelial tissue damage from direct contact and, therefore, epithelial acanthosis is 

considered a suitable critical noncancer end point for deriving an oral MRL. Tissue damage would be 

expected to occur at the point of contact, even if it were another part of the gastrointestinal tract. Because 

sulfur mustard is a highly corrosive agent, epithelial lesions at the point of entry into the stomach are 

likely to occur across species. For this reason, the typical default value of 10 for the uncertainty factor for 

extrapolation of data from animals to humans is considered to be too high and a lower value of 3 was 

applied. 

An uncertainty factor default value of 10 for extrapolation from animals to humans was applied in 

deriving an acute oral MRL based on inflamed mesenteric lymph nodes in the rat dams and reduced 

ossification in the fetuses (DOA 1987). 

As discussed in Section 3.2.1.2, short-term respiratory effects similar to those described in humans have 

been reported in experimental animals, which suggests that knowledge obtained regarding respiratory 

effects in animal models can be usefully applied to humans. 
 

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3.6 TOXICITIES MEDIATED THROUGH THE NEUROENDOCRINE AXIS 

Recently, attention has focused on the potential hazardous effects of certain chemicals on the endocrine 

system because of the ability of these chemicals to mimic or block endogenous hormones. Chemicals 

with this type of activity are most commonly referred to as endocrine disruptors. However, appropriate 

terminology to describe such effects remains controversial. The terminology endocrine disruptors, 

initially used by Colborn and Clement (1992), was also used in 1996 when Congress mandated the 

Environmental Protection Agency (EPA) to develop a screening program for “...certain substances 

[which] may have an effect produced by a naturally occurring estrogen, or other such endocrine 

effect[s]...”. To meet this mandate, EPA convened a panel called the Endocrine Disruptors Screening and 

Testing Advisory Committee (EDSTAC), which in 1998 completed its deliberations and made 

recommendations to EPA concerning endocrine disruptors. In 1999, the National Academy of Sciences 

released a report that referred to these same types of chemicals as hormonally active agents. The 

terminology endocrine modulators has also been used to convey the fact that effects caused by such 

chemicals may not necessarily be adverse. Many scientists agree that chemicals with the ability to disrupt 

or modulate the endocrine system are a potential threat to the health of humans, aquatic animals, and 

wildlife. However, others think that endocrine-active chemicals do not pose a significant health risk, 

particularly in view of the fact that hormone mimics exist in the natural environment. Examples of 

natural hormone mimics are the isoflavinoid phytoestrogens (Adlercreutz 1995; Livingston 1978; Mayr et 

al. 1992). These chemicals are derived from plants and are similar in structure and action to endogenous 

estrogen. Although the public health significance and descriptive terminology of substances capable of 

affecting the endocrine system remains controversial, scientists agree that these chemicals may affect the 

synthesis, secretion, transport, binding, action, or elimination of natural hormones in the body responsible 

for maintaining homeostasis, reproduction, development, and/or behavior (EPA 1997). Stated differently, 

such compounds may cause toxicities that are mediated through the neuroendocrine axis. As a result, 

these chemicals may play a role in altering, for example, metabolic, sexual, immune, and neurobehavioral 

function. Such chemicals are also thought to be involved in inducing breast, testicular, and prostate 

cancers, as well as endometriosis (Berger 1994; Giwercman et al. 1993; Hoel et al. 1992). 

It is possible that sulfur mustard modifies the feedback of endogenous hormones and, through the 

complex interactions of central nervous system and endocrine function regulation, behavior (i.e., libido). 

In a survey of 800 Iranian men who were exposed to sulfur mustard during the Iran-Iraq War, 279 men 

(34.8%) reported decreased libido, 342 (42.8%) reported no change, 6 (0.8%) reported increased libido, 
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and 173 (21.6%) did not respond to this survey question (Pour-Jafari and Moushtaghi 1992). Of these 

men, 86.6% still suffered symptoms from chemical injury, namely lung and skin lesions. 

There is limited evidence to suggest that sulfur mustard affects follicle stimulating hormone (FSH) levels 

and thus plays a role in reproductive function. The time course of changes in serum concentrations of 

total and free testosterone, luteinizing hormone (LH), dehydroepiandrosterone (DS), FSH, 17 α-OH 

progesterone, and prolactin were studied in 16 men during the first 3 months after chemically confirmed 

exposure to chemical weapons containing sulfur mustard in 1987 during the Iran-Iraq War (Azizi et al. 

1995). A group of 34 healthy unexposed men of similar age served as controls. Released from the 

pituitary, LH stimulates the Leydig cells to produce testosterone, while FSH stimulates the Sertoli cells to 

produce sperm. At 1 week after exposure, total testosterone, free testosterone, and DS were significantly 

lower, 57, 72, and 53%, respectively, in exposed men than in controls, while levels of the remaining 

hormones were comparable between groups. Total testosterone, free testosterone, and DS levels 

continued to decrease during the first 5 weeks after exposure. At 1 week, 4 of 16 exposed men (25%) had 

serum testosterone levels that were reduced by >60% below the control average; by the 5th week, the 

number increased to 11 (69%). DS mean values reached as low as 18% of the mean of control subjects. 

After the 5th week, these three hormone levels increased returning to normal levels at 12 weeks after 

injury. Small but significant increases in mean serum concentration of LH at the 3rd week and that of 

FSH and prolactin at the 5th week were measured. Normal levels of LH, FSH, and prolactin were 

measured at 12 weeks. FSH and LH response levels to 100 μg of gonadotropin releasing hormone 

(GnRH) administered intravenously during the first week after exposure, were subnormal in four of five 

patients. Testosterone levels in these men returned to normal 12 weeks after exposure. 

In a follow-up study of 42 men, ages 18–37, injured by sulfur mustard during the Iran-Iraq War, serum 

testosterone, LH, and prolactin concentrations were normal in all men 1–3 years following exposure 

(Azizi et al. 1995). A comparison of the mean serum FSH concentration in 13 subjects with sperm count 

below 20 million and in 20 subjects with sperm counts above 60 million, revealed a nearly 2-fold increase 

in FSH concentration in those with the lower sperm count; the increased FSH level was 38% above the 

mean FSH concentration in a group of 34 healthy unexposed males. Inhibition of spermatogenesis was 

also observed in male mice following intravenous injection of sulfur mustard (Graef et al. 1948). 

Elevated FSH has been correlated clinically with testicular failure, germinal aplasia, or hypergonadotropic 

hypogonadism. It appears unlikely that alteration of FSH levels is related to the effect of sulfur mustard 

on the pituitary since LH levels were unaffected in males. A possible target is inhibin secretion by testes 

Sertoli cells, which suppresses pituitary FSH secretion. 
 

 

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Administration of sulfur mustard did not affect the reproductive potential of female mice because the 

fertility of the mice was not altered and no injurious effects were observed in the ovaries (Graef et al. 

1948). Chronic (52 weeks) inhalation exposure of male rats to sulfur mustard (0.1 mg/m3

) was reported 

to produce significant dominant lethal mutation rates (a maximum of 9.4% at 12–52 weeks), but exposure 

of pregnant females to the same concentration for a shorter time interval did not (Rozmiarek et al. 1973). 

McNamara et al. (1975) subsequently concluded from these same data that there were no differences 

between the control and experimental groups and no evidence of mutagenesis. The conflict between these 

two reports is not readily resolvable, but the fetal mortality values presented by McNamara et al. (1975) 

suggest at least a trend for a dominant lethal effect. Complete control data and statistical analyses of the 

results are not presented, but percentages of fetal death at week 12 were 4.12, 4.24, and 21.05 for 

controls, 0.001, and 0.1 mg/m3

 exposure groups, respectively. 

In a dominant lethal study of sulfur mustard, rats were orally gavaged with 0.08, 0.2, or 0.5 mg/kg/day 

sulfur mustard 5 days/week for 10 weeks (Sasser et al. 1993). In female dominant lethality experiments, 

reproductive performance indicators (number of live or dead implants, resorptions, and preimplantation 

losses) in treated female rats mated to treated or nontreated males were not significantly different from 

controls. In male dominant lethality experiments (treated males were mated with untreated females), 

resorptions and preimplantation losses in the mid- and high-dose groups were significantly elevated. 

High-dose male sperm morphology data at all postexposure sampling times, 0, 5, and 12 weeks, showed a 

statistically significant decrease in the percentage of normal sperm. Blunthook and banana-shaped sperm 

heads were observed at 0, 5, and 12 weeks, whereas amorphous and short head abnormalities were 

observed only at 5 and 12 weeks. Overall, there was a total 2-fold increase in abnormal sperm heads in 

high-dose sulfur mustard-treated males. In summary, female fertility was not affected by these sulfur 

mustard exposures; however, a male dominant lethal effect was demonstrated at the mid and high doses 

of sulfur mustard. This lack of reproductive effects in female animals further supports the testes, rather 

than the pituitary, as the target organ in connection with possible sulfur mustard-induced alteration in 

FSH levels. 

The time course of changes in thyroid indices, serum T3, T4, TSH, reverse T3, thyroglobulin and cortisol, 

plasma ACTH, and free T3 and T4 indexes (FT3I, FT4I) were studied in 13 male soldiers, ages 21– 

32 years, during the first 5 weeks after chemically confirmed exposure in 1987 during the Iran-Iraq War 

to chemical weapons containing sulfur mustard (Azizi et al. 1993). A group of 34 healthy unexposed men 

of similar age served as controls. T4 and FT4I were not consistently affected following injury; compared 
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to controls, significantly decreased values were measured at 1 and 5 weeks after exposure, and but values 

slightly above normal were measured at 3 weeks. T3 and FT3I were significantly lower (11–23%) than 

control at 1, 3, and 5 weeks after injury. Reverse T3 concentration in injured men was significantly 

higher (29%) than mean control value at 1 week, but was normal at weeks 3 and 5. TSH and 

thyroglobulin levels in the injured soldiers were comparable to controls during the 5 postexposure weeks. 

Cortisol was significantly higher (40%) than normal 1 week after exposure, within the normal range at 

week 3, and significantly decreased (50%) below normal at week 5. ACTH was significantly increased 

(57–80%) above the normal control value at 1, 3, and 5 weeks after exposure. No follow-up studies of 

thyroid indices were located to determine whether normal levels returned or if any chronic effects exist. 

3.7 CHILDREN’S SUSCEPTIBILITY 

This section discusses potential health effects from exposures during the period from conception to 

maturity at 18 years of age in humans, when all biological systems will have fully developed. Potential 

effects on offspring resulting from exposures of parental germ cells are considered, as well as any indirect 

effects on the fetus and neonate resulting from maternal exposure during gestation and lactation. 

Relevant animal and in vitro models are also discussed. 

Children are not small adults. They differ from adults in their exposures and may differ in their 

susceptibility to hazardous chemicals. Children’s unique physiology and behavior can influence the 

extent of their exposure. Exposures of children are discussed in Section 6.6 Exposures of Children. 

Children sometimes differ from adults in their susceptibility to hazardous chemicals, but whether there is 

a difference depends on the chemical (Guzelian et al. 1992; NRC 1993). Children may be more or less 

susceptible than adults to health effects, and the relationship may change with developmental age 

(Guzelian et al. 1992; NRC 1993). Vulnerability often depends on developmental stage. There are 

critical periods of structural and functional development during both prenatal and postnatal life and a 

particular structure or function will be most sensitive to disruption during its critical period(s). Damage 

may not be evident until a later stage of development. There are often differences in pharmacokinetics 

and metabolism between children and adults. For example, absorption may be different in neonates 

because of the immaturity of their gastrointestinal tract and their larger skin surface area in proportion to 

body weight (Morselli et al. 1980; NRC 1993); the gastrointestinal absorption of lead is greatest in infants 

and young children (Ziegler et al. 1978). Distribution of xenobiotics may be different; for example, 
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infants have a larger proportion of their bodies as extracellular water and their brains and livers are 

proportionately larger (Altman and Dittmer 1974; Fomon 1966; Fomon et al. 1982; Owen and Brozek 

1966; Widdowson and Dickerson 1964). The infant also has an immature blood-brain barrier (Adinolfi 

1985; Johanson 1980) and probably an immature blood-testis barrier (Setchell and Waites 1975). Many 

xenobiotic metabolizing enzymes have distinctive developmental patterns. At various stages of growth 

and development, levels of particular enzymes may be higher or lower than those of adults, and 

sometimes unique enzymes may exist at particular developmental stages (Komori et al. 1990; Leeder and 

Kearns 1997; NRC 1993; Vieira et al. 1996). Whether differences in xenobiotic metabolism make the 

child more or less susceptible also depends on whether the relevant enzymes are involved in activation of 

the parent compound to its toxic form or in detoxification. There may also be differences in excretion, 

particularly in newborns who all have a low glomerular filtration rate and have not developed efficient 

tubular secretion and resorption capacities (Altman and Dittmer 1974; NRC 1993; West et al. 1948). 

Children and adults may differ in their capacity to repair damage from chemical insults. Children also 

have a longer remaining lifetime in which to express damage from chemicals; this potential is particularly 

relevant to cancer. 

Certain characteristics of the developing human may increase exposure or susceptibility, whereas others 

may decrease susceptibility to the same chemical. For example, although infants breathe more air per 

kilogram of body weight than adults breathe, this difference might be somewhat counterbalanced by their 

alveoli being less developed, which results in a disproportionately smaller surface area for alveolar 

absorption (NRC 1993). 

Information on children’s health effects is provided from reports of children exposed to sulfur mustard 

from air bombs during the Iran-Iraq War (Momeni and Aminjavaheri 1994). In children, as in adults, the 

most severe effects were contact effects to the eyes, skin, and respiratory tract as might be expected for a 

vesicant; however, some differences in clinical manifestations were reported. The onset of symptoms in 

children was sooner than in adults (Momeni and Aminjavaheri 1994). Generally, clinical manifestations 

of sulfur mustard exposure in the adults examined were delayed by about 8–24 hours, whereas 

manifestations in children first occurred 4–18 hours after exposure. Cough and vomiting were the first 

signs of poisoning in the children, but not in adults. Blisters appeared sooner in the children and teenager 

group than in adults. Cough and vomiting were the first symptoms in the children, but not in adults. The 

severity of ocular effects was greater in the children and teenager subgroup than in adults. Pulmonary and 

gastrointestinal symptoms were more frequent in children and teenagers (78% and 69%, respectively), 

compared with adults (11%). Genital lesions were less frequent in children and teenagers (42%) than 
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adults (70%); however, even within the group of children, the incidence and severity of genital lesions 

increased with age. Other skin lesions had no apparent age-relation. The only information located 

regarding possible adverse developmental effects in humans suggested an association between parental 

exposure to chemical agents, including, but not limited to, sulfur mustard, and elevated rates for 

congenital malformations (Pour-Jafari 1994b). Studies of animals administered sulfur mustard by gavage 

in oil during pregnancy have indicated reduced fetal weight and reduced ossification of the vertebrae 

and/or sternebrae, but only at levels that were also toxic to the mother (DOA 1987; Sasser et al. 1996a). 

No information was located regarding pharmacokinetics of sulfur mustard in children nor it is known 

whether sulfur mustard can be stored and excreted in breast milk. There have been no direct 

measurements to determine whether sulfur mustard can cross the placenta. There is no information on 

whether sulfur mustard can be stored in maternal tissues and be mobilized during pregnancy or lactation. 

There are no biomarkers of exposure or effect for sulfur mustard that have been validated in children or in 

adults exposed as children. No studies were located regarding interactions of sulfur mustard with other 

chemicals in children or adults. 

No information was located regarding pediatric-specific methods for reducing peak absorption following 

exposure to sulfur mustard, reducing body burden, or interfering with the mechanism of action for toxic 

effects. In addition, no data were located regarding whether methods for reducing toxic effects of sulfur 

mustard in adults might be contraindicated in children. 

Kurt et al. (1998) report differential sensitivity related to cytokine release of cultured adult and neonatal 

human epidermal keratinocytes treated with sulfur mustard, but the significance of these findings are not 

known. 

3.8 BIOMARKERS OF EXPOSURE AND EFFECT 

Biomarkers are broadly defined as indicators signaling events in biologic systems or samples. They have 

been classified as markers of exposure, markers of effect, and markers of susceptibility (NAS/NRC 

1989). 
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Due to a nascent understanding of the use and interpretation of biomarkers, implementation of biomarkers 

as tools of exposure in the general population is very limited. A biomarker of exposure is a xenobiotic 

substance or its metabolite(s) or the product of an interaction between a xenobiotic agent and some target 

molecule(s) or cell(s) that is measured within a compartment of an organism (NAS/NRC 1989). The 

preferred biomarkers of exposure are generally the substance itself or substance-specific metabolites in 

readily obtainable body fluid(s), or excreta. However, several factors can confound the use and 

interpretation of biomarkers of exposure. The body burden of a substance may be the result of exposures 

from more than one source. The substance being measured may be a metabolite of another xenobiotic 

substance (e.g., high urinary levels of phenol can result from exposure to several different aromatic 

compounds). Depending on the properties of the substance (e.g., biologic half-life) and environmental 

conditions (e.g., duration and route of exposure), the substance and all of its metabolites may have left the 

body by the time samples can be taken. It may be difficult to identify individuals exposed to hazardous 

substances that are commonly found in body tissues and fluids (e.g., essential mineral nutrients such as 

copper, zinc, and selenium). Biomarkers of exposure to sulfur mustard are discussed in Section 3.8.1. 

Biomarkers of effect are defined as any measurable biochemical, physiologic, or other alteration within an 

organism that, depending on magnitude, can be recognized as an established or potential health 

impairment or disease (NAS/NRC 1989). This definition encompasses biochemical or cellular signals of 

tissue dysfunction (e.g., increased liver enzyme activity or pathologic changes in female genital epithelial 

cells), as well as physiologic signs of dysfunction such as increased blood pressure or decreased lung 

capacity. Note that these markers are not often substance specific. They also may not be directly 

adverse, but can indicate potential health impairment (e.g., DNA adducts). Biomarkers of effects caused 

by sulfur mustard are discussed in Section 3.8.2. 

A biomarker of susceptibility is an indicator of an inherent or acquired limitation of an organism's ability 

to respond to the challenge of exposure to a specific xenobiotic substance. It can be an intrinsic genetic or 

other characteristic or a preexisting disease that results in an increase in absorbed dose, a decrease in the 

biologically effective dose, or a target tissue response. If biomarkers of susceptibility exist, they are 

discussed in Section 3.10 “Populations that are Unusually Susceptible.” 

3.8.1 Biomarkers Used to Identify or Quantify Exposure to Sulfur mustard 

Several analytical methods are available that can be used to quantitatively determine thiodiglycol, a major 

sulfur mustard hydrolysis product, and metabolites that yield thiodiglycol under sample preparation 
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conditions in the urine of persons exposed to sulfur mustard (Jakubowski et al. 2000). However, 

thiodiglycol, not associated with sulfur mustard exposure, has been detected at low levels in normal 

human urine. A significantly higher urinary level of thiodiglycol, compared with the range found in 

normal urine from unexposed individuals, is generally consistent with exposure to sulfur mustard, but 

does not definitively prove mustard poisoning (Wils et al. 1985, 1988). Elevated levels of thiodiglycol 

have been detected in the urine of persons exposed to sulfur mustard up to about two weeks after 

exposure (Jakubowski et al. 2000). Unmetabolized sulfur mustard may be detected in the urine if a 

person is exposed to very high levels (Heyndrickx and Heyndrickx 1984; Mandl and Freilinger 1984; 

Pauser et al. 1984; Vycudilik 1985). Thiodiglycol was not unambiguously detected in sulfur mustardinduced blister fluid, but chromatographic components have provided strong evidence for thiodiglycolrelated fragments (Jakubowski et al. 2000). However, the need for low-level and retrospective detection 

of exposure has been illustrated in the attempts to clarify the causes of the significant number of postwar 

symptoms experienced by soldiers involved in the Persian Gulf War. 

Black et al. (1992a) identified, in addition to several other metabolites, thiodiglycol sulphoxide as the 

major urinary excretion product, and not the initial hydrolysis product thiodiglycol. In two subjects 

accidentally exposed to sulfur mustard, urine thiodiglycol sulphoxide concentrations were 20–35 times 

thiodiglycol concentrations (Black and Read 1995a). However, the use of thiodiglycol sulphoxide as a 

biological marker for sulfur mustard poisoning, as is the case for thiodiglycol, is limited by its presence at 

low concentrations in normal human urine. Of the remaining metabolites, several are conjugates of sulfur 

mustard with N-acetylcysteine, most of which have poor mass spectrometric and/or gas chromatography 

properties mainly due to thermal instability (Black et al. 1991). Two closely related metabolites of sulfur 

mustard, 1,1'-sulphonylbis[2-(methylsulphinyl)ethane] and 1-methylsulphinyl-2-[2-methylthio)ethylsulphonyl]ethane, derived from the action of β-lyase on cysteine conjugates, have been detected in urine 

collected from Iran-Iraq War casualties of sulfur mustard poisoning (Black and Read 1995b); there were 

no background levels of these metabolites detected in human or rat urine (Black et al. 1991). 

Since sulfur mustard is known to alkylate DNA, RNA, and proteins, attempts have been made to detect 

these adducts in blood and, subsequent to release from dying cells, in urine (Somani and Babu 1989). In 

DNA, N-alkylated purines, such as N7-hydroxyethylguanine, have been identified from enzymatic digests 

as active sites for sulfur mustard (Fidder et al. 1994, 1996b; Niu et al. 1996; Somani and Babu 1989; Van 

der Schans et al. 1994). Van der Schans et al. (1994) synthesized N7-(2-hydroxyethylthioethyl)-GMP 

(N7-HETE-GMP) for use as a hapten to generate monoclonal antibodies against the major adduct, 

N7-(2-hydroxyethylthioethyl)guanine (N7-HETE-guanine), formed after alkylation of DNA with sulfur 
 

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3. HEALTH EFFECTS 

mustard. Another sulfur mustard adduct in DNA, the 2′-deoxyguanosine derivative of N7-HETEguanine, N7-(2-hydroxyethylthioethyl)-2′-deoxyguanosine, has been detected by immunochemical 

analysis in the blood of two victims of the Iran-Iraq War (Benschop et al. 1997). Presently, these adducts 

in white blood cells can be detected after exposure of human blood to sulfur mustard concentrations 

≥2 μM (van der Schans et al. 1994). The metabolite, N7-HETE-guanine, derived from sulfur mustard 

DNA alkylation, was detected by immunochemical analysis in the urine of guinea pigs administered 

sulfur mustard intravenously (Fidder et al. 1996b). These antibodies also have potential in the 

development of a single-cell assay with immunofluorescence microscopy to quantify adduct formation in 

skin exposed to sulfur mustard. 

To enable detection of low-level exposure to sulfur mustard, sulfur mustard adducts with proteins have 

also been explored. Sulfur mustard alkylates hemoglobin (Black et al. 1997a, 1997b; Fidder et al. 1996a; 

Noort et al. 1996, 1997) and albumin (Noort et al. 1999). In hemoglobin, histidine residues and the 

N-terminal valine on both the α and β chains were identified as key sites of interaction (Black et al. 

1997a, 1997b; Fidder et al. 1996a; Noort et al. 1997). A procedure employing gas chromatography-mass 

spectrometry with modified Edman degradation has been developed for the determination of the adduct of 

sulfur mustard with the N-terminal valine residue of hemoglobin (Fidder et al. 1996a). Metabolite 

N7-HETE-valine was detected in the urine of guinea pigs administered sulfur mustard intravenously 

(Fidder et al. 1996a). A cysteine residue of albumin was identified as a site of sulfur mustard alkylation 

(Noort et al. 1999). A mass spectrometric analysis of the adduct of sulfur mustard with the cysteine 

residue of albumin, S-HETE-Cys-Pro-Phe, provided a detection limit for sulfur mustard an order of 

magnitude lower than the modified Edman assay for hemoglobin (Noort et al. 1999). Compared to the 

hemoglobin, the drawback for albumin-sulfur mustard adduct detection is the faster elimination rate. The 

half-life of albumin is 20–25 days versus the 120-day life span of hemoglobin. Both albumin- and 

hemoglobin-sulfur mustard adducts have been detected in the blood of two victims of the Iran-Iraq War 

using the respective assay (Benschop et al. 1997; Noort et al. 1999). 

3.8.2 Biomarkers Used to Characterize Effects Caused by Sulfur mustard 

There are no specific biomarkers of effects for sulfur mustard. Sulfur mustard is one of many vesicant 

agents that affect mucosal and non-mucosal surfaces with which it comes in contact. Thus, the primary 

targets for exposure to sulfur mustard in the air are the skin, eyes, and respiratory tract and, if ingested, 

the gastrointestinal tract. 
 

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3. HEALTH EFFECTS 

3.9 INTERACTIONS WITH OTHER CHEMICALS 

No data were located on the interactions of sulfur mustard with other toxicants likely to be found at 

hazardous waste sites. 

3.10 POPULATIONS THAT ARE UNUSUALLY SUSCEPTIBLE 

A susceptible population will exhibit a different or enhanced response to sulfur mustard than will most 

persons exposed to the same level of sulfur mustard in the environment. Reasons may include genetic 

makeup, age, health and nutritional status, and exposure to other toxic substances (e.g., cigarette smoke). 

These parameters result in reduced detoxification or excretion of sulfur mustard, or compromised function 

of organs affected by sulfur mustard. Populations who are at greater risk due to their unusually high 

exposure to sulfur mustard are discussed in Section 6.7, Populations With Potentially High Exposures. 

Humans show varying degrees of dermal sensitivity to sulfur mustard (Renshaw 1946; Sulzberger et al. 

1947); fair-skinned people are more sensitive than dark-skinned people. These reports also indicate that 

individuals with previous exposure are more sensitive to the dermal effects of sulfur mustard. It is 

possible that individuals with respiratory problems (asthma, emphysema, etc.) might be more sensitive to 

the effects of sulfur mustard and might suffer acceleration of their disease following exposure. Since 

sulfur mustard has been associated with lung cancer, people who smoke may be at greater risk. Children 

may be more susceptible to the effects of sulfur mustard than adults (see Section 3.7). 

3.11 METHODS FOR REDUCING TOXIC EFFECTS 

This section will describe clinical practice and research concerning methods for reducing toxic effects of 

exposure to sulfur mustard. However, because some of the treatments discussed may be experimental and 

unproven, this section should not be used as a guide for treatment of exposures to sulfur mustard. When 

specific exposures have occurred, poison control centers and medical toxicologists should be consulted 

for medical advice. The following texts provide specific information about treatment following exposures 

to sulfur mustard: 

Augerson WS, Sivak A, Marley WS. 1986. Chemical casualty treatment protocol development - 

treatment approaches. Vol II-IV. Cambridge, MA: Arthur D. Little, Inc. 
 

 

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3. HEALTH EFFECTS 

Marrs TC, Maynard RL, Sidell FR. 1996. Chemical warfare agents. John Wiley & Sons, New York. 

NIOSH. 2003. Mustard emergency response card. National Institute for Occupational Safety and 

Health. http://www.bt.cdc.gov/agent/mustardgas/erc505-60-2pr.asp. March 20, 2003. 

OPCW. 2001. Organization for the prohibition of chemical weapons, decontamination of chemical 

warfare agents. http://www.opcw.nl/chemhaz/decon.htm. March 13, 2001. 

SBCCOM. 2001. Material safety data sheet, sulfur mustard. Aberdeen Proving Ground, MD: U.S. 

Army Soldier and Biological Chemical Command. http://in1.apgea.army.mil/RDA/msds/hd.htm. March 

13, 2001. 

U.S. Army. 1995. Treatment of chemical agent casualties and conventional military chemical injuries. 

Washington, DC: U.S. Department of the Army, FM 8-285. http://www.adtdl.army.mil/cgibin/atdl.dll/query/info/FM+8-285. March 22, 2001. 

Willems JL. 1989. Clinical management of sulfur mustard casualties. Annales Medicinae Militaris 

Belgicae. Vol 3: (Suppl.) Heymans Institute of Pharmacology. Ghent, Belgium: University of Ghent 

Medical School and Royal School of the Medical Services. 

3.11.1 Reducing Peak Absorption Following Exposure 

Decontamination procedures should be initiated immediately after exposure. Hypochlorite bleaches were 

the earliest decontaminants used to detoxify mustard. During World War II, both common bleach 

[NaOCl-

] and superchlorinated bleaches [Ca(OCl-)2] were used. More stable N-chloro compounds, such 

as chloramine, have been used in more modern personal decontamination systems. In the 1950s, a nonaqueous equipment decontamination solution "DS2" (2% NaOH, 70% diethylenetriamine, 28% ethylene 

glycol monomethyl ether) was developed in which the conjugate base of the glycol ether reacts rapidly 

with mustard via double elimination. The currently fielded U.S. ARMY M291 skin decontamination kit 

contains the decontaminant powder XE-555 resin (Amberguard 555) (SBCCOM 2001). 

The eyes should be washed immediately with as much water as tolerable, for at least 15 minutes, even if 

no symptoms are present, since it is known that ocular and dermal symptoms are delayed (Dreisbach and 

Robertson 1987; Goldfrank et al. 1990; Solberg et al. 1997). Of the many fluids studied for eye 

irrigation, none has proven more effective than tap water (Solberg et al. 1997). Contaminated clothing 

should be removed and the skin, particularly the groin, axillae, and perineal areas, should be 

decontaminated. Rapid removal from skin is critical, as sulfur mustard penetrates skin within minutes of 

exposure. Skin decontamination may be accomplished with copious amounts of water, a 0.5% 

hypochlorite solution, or a skin decontamination kit. 
 

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Topical decontamination with hypochlorite solutions was examined in euthymic hairless guinea pigs 

(Gold et al. 1994) and rabbits (Hobson et al. 1993). No significant wound differences were found 

between decontamination with water only and various concentrations of hypochlorite solutions; however, 

decontamination with a 0.5% solution is standard in many vesicant exposure management protocols 

(SBCCOM 2002). It has been suggested that removal of sulfur mustard with water alone may be contraindicated as sulfur mustard spreads over more skin surface and increases the area of blistering (Kumar et 

al. 1991). Absorbent decontaminants including fuller’s earth, calcium chloride powder, or XE-555 resin 

may be sprinkled onto the exposed skin, allowed to absorb the sulfur mustard, and then washed off with 

water (Chilcott et al. 2000, 2001; Kumar et al. 1991; Solberg et al. 1997). Of decontaminants including 

fuller’s earth, Ambergard, and BDH spillage granules, fuller’s earth was most effective in reducing skin 

absorption in in vitro studies using human epidermal membranes (Chilcott et al. 2001). When fuller’s 

earth, N,N’-dichloro-bis (2,4,6-trichlorophenyl) urea (CC-2), and their various combinations (w/w ratios) 

were evaluated for their decontamination efficacy against sulfur mustard applied on mouse skin, 

maximum protection was obtained with fuller’s earth and CC-2 in a combination of 80:20 (w/w) (Kumar 

et al. 1991); however, disparities have been evident in measured decontaminant efficiencies between 

animal models and man (Chilcott et al. 2001). 

3.11.2 Reducing Body Burden 

There is no specific antidote for sulfur mustard, and therapy is supportive. Victims should be removed 

from contaminated areas. Patient care should include supportive treatment protocols for skin injury, 

respiratory distress, and cardiac dysrhythmias (Dreisbach and Robertson 1987; Haddad and Winchester 

1990). There is usually a delay of onset of toxicity in exposed individuals. Severe respiratory distress 

may be delayed for up to 72 hours depending on the concentration and duration of exposure (Ellenhorn 

and Barceloux 1988). In cases of damage to the upper respiratory tract, antibiotic cover is recommended 

to prevent infection (Murray and Volans 1991). In severely injured victims, administration of systemic 

analgesics should be considered after examination. Mortality can be reduced by intravenous 

administration of electrolyte solutions commencing early and continuing throughout the intoxication 

period (Cullumbine 1947). Electrolyte replacement is needed due to losses from skin locally and in the 

intestine, and via saliva, vomitus, and diarrheic stools. A single dose of saline or glucose-saline (5 mg 

glucose/kg) administered intraperitoneally to mice offered protection after topical sulfur mustard 

exposure; survival was 83% with saline treatment compared to 33% without treatment (Sugendran et al. 

1994). 
 

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In cases of ocular injury, local anesthetic drops should be avoided other than for ophthalmologic 

examination, as they are toxic to both healthy and damaged corneas. Patients whose ocular injuries are 

limited to the conjunctiva require no additional treatment subsequent to irrigation. Corneal lesions may 

be detected by staining with fluorescein and examining with blue light. Treatment for injury to the cornea 

should include daily irrigation, mydriatics to ease the eye pain produced by spasm of the ciliary muscle 

and to prevent posterior iridolenticular adhesions, antibiotic drops to prevent secondary bacterial 

infections, local medications to control intraocular pressure, and systemic analgesics (Solberg et al. 1997). 

In cases of ocular injury, local anesthetic drops should be avoided other than for ophthalmologic 

examination, as they are toxic to both healthy and damaged corneas. Although recommended, the use of 

sterile petroleum jelly to prevent the eyelid margins from sticking together should be delayed until after 

sufficient irrigation, since sulfur mustard will dissolve and concentrate in the jelly (Solberg et al. 1997). 

Ocular bandages should not be applied as they might raise the corneal temperature and increase the toxic 

effects (Solberg et al. 1997). Delayed keratitis should be treated with ocular lubricants, therapeutic 

lenses, and in severe cases, tarsorrhaphy (suturing of the eyelids together) (Solberg et al. 1997). 

Keratoplasty should be considered if there is significant opacification of the cornea. 

Faster healing and less scarring have been reported when skin blisters were drained. While aseptic 

procedures are prudent for handling all bodily fluids, there are conflicting reports as to the danger of the 

blister fluid itself. There are no reports of sulfur mustard detected in blister fluid (Jakubowski et al. 

2000); however, secondary blistering running proximal to an original blister, thought to be due to leaking 

fluid, was reported in a case of accidental exposure during destruction of sulfur mustard stockpiles (Bide 

et al. 1993). Canadian Reactive Skin Decontamination Lotion (RSDL), which is a 1.25 molal solution of 

potassium 2,3-butanedionemonoximate (KBDO) in polyethyleneglycol monoethylether (500 nominal 

weight) and water, was shown to reduce the severity and scarring of sulfur mustard-induced lesions on the 

shaved back of guinea pigs (Bide et al. 1993). A case was also reported of an employee who suffered 

minor sulfur mustard burns to the wrist and forearm during destruction of sulfur mustard stockpiles at the 

Canadian Defense Research Establishment Suffield (DRES). Treatment was carried out partly at DRES 

and partly at a local hospital. One set of burns received treatment with RSDL at DRES, where it was 

available, and another set did not, as RSDL was not available at the local hospital. The blister without 

RSDL treatment initially burst, and a series of secondary burns running proximal to the original blister 

formed. The RSDL-treated burn was much less severe and no secondary burns formed (Bide et al. 1993). 
 

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Pulsed carbon dioxide (CO2) laser debridement has been shown to be effective in clearing the epidermis 

of sulfur mustard damaged cells (Smith et al. 1997b). In weanling pigs, whose skin was exposed to sulfur 

mustard, CO2 laser debridement of the exposed skin resulted in clearing of the cytologic atypia, reduced 

inflammatory infiltrate, and increased numbers of stromal cells within the papillary dermis. At 14 days 

postexposure, there was no significant difference between skin laser-debrided at 6, 24, or 48 hours after 

exposure. 

Animal experiments have shown that sodium thiosulfate, N-acetyl-L-cysteine, nicotinamide, nicotinic 

acid, promethazine, dexamethasone, prednisone, and vitamin E have decreased tissue damage, but their 

efficacy in humans is not known (Dabney 1991; Papirmeister et al. 1991; Vojvodic et al. 1985). 

Thiosulfate likely acts as a mustard scavenger, vitamin E as an antioxidant, and the corticosteroids by 

inhibiting lipooxygenase activity leading to synthesis of prostaglandins and leukotrienes (Borak and 

Sidell 1992). In guinea pigs injected intratracheally with sulfur mustard, subsequent treatment with 

betamethasone, a glucocorticoid, significantly increased tracheal epithelium height by about 20% and cell 

density, compared to untreated animals (Calvet et al. 1996). Application of provodine iodine (PI) 

ointment to the shaved back of guinea pigs up to 10 minutes following sulfur mustard exposure has been 

shown to provide significant protection from ulceration (Wormser et al. 1997). Histopathological 

evaluation of PI-treated skin showed only moderate thickening of the epidermis with slight 

hyperkeratosis, whereas deep epidermal ulceration involving the superficial dermis was evident without 

PI treatment. In a comparative study of chemical burn therapies in guinea pigs, debridement with trypsinlinked gauze (Debridase) was more effective in reducing the lesion area than surgical excision or laser 

ablation (Eldad et al. 1998b). A recent study with amifostine, an organophosphorothioate, and its 

analogues showed that pretreatment of mice with the chemical either intraperitoneally or orally protected 

against the acute toxicity of dermally applied sulfur mustard (Vijayaraghavan et al. 2001). Amifostine, 

originally developed as a radioprotector, can neutralize and reduce the concentration of sulfur mustard 

inside the cell after it is dephosphorylated to its free thiol molecule by membrane-bound alkaline 

phosphatase. 

Topically applied pretreatments have been shown to be effective in reducing the severity of sulfur 

mustard-induced skin lesions (Kwong and Segers 1996). Superoxide dismutase was effective in reducing 

the lesion area when administered before, but not after, topical application of sulfur mustard to guinea 

pigs (Eldad et al. 1998a). In a study of sulfur mustard vesication following pretreatment with topically 

applied agents, the most promising barrier cream was comprised of petrolatum, sorbitan stearate, and 

water with either of the N-halo oxidants 1,3,4,6-tetrachloro-7,8-diphenyl-2,5-diiminoglycoluril (S-330) or 
SULFUR MUSTARD 105 

3. HEALTH EFFECTS 

1,3-dichloro-5-5-dimethylhydantoin, and optionally, with a barrier-providing polymer such as 

perfluoroalkylpolyether (FOMBLIN HC/04, HC/25, or HC/R) or a polysiloxane (Kwong and Segers 

1996). A topical skin protectant cream containing perfluoroalkylpolyether and polytetrafluoroethylene, 

ICD 2289, being developed to protect service members from exposure to chemical warfare agents, was 

shown to reduce the sulfur mustard-induced lesion area to 18% of the untreated lesion area when applied 

as a pretreatment in rabbits (Liu et al. 1999). A new destructive absorption technology (DAT) employs 

highly reactive nanoparticles (RNP; small [≥ 4nm] crystals of metal oxides) to neutralize toxic substances 

including sulfur mustard. Preliminary studies indicate that RNP remain active against chemical agents 

when incorporated into a base cream and are compatible with skin contact (Koper et al. 1999). Extensive 

antivesicant research is currently in progress with significant developments likely to be reported in the 

near future. 

3.11.3 Interfering with the Mechanism of Action for Toxic Effects 

Research has elucidated areas of biochemical/pathological alterations induced in cells or tissues by sulfur 

mustard that provide targets for pharmacological interventions including macromolecular alkylation, 

DNA damage, activation of poly(ADP-ribose) polymerase (PARP), tissue proteolysis, and inflammation 

(Papirmeister et al. 1991; Smith et al. 2000). 

Sulfur mustard is thought to induce structural changes in cellular DNA, as indicated by altered dye 

response in flow cytometric studies (Smith et al. 1993a). The unsaturated keto groups of DNA appear to 

be functional groups that are attacked by mustard alkylating agents (Baskin et al. 2000). Toxic effects of 

sulfur mustard have been attributed to DNA modification, uncoiling in part (Baskin et al. 2000), with the 

formation of N7-(2-hydroxyethylthioethyl)guanine (Fidder et al. 1994, 1996a; Matijasevic et al. 1996; 

Niu et al. 1996; Somani and Babu 1989; Van der Schans et al. 1994), 3-hydroxyethylthioethyl adenine 

and the cross-link, di-(2-guanin-7-yl-ethyl)sulfide (Matijasevic et al. 1996). Reducing or preventing the 

ability of sulfur mustard to alkylate DNA and critical target molecules would reduce toxicity. Reversal of 

secondary consequences of alkylation requires a better understanding of the biochemical pathways of 

toxicity and may require interventions for more than one mechanism of action. As pointed out by 

Papirmeister et al. (1991), this strategy would provide temporary measures, slowing down the injury 

process and buying time for intracellular repair processes, thereby avoiding the simultaneous necrosis of 

massive numbers of cells as occurs in sulfur mustard-induced epithelial lesions. Tissue function may 

remain close to normal if cell death can be spread out over a sufficiently long period of time, and dead 

cells are replaced through endogenous tissue repair and regeneration mechanisms. 
 

 

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Reduction of target structural changes may by possible by the use of compounds that react with or 

scavenge sulfur mustard and lower target alkylation levels. The speed at which sulfur mustard reacts 

presents a difficulty to this strategy of treatment. However, several anionic sulfur compounds, such as 

thiosulfate, have been shown to reduce the toxic effects of mustard agents when administered as a 

pretreatment (Baskin et al. 2000; Papirmeister et al. 1991). Thiosulfate’s protective effect is due, at least 

in part, to its extracellular detoxification of mustard agents by direct chemical reaction. However, a small 

percentage (3–5%) of thiosulfate enters cells, but it is not yet known if any intracellular interactions 

contribute to its efficacy (Baskin et al. 2000). 

DNA repair enzymes may offer some protection against the toxic action of sulfur mustard. Li et al. 

(1997) investigated the action of formamidopyrimidine-DNA glycosylase (Fpg), purified from E. coli, on 

the ring-opened (ro) form of sulfur mustard-DNA adduct N7-(2-hydroxyethylthioethyl)guanine 

(N7-HETE-guanine). Fpg protein is thought to protect cells from toxicity by removing ring-opened 

N7-guanine adducts from DNA. Fpg protein released ro-HETE-guanine from DNA modified by 

[

14C]sulfur mustard in an enzyme- and time-dependent manner. Bacterial 3-methyladenine DNA 

glycosylase II (Gly II) was found to release both HETE-adenine and HETE-guanine from calf thymus 

DNA modified with [14C]sulfur mustard, also suggesting that glycosylase action may play a role in 

protecting cells from the toxic effects of sulfur mustard (Matijasevic et al. 1996). Modulation of other 

known or putative DNA repair enzymes, such as DNA ligase I or PARP, may provide a useful approach 

in preventing or reducing sulfur mustard toxicity (Bhat et. al. 2000). 

Cell cycle kinetics are involved in the cytotoxic processes following sulfur mustard exposure. Sulfur 

mustard-induced damage to genomic DNA in cultured human epidermal keratinocytes (HEK), at 

subvesicating concentrations (<50 μM), resulted in a dose-related reversible block at the G2/M phase of 

the cell cycle (Smith et al. 1993a). Okadaic acid and calyculin A, inhibitors of protein phosphatase 2A 

(PP2A), completely reversed the sulfur mustard-induced G2/M block (Hart and Schlager 1997). Exposure 

of human peripheral blood lymphocytes (PBL) to vesicating-equivalent concentrations of sulfur mustard 

(≥50 μM) resulted in irreversible blockage at the G1/S interface (Smith et al. 1998). DNA became 

terminally fragmented. Compounds might be used to hold cells in a selected phase in order to permit 

DNA repair processes to correct the damaged DNA before normal proliferative events are allowed to 

proceed. Mimosine, one such inhibitor, was shown to provide limited protection against cytotoxicity of 

vesicating-equivalent concentrations of sulfur mustard in HEK and HeLa cells (Smith et al. 1998). 
 

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3. HEALTH EFFECTS 

Niacinamide (750 mg/kg, intraperitoneal), while not effective as a postexposure treatment, did inhibit 

microvesicle formation by 50% when given as a pretreatment to cutaneous sulfur mustard exposure in 

hairless guinea pigs (Yourick et al. 1991). When niacinamide was administered as a 30-minute 

pretreatment, NAD+

 content in sulfur mustard treated skin biopsies decreased to about 40% of control 

levels. However, when niacinamide was administered twice, both as a 30-minute pretreatment and as a 

2-hour treatment, NAD+

 was maintained at control levels, but microvesicle formation was about the same 

as in the pretreatment-only case, indicating that maintaining skin NAD+

 content did not absolutely confer 

protection from microvesication, nor was it a necessary factor for preventing microvesication. 

Arginine analogue nitric oxide synthase (NOS) inhibitors, L-nitroarginine methyl ester (L-NAME) 

(Sawyer 1998; Sawyer et al.1996) and L-thiocitrulline (L-TC) (Sawyer et al. 1998), have been shown to 

have protective activity against the cytotoxicity of sulfur mustard not related to their NOS-inhibiting 

activities. L-TC acted rapidly (minutes of preincubation) and was equipotent in protecting either 

immature (1 day) or mature (5 days) cultures of chick embryo neurons against the toxicity of sulfur 

mustard (Sawyer et al. 1998), while L-NAME was effective (1 hour pre- to 3 hours post-sulfur mustard 

exposure) only in mature cultures (Sawyer et al. 1996, 1998). Coadministration of L-TC and L-NAME 

resulted in synergistic protection only when L-TC was added to the cultures prior to sulfur mustard 

treatment (Sawyer 1999). These characteristics suggest that they act at different sites to exert their 

protective effect. Based on these findings, Sawyer (1999) proposed that sulfur mustard initiates its 

toxicity extremely rapidly through a cell surface-mediated event that that can be blocked by L-TC. A 

signal may be transduced into the cell that results in an additional event or lesion that manifests itself 

several hours later, which progresses to cell death unless blocked reversibly by L-NAME (Sawyer 1999). 

3.12 ADEQUACY OF THE DATABASE 

Section 104(i)(5) of CERCLA, as amended, directs the Administrator of ATSDR (in consultation with the 

Administrator of EPA and agencies and programs of the Public Health Service) to assess whether 

adequate information on the health effects of sulfur mustard is available. Where adequate information is 

not available, ATSDR, in conjunction with the National Toxicology Program (NTP), is required to assure 

the initiation of a program of research designed to determine the health effects (and techniques for 

developing methods to determine such health effects) of sulfur mustard. 
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3. HEALTH EFFECTS 

The following categories of possible data needs have been identified by a joint team of scientists from 

ATSDR, NTP, and EPA. They are defined as substance-specific informational needs that if met would 

reduce the uncertainties of human health assessment. This definition should not be interpreted to mean 

that all data needs discussed in this section must be filled. In the future, the identified data needs will be 

evaluated and prioritized, and a substance-specific research agenda will be proposed. 

An acute-duration inhalation MRL was derived for sulfur mustard based on human data. An 

intermediate-duration inhalation and an acute- and intermediate-duration oral MRLs were derived based 

on animal data. While additional chronic oral data are needed to derive a chronic-duration oral MRL 

according to ATSDR guidelines, there is a greater need for additional chronic inhalation and dermal data 

over oral data in animals, as sulfur mustard hydrolyzes in water, and oral exposure is the least likely of 

the three routes. Laboratory animals with fur do not provide optimal models for dermal exposure as they 

do not have sweat glands on most of their body. Further exploration of relevant models including human 

skin grafts, porcine skin flaps in explant culture, nude mice, and hairless guinea pigs is prudent to study 

the biochemical events in sulfur mustard toxicity and identify effective therapies. 

Questions still remain regarding the mechanisms of toxicity of sulfur mustard. According to Papirmeister 

(1993), the database would benefit from research leading to greater understanding of the following: 

•	 The involvement of apoptotic and necrotic cell death processes to the cytotoxic and acute skin 

injury actions of sulfur mustard. 

•	 The importance of DNA repair and the cell cycle in skin cells that undergo apoptosis leading to 

lesion formation. 

•	 The reason that poly(ADP-ribose) polymerase (PADPRP) inhibitors prevent losses of NAD+

, 

ATP, and viability in sulfur mustard-treated human peripheral blood lymphocytes (PBL), but fail 

to prevent sulfur mustard-induced cytotoxicity in human epidermal keratinocytes (HEK) or sulfur 

mustard-induced acute skin injury. 

•	 Any pathways, other than the PADPRP-mediated NAD+

 loss, by which sulfur mustard-induces 

inhibition of glycolysis and energy depletion in HEK. 

•	 The mechanism(s) responsible for increasing and maintaining high levels of intracellular calcium 

in sulfur mustard exposed cells. 

•	 Relationships between sulfur mustard and protein regulation in connection with vesication. 
SULFUR MUSTARD 109 

3. HEALTH EFFECTS 

• The contribution of reactive oxygen species to sulfur mustard cytotoxicity. 

• The role of inflammation in the development of the acute cutaneous sulfur mustard injury. 

• The events within the initial lag period before blistering occurs. 

• The identification of therapeutic countermeasures. 

3.12.1 Existing Information on Health Effects of Sulfur Mustard 

The existing data on health effects of inhalation, oral, and dermal exposure of humans and animals to 

sulfur mustard is summarized in Figure 3-4. The purpose of this figure is to illustrate the existing 

information concerning the health effects of sulfur mustard Each dot in the figure indicates that one or 

more studies provide information associated with that particular effect. The dot does not necessarily 

imply anything about the quality of the study or studies, nor should missing information in this figure be 

interpreted as a “data need”. A data need, as defined in ATSDR’s Decision Guide for Identifying 

Substance-Specific Data Needs Related to Toxicological Profiles (Agency for Toxic Substances and 

Disease Registry 1989), is substance-specific information necessary to conduct comprehensive public 

health assessments. Generally, ATSDR defines a data gap more broadly as any substance-specific 

information missing from the scientific literature. 

Data are available for humans regarding respiratory disease and cancer, and the deaths caused by these 

diseases following acute and chronic inhalation exposure. Very limited animal data are available 

regarding death, developmental and reproductive effects, and cancer following inhalation exposure. There 

are no data available on the toxicity of sulfur mustard from oral exposure in humans. Data are available 

on effects in animals following acute- and intermediate-duration exposures. Limited data are available in 

humans and animals regarding skin effects from dermal exposure, and cancer in humans from dermal 

exposure. 

3.12.2 Identification of Data Needs 

Acute-Duration Exposure. Sufficient information is available from human exposure data to identify 

the eyes (Anderson 1942; Guild et al. 1941; Momeni and Aminjavaheri 1994; Momeni et al. 1992; Reed 
 

SULFUR MUSTARD 110 

3. HEALTH EFFECTS 

Figure 3-4. Existing Information on Health Effects of Sulfur Mustard 
SULFUR MUSTARD 111 

3. HEALTH EFFECTS 

1918), skin (Franke 1967; Jakubowski et al. 2000; Momeni and Aminjavaheri 1994; NRC 1985; Renshaw 

1946; Sinclair 1948, 1950; Smith et al. 1919; Sulzberger et al. 1947; Wulf et al. 1985), and respiratory 

passages (Beebe 1960; Case and Lea 1955; Momeni and Aminjavaheri 1994; Momeni et al. 1992; 

Norman 1975) as target organs from acute exposure to sulfur mustard. Data from animal studies also 

suggest that acute exposure to sulfur mustard in the air is harmful to the eyes (Gates and Moore 1946), 

gastric mucosa (DOA 1987), skin (McAdams 1956; Venkateswaran et al. 1994a; Young 1947), and 

respiratory passages (Allon et al. 1993; Heston 1953b; Vijayaraghavan 1997; Winternitz and Finney 

1920). Direct application to the skin of animals produced vascular leakage, leukocytic infiltration, and 

death of basal epidermal cells (Chauhan et al. 1993a, 1993b, 1995; Vogt et al. 1984). Since sulfur 

mustard has been used in combat, it is known to be lethal from primary (acute pulmonary edema) or 

secondary effects (respiratory infections) (Case and Lea 1955; Sinclair 1948, 1950; Somani and Babu 

1989). While no human definitive oral data are available, effects to the gastric mucosa would be expected 

as sulfur mustard is a vesicant and direct alkylating agent. Acute inhalation and oral MRLs have been 

derived. No additional acute-duration testing to identify adverse health effects appears warranted. 

Intermediate-Duration Exposure. Intermediate-duration exposure during combat has shown that 

sulfur mustard can be lethal. Wartime and occupational studies in humans have identified the eyes 

(Momeni and Aminjavaheri 1994; Momeni et al. 1992; Pechura and Rall 1993), skin (Bullman and Kang 

2000; NRC 1985; Sinclair 1948, 1950; Wulf et al. 1985), and respiratory passages (Bullman and Kang 

2000; Case and Lea 1955; Easton et al. 1988; Nishimoto et al. 1970; Somani and Babu 1989) as the target 

organs for sulfur mustard for intermediate-duration exposure. Data from animal studies also suggest that 

intermediate-duration oral exposure to sulfur mustard is harmful to the gastric mucosa (Sasser et al. 

1996a, 1996b). While no human oral data are available, effects to the gastric mucosa would be expected 

as sulfur mustard is a vesicant and direct alkylating agent. Intermediate-duration inhalation and oral 

MRLs have been derived. However, further well-conducted intermediate-duration inhalation studies 

would be useful to support the rather limited available data. The same can be said for dermal data. 

Further oral studies do not seem warranted since oral exposure is not a likely route of exposure. Male 

dominant lethal studies in animals with exposure by the inhalation and dermal routes including site of 

application histological examinations would provide valuable data. It seems likely that, as with the oral 

route, the application site would be more sensitive to the effects of sulfur mustard than the male 

reproductive system; however, when considering combat exposure, the genital area was frequently a site 

affected. 
SULFUR MUSTARD 112 

3. HEALTH EFFECTS 

Chronic-Duration Exposure and Cancer. Epidemiological studies of sulfur mustard workers 

have identified the eyes (Laughlin 1944b, 1944c; Morgenstern et al. 1947), skin (Inada et al. 1978; Klehr 

1984; NRC 1985), and respiratory system (Easton et al. 1988; Manning et al. 1981; Morgenstern et al. 

1947; Nishimoto et al. 1970; Somani and Babu 1989; Tokuoka et al. 1986; Wada et al. 1968; Weiss and 

Weiss 1975; Yamada 1963; Yamakido et al. 1996) as the target organs; however, none of these studies 

has involved the measurement of exposure concentrations, and interpretation of these studies is limited 

due to potential simultaneous exposure to other toxic agents. Chronic-duration inhalation and oral MRLs 

were not derived because no chronic bioassays were located. In order to derive these MRLs according to 

ATSDR guidelines, additional studies would be needed for both exposure routes. However, studies by 

the inhalation route of exposure should have priority since oral exposure is unlikely. 

Factory workers who have been exposed to undetermined levels of sulfur mustard for a number of years 

have been shown to develop respiratory cancer (Easton et al. 1988; Manning et al. 1981; Morgenstern et 

al. 1947; Nishimoto et al. 1970; Tokuoka et al. 1986; Wada et al. 1968; Weiss and Weiss 1975; Yamada 

1963; Yamakido et al. 1996). There is some evidence that former sulfur mustard factory workers may 

have an increased risk of developing digestive tract and skin tumors (Inada et al. 1978; Klehr 1984; 

Yamada 1974). Two animal studies, of low predictive quality due to species strain tendency to develop 

lung tumors, insufficient animals, and inadequate doses, have also shown increases in tumors from 

exposure to sulfur mustard in the air (Heston 1953b; McNamara et al. 1975). IARC has classified sulfur 

mustard as “carcinogenic to humans” (Group 1) based on sufficient evidence in humans, limited evidence 

in experimental animals, supporting evidence that sulfur mustard is a bifunctional alkylating agent, and 

positive results in a number of assays for genotoxic effects (IARC 1975, 1987). In order to develop 

cancer effect levels, appropriate animal studies would be necessary since there are no adequate studies 

currently available. In the absence of a chronic animal bioassay, several diverse methods (potency 

relative to benzo(a)pyrene, linear extrapolation from the benchmark dose of forestomach lesions or 

hyperplasia, potency relative to maximum tolerated dose) have been applied for estimating an upper limit 

on carcinogenic potency (USACHPPM 1999). 

Genotoxicity. Sulfur mustard is known to be highly genotoxic in vitro, and further studies would 

likely not alter this conclusion (Ashby et al. 1991; Auerbach 1947; Ball and Roberts 1971/72; Capizzi et 

al. 1974; Fahmy and Fahmy 1971, 1972; Fan and Bernstein 1991; Ichinotsubo et al. 1977; Kircher and 

Brendel 1983; Lin et al. 1996a, 1996b; Ludlum et al. 1994; Ribeiro et al. 1991; Scott et al. 1974; Venitt 

1968; Venkateswaran et al. 1994a; Walker and Thatcher 1968). 
 

 

 

SULFUR MUSTARD 113 

3. HEALTH EFFECTS 

Reproductive Toxicity. Several human and animal studies suggest that sulfur mustard affects male 

reproductive function (Azizi et al. 1995; Graef et al. 1948; McNamara et al. 1975; Pour-Jafari and 

Moushtagi 1992; Rozmiarek et al. 1973; Sasser et al. 1993). Data from animal studies regarding oral 

exposure to sulfur mustard indicate that the acute- and intermediate oral MRLs derived within this profile 

would be protective of this system. The mechanism by which sulfur mustard affects reproductive 

parameters is not known; however, it is reasonable to assume that effects can be produced following any 

route of exposure providing that enough chemical is absorbed. Additional acute- and intermediateduration inhalation reproductive studies (including multigeneration) may be needed if the results of a 

90-day toxicity study suggest that reproductive organs are targets for sulfur mustard toxicity. 

Developmental Toxicity. The only relevant information in humans is that from Pour-Jafari et al. 

(1994b), who reported an increased incidence of congenital malformations among offspring of Iranian 

chemical victims (males and females). However, there may have also been exposure to several other 

chemical agents. In an oral study in animals, fetal toxicity was evidenced by reduced body weight and 

ossification (DOA 1987). The limited data available suggest that adverse developmental effects occur at 

doses or exposure levels that produce maternal toxicity. There is no reason to believe that the 

developmental effects of sulfur mustard are route-specific. Data are lacking regarding the 

pharmacokinetics of sulfur mustard during pregnancy. Data from animal studies regarding oral exposure 

to sulfur mustard indicate that the acute-duration oral MRL derived within this profile would be 

protective of fetal development. 

Immunological and Lymphoreticular Toxicity. Sulfur mustard-induced damage to lymphoid 

tissue was found in war casualties and in animals studies following inhalation, oral, or dermal exposure 

(Alexander 1947; Cameron 1946; DOA 1987; Venkateswaran et al. 1994a). Sulfur mustard-induced 

lymphoreticular toxicity does not appear to be route- or species-specific. Data from animal studies 

regarding inhalation and oral exposure to sulfur mustard indicate that the acute-duration inhalation and 

oral MRLs derived within this profile would be protective of the lymph system. Additional chronic 

inhalation studies are required to determine exposure levels for these routes that would limit 

lymphoreticular toxicity. 

Neurotoxicity. There is no evidence that the nervous system is a target for sulfur mustard toxicity. 

Only minimal animal data are available regarding the neurotoxicity of sulfur mustard (Sasser et al. 1993; 

Winternitz and Finney 1920). Chronic or latent pain in the exposed skin area experienced by victims of 

sulfur mustard attacks suggests that sulfur mustard may cause persistent damage to the afferent nerve 
 

SULFUR MUSTARD 114 

3. HEALTH EFFECTS 

system (Thomsen et al. 1998). This effect appears specifically related to dermal exposure and is probably 

due to a direct effect of sulfur mustard on sensory nerve terminals innervating the skin and would not be 

expected to occur following inhalation or oral exposure. 

Epidemiological and Human Dosimetry Studies. Three types of human epidemiology studies 

are available: those of men who were exposed briefly during combat in World War I (Beebe 1960; Case 

and Lea 1955; Norman 1975; Sinclair 1948, 1950), those of subjects exposed for a longer period when 

producing sulfur mustard in Japanese (Nishimoto et al. 1970, 1983; Tokuoka et al. 1986; Wada et al. 

1968; Inada et al. 1978; Yamada 1963; Yamakido et al. 1996), German (Weiss and Weiss 1975), British 

(Easton et al. 1988; Manning et al. 1981), or American factories (Bullman and Kang 2000), and those of 

people exposed during the Iran-Iraq War. In none of these studies were the exposure duration and levels 

quantified. However, in some cases, a relation to dose is apparent as, for example, deaths due to lung 

cancer increased with greater likelihood of exposure or service years in factories. Currently, the only 

people with potential exposure to sulfur mustard are those working in military facilities where sulfur 

mustard is stored and those involved in the destruction of the existing stockpile of sulfur mustard. 

Monitoring of the former may provide information on potential effects due to long-term exposure. 

Continued monitoring of sulfur mustard victims of the Iran-Iraq War would provide valuable information 

on long-term effects caused by acute high-exposure. 

Biomarkers of Exposure and Effect. 

Exposure. Two closely related metabolites of sulfur mustard that are not detected in normal urine, 

1,1'sulphonylbis[2-(methylsulphinyl)ethane] and 1-methylsulphinyl-2-[2-methylthio)ethylsulphonyl]­

ethane, have been detected in urine collected from Iran-Iraq War casualties of sulfur mustard poisoning 

(Black and Read 1995b; Black et al. 1991). Sulfur mustard has also been shown to alkylate hemoglobin 

(Black et al. 1997a, 1997b; Fidder et al. 1996a; Noort et al. 1996, 1997) and albumin (Noort et al. 1999). 

Both protein adducts have been detected in the blood of Iran-Iraq War victims (Benschop et al. 1997; 

Noort et al. 1999). Development and validation of standard assays for these urine metabolites and blood 

protein adducts would be valuable tools for retrospective detection of exposure. 

Effect. Various local enzymatic activity and protein alterations have been reported in connection with 

sulfur mustard exposure, thus providing potential as biomarkers of effect. Additional research providing 

a further understanding of the mechanisms of sulfur mustard toxicity is required before assay validation. 
 

SULFUR MUSTARD 115 

3. HEALTH EFFECTS 

Absorption, Distribution, Metabolism, and Excretion. There is limited information on the 

toxicokinetics of sulfur mustard by the inhalation and dermal routes in humans and in animals. 

Considerable more toxicokinetics information is available for intravenous and intraperitoneal routes of 

sulfur mustard exposure in animals. These data indicate that it can be absorbed (Cameron et al. 1946; 

Cullumbine 1946, 1947; Drasch et al. 1987; Hambrook et al. 1993; Klain et al. 1991; Langenberg et al. 

1998; Nagy et al. 1946; Papirmeister et al. 1984a, 1984b; Renshaw 1946; Smith et al. 1919) and is 

excreted in the urine (Black et al. 1992a, 1992b; Davison et al. 1961; Hambrook et al. 1992; Jakubowski 

et al. 2000; Maisonneuve et al. 1993; Roberts and Warwick 1963; Sandelowsky et al. 1992; Smith et al. 

1958; Wils et al. 1985, 1988). Langenberg et al. (1998) detected sulfur mustard DNA adducts in tissues 

following inhalation exposure in guinea pigs. Metabolic pathways are presumed based on these data. 

The available information is insufficient to determine whether saturation phenomena play a role in 

absorption, distribution, or metabolism. As the route of exposure appears to be an important toxicokinetic 

factor, more studies would be helpful to adequately characterize the rate and extent of sulfur mustard 

absorption, distribution, and excretion via the dermal and inhalation routes, the most relevant routes of 

potential exposure. 

Comparative Toxicokinetics. Data are available to indicate that the skin, respiratory tract, male 

reproductive system, and lymph nodes are targets in both humans and animals. Since humans do not have 

the fur that most laboratory animals do, and since humans have sweat glands over most of their body 

whereas animals do not, human responses to skin irritants such as sulfur mustard are different from those 

of animals. The hairless guinea pig model has been used to study the biochemical events in sulfur 

mustard toxicity. Toxicokinetic studies in animals (rats, mice, and pigs) (Black et al. 1992a, 1992b; 

Davison et al. 1961; Fidder et al. 1996a; Hambrook et al. 1992; Roberts and Warwick 1963; Sandelowsky 

et al. 1992; Smith et al. 1958) and humans (Benschop et al. 1997; Black and Read 1995b; Black et al. 

1991; Jakubowski et al. 2000; Noort et al. 1999; Wils et al. 1985) indicate that the metabolites are similar 

across species. 

Methods for Reducing Toxic Effects. There are established general decontamination procedures 

to reduce absorption of sulfur mustard (SBCCOM 2001), but there are no established procedures to 

reduce body burden or interfere with the mechanism of action of sulfur mustard in humans. Treatments to 

improve compromised function are primarily supportive. Based on current concepts regarding the 

mechanisms of toxicity of sulfur mustard, compounds with known biochemical or cellular actions can be 

identified that may interfere with some or all of pathways of toxicity. Additional studies providing a 
SULFUR MUSTARD 116 

3. HEALTH EFFECTS 

more thorough mechanistic understanding, identification of additional toxicity pathways, and validation 

of the efficacy of existing compounds would be valuable. 

Children’s Susceptibility. There is qualitative evidence that children are a sensitive group at risk 

(Momeni et al. 1992; Momeni and Aminjavaheri 1994). Besides two reports of accidental deaths of 

children exposed to sulfur mustard (Dacre and Goldman 1996; Heully et al. 1956), clinical reports of 

children exposed during the Iran-Iraq War provide the only non-lethal effects data in children (Momeni et 

al. 1992; Momeni and Aminjavaheri 1994). The main exposure pathways for children are the same as for 

adults. The time of onset of sulfur mustard manifestations appears to be shorter, and the lesion severity 

greater, in children than in adults, possibly due to more delicate skin and epithelial tissues. Children’s 

susceptibility to the effects of sulfur mustard is likely correlated to their understanding of the need for 

precautionary measures, ability to recognize exposure, and initiate decontamination. 

Child health data needs relating to exposure are discussed in Section 6.8.1 Identification of Data Needs: 

Exposures of Children. 

3.12.3 Ongoing Studies 

One of the major goals of future medical chemical defense research on vesicants is the search for 

effective prophylactic and therapeutic countermeasures. Screening programs exist for candidate 

antidotes. 

Ongoing studies pertaining to sulfur mustard identified in the Federal Research in Progress database 

(FEDRIP 2002) are shown in Table 3-4. 
SULFUR MUSTARD 117 

3. HEALTH EFFECTS 

Table 3-4. Ongoing Studies on Health Effects of Sulfur Mustard 

Investigator Affiliation Research description Study sponsor 

Back, DD Mainstream Engineering Highly destructive polymer-contained Army 

Corporation neutralizing skin protectants: 

Rockledge, Florida Feasibility of coated topical skin 

protectant additives using a new class 

of reactive metal alloys 

Hendler, FJ Department of Veterans Effect of hazardous substances on Department of 

MD, PhD Affairs reproductive capacity and Veterans Affairs 

Louisville, Kentucky developmental abnormalities Washington, DC 

Hinshaw, DB Department of Veterans The cytoskeleton and ATP in sulfur Department of 

MD Affairs mustard-mediated injury to endothelial Veterans Affairs 

Ann Arbor, Michigan cells and keratinocytes Washington, DC 

Klabunde, KJ Nantek, Inc. Development of reactive topical skin Army 

Manhattan, Kansas protectants against sulfur mustard 

and nerve agents 

Myer, SB Tienzyme, Inc. Use of fungal peroxidases for Army 

State College, Pennsylvania neutralization of mustard gas 

Richmond, A Department of Veterans The role of chemokines in wound Department of 

PhD Affairs healing and sepsis:chemical burn Veterans Affairs 

Nashville, Tennessee (sulfur mustard) model of injury Washington, DC 

Sweeney, JF Department of Veterans Regulation of polymorphonuclear- Department of 

MD Affairs leukocyte (PMN) survival and function Veterans Affairs 

Ann Arbor, Michigan by proinflammatory agents that are Washington, DC 

released as a consequence of sulfur 

mustard mediated injury 

Source: FEDRIP 2002 

SULFUR MUSTARD 119 

4. CHEMICAL AND PHYSICAL INFORMATION 

4.1 CHEMICAL IDENTITY 

Information regarding the chemical identity of sulfur mustard is located in Table 4-1. Sulfur mustard has 

several synonyms; the most common are “mustard gas”, “H”, and “HD”. The term “mustard gas” may be 

used interchangeably to identify “sulfur mustard.” “H” refers to undistilled or raw sulfur mustard, which 

contains a large fraction of impurities (see Table 4-2). “HD” refers to a distilled or purified form of sulfur 

mustard (see Table 4-3). “HT” is often called sulfur mustard even though it is a mixture of 60% “HD”, 

<40% Agent T (bis[2-(2-chloroethylthio)ethyl]ether, CAS# 63918-89-8), and a variety of sulfur 

contaminants and impurities. Most studies on sulfur mustard are based on its distilled or purified form, 

“HD” (Munro et al. 1999). Other mustard agents, such as “HN” or nitrogen mustard (i.e., bis(2-chloroethyl)methylamine hydrochloride; CAS No. 55-86-7) and lewisite (i.e., 2-chlorovinyldichloroarsine; CAS 

No. 541-25-3) are related to sulfur mustard. Information about “HN”, “HT”, and lewisite are not included 

in this document. 

4.2 PHYSICAL AND CHEMICAL PROPERTIES 

Information regarding the physical and chemical properties of sulfur mustard (HD) is located in 

Table 4-4. Weapons-grade sulfur mustard can contain stabilizers, starting materials, or by-products 

formed during manufacturing, and products formed from slow reactions during storage (Munro et al. 

1999). The typical compositions of HD and H are illustrated in Tables 4-3 and 4-4, respectively (NRC 

1999; Rosenblatt et al. 1996). In general, a residual “heel” (i.e., a gel that will not flow) forms with the 

ageing of sulfur mustard. The heel can amount to more than 10% of the agent and usually contains 14– 

53% sulfur mustard, 42–86% cyclic sulfonium ions, and metals, such as iron sulfide (NRC 1999). 
 

SULFUR MUSTARD 120 

4. CHEMICAL AND PHYSICAL INFORMATION 

Table 4-1. Chemical Identity of Sulfur Mustard 

Characteristic Information Reference 

Chemical name Bis(2-chloroethyl) sulfide HSDB 2002 

Synonym(s) β,β=-Dichloroethyl sulfide; β,β=-Dichloroethyl sulphide; HSDB 2002 

1-Chloro-2-(β-chloroethylthio)ethane; 1,1=-Thiobis­

(2-chloroethane); 2,2'-Dichlorodiethyl sulfide; 

2,2=-Dichlorodiethyl sulphide; 2,2=-Dichloroethyl sulphide; 

2,2=-Dichloroethyl sulfide; Bis(β-chloroethyl)sulfide; Bis­

(β-chloroethyl)sulphide; Bis(2-chloroethyl)sulphide; 

Di-2-chloroethyl sulfide; Di-2-chloroethyl sulphide; 

Dichloro-diethyl-sulphide; Dichlorodiethyl sulfide; 

Dichloroethyl sulfide; Diethyl sulfide, 2,2=-dichloro; 

Distilled mustard; Ethane, 1,1=-thiobis(2-chloro-; 

Gelbkreuz; H; HD; Kampstoff ALost@; Lost; Mustard, 

sulfur; Mustard vapor; Mustard gas; Mustard HD; S 

mustard; S-lost; S-Lost; S-yperite; Schwefel-Lost; 

Senfgas; Sulfide, bis(2-chloroethyl); Sulfur mustard gas; 

Sulfur mustard; Yellow Cross Liquid; Yellow Cross Gas 

Registered trade name(s) No data 

Chemical formula C4H8Cl2S Budavari et al. 

1996 

Chemical structure Budavari et al. 

Cl Cl 1996; IARC 1975 

Identification numbers: 

CAS registry 505-60-2 HSDB 2002 

 NIOSH RTECS WQ0900000 HSDB 2002 

EPA hazardous waste No data 

 OHM/TADS No data 

 DOT/UN/NA/IMCO UN 2810 DOT 2002 

shipping 

HSDB 336 HSDB 2002 

NCI No data 

S 

CAS = Chemical Abstracts Services; DOT/UN/NA/IMCO = Department of Transportation/United Nations/North 

America/International Maritime Dangerous Goods Code; EPA = Environmental Protection Agency; 

HSDB = Hazardous Substances Data Bank; NCI = National Cancer Institute; NIOSH = National Institute for 

Occupational Safety and Health; OHM/TADS = Oil and Hazardous Material/Technical Assistance Data system; 

RTECS = Registry of Toxic Effects of Chemical Substances 
 

SULFUR MUSTARD 121 

4. CHEMICAL AND PHYSICAL INFORMATION 

Table 4-2. Typical Composition of Sulfur Mustard (H) from an
 

Old Chemical Munition 

Compound CAS No. GC/MS peak area percent 

Sulfur mustard 505-60-2 62.2 

Bis(2-chloroethyl) disulfide 1002-41-1 10.9 

1,4-Dithiane 505-29-3 3.2 

Bis(2-chloroethyl) trisulfide 19149-77-0 9.6 

1,2-Bis(2-chloroethylthio)ethane 3563-36-8 2.6 

1,2,3-Trithiolane C 2.4 

1,4-Thioxane 15980-15-1 0.1 

1,2,5-Trithiepane 6576-93-8 0.9 

1,2,3,4-Tetrathiane C 1.4 

1,2-Dichloroethane 107-06-2 3.2 

HD tetrasulfide C 0.6 

Tetrachloroethene 127-18-4 0.3 

Sulfur 7704-34-9 0.5 

Other C 1.3 

GC/MS = gas chromatography/mass spectrometry 

Source: Rosenblatt et al. 1996 
SULFUR MUSTARD 122 

4. CHEMICAL AND PHYSICAL INFORMATION 

Table 4-3. Typical Composition of Sulfur Mustard (HD) in 1-Ton Storage 

Containers (Aberdeen, Maryland) 

Compound CAS No. Mole percent 

Sulfur mustard 505-60-2 91.38 

Q sulfonium 30843-67-5 6.08 

2-Chloroethyl 4-chlorobutyl sulfide 114811-35-7 0.86 

1,4-Dithiane 505-29-3 0.81 

1,2-Dichloroethane 107-06-2 0.35 

Bis-3-chloropropyl sulfide 22535-54-2 0.18 

2-Chloropropyl 3=-chloropropyl sulfide C 0.18 

2-Chloroethyl 3-chloropropyl sulfide 71784-01-5 0.14 

1-Chloropropyl 2-chloroethyl sulfide C 0.02 

1,4-Thioxane 15980-15-1 <0.01 

Source: NRC 1999 
 

 

SULFUR MUSTARD 123 

4. CHEMICAL AND PHYSICAL INFORMATION 

Table 4-4. Physical and Chemical Properties of Sulfur Mustard 

Property Information Reference 

Molecular weight 159.08 Budavari et al. 1996 

Color Clear Budavari et al. 1996 

Pale yellow, black if impure Munro et al. 1999 

Physical state Oily liquid Budavari et al. 1996 

Melting point 13B14 EC Budavari et al. 1996 

Boiling point 217.5 EC Budavari et al. 1996 

Density: 

1.338 at 13 EC Budavari et al. 1996 

1.2685 at 25 EC Rosenblatt et al. 1996 

Odor Weak, sweet, agreeable odor Budavari et al. 1996 

Odor threshold: 

 Water No data 

Air 0.6 mg/m3

 Bowden 1943 

Solubility: 

 Water 920 mg/L at 22 EC Rosenblatt et al. 1996 

684 mg/L at 25 EC Seidell 1941 

Organic solvent(s) Soluble in alcohol, ether, acetone, HSDB 2002 

and benzene; miscible with 

petroleum ether 

Soluble in fat solvents and other IARC 1975 

common organic solvents 

Partition coefficients: 

 Log Kow 2.41 HSDB 2002 

1.37 Rosenblatt et al. 1996 

 Log Koc 2.43 HSDB 2002 

Vapor pressure: 

at 22 EC 0.082 mmHg Rosenblatt et al. 1996 

at 25 EC 0.1059 mmHg Rosenblatt et al. 1996 

Henry=s law constant 

2.4x10-5 atm-m3

/mol Opresko et al. 1998 

1.87x10-5 atm-m3

/mol Rosenblatt et al. 1996 

Autoignition temperature No data 

Flashpoint 221 EF Sax 1989 

Conversion factors: No data 

Explosive limits No data 

 

SULFUR MUSTARD 125 

5. PRODUCTION, IMPORT/EXPORT, USE, AND DISPOSAL 

5.1 PRODUCTION 

Sulfur mustard is a synthetic organic compound. It was first manufactured in 1822 by the action of 

ethene on sulfur monochloride or dichloride. Since then, the methods of manufacture have been refined, 

although they have not been changed substantially. Three main processes have been used. The Germans 

produced sulfur mustard using the Meyer process, which involved treating ethylene with hypochlorous 

acid followed by sodium sulfide, yielding β,β'-dihydroxy-methyl sulfide. This in turn was heated with 

hydrochloric acid, which produced sulfur mustard. In the United States, sulfur mustard was formerly 

made using the Levenstein process in which ethylene was reacted with sulphur monochloride at 30– 

35 °C. Sulfur mustard produced by this process contains 62–64% distilled sulfur mustard (or HD) 

(Munro et al. 1999). This process produces a complex mixture that includes constituents that are more 

toxic than sulfur mustard itself (Rosenblatt et al. 1975). The most recent process used in the United 

States involved the formation of bis-(2-hydroxyethyl)-thioether from ethylene oxide and hydrogen 

sulfide; this was then reacted with hydrochloric acid to form sulfur mustard (Franke 1967; IARC 1975; 

Rosenblatt et al. 1975). Sulfur mustard produced by this process contains 89% HD (Munro et al. 1999). 

Sulfur mustard was manufactured in large quantities during World Wars I and II, but has not been 

manufactured on an industrial basis in the United States since 1968 (NRC 1994). Stockpiles of sulfur 

mustard are stored in 1-ton containers and/or chemical munitions at Blue Grass Army Depot in Kentucky, 

Anniston Army Depot in Alabama, Umatilla Depot Activity in Oregon, Pine Bluff Arsenal in Arkansas, 

Tooele Army Depot in Utah, Pueblo Army Depot Activity in Colorado, and Aberdeen Proving Grounds 

in Maryland. Stockpiles of sulfur mustard were also located at the U.S. territory of Johnston Atoll in the 

North Pacific Ocean. Destruction of sulfur mustard at this location was completed in 2000. Sulfur 

mustard may also be found at non-stockpile locations in various containers, buried chemical munitions, 

and at former production facilities. These are currently 45 non-stockpile locations with sulfur mustard 

across the United States and in the U.S. Virgin Islands as shown in Figure 5-1 (NRC 1996, 2000). Sulfur 

mustard is probably still being made for laboratory experiments on a small scale. 

Information about other mustard agents, such as nitrogen mustard (HN), thickened mustard (HT), and 

lewisite, are not included in this document (see Chapter 4). 
 

SULFUR MUSTARD 126 

5. PRODUCTION, IMPORT/EXPORT, USE, AND DISPOSAL 

Figure 5-1. Locations of Sulfur Mustard Stockpile and Non-stockpile 

Sites in the United Statesa
 

Source: OA 2000, 2002 () = Stockpile sites; (O) = Non-stockpile sites 

AL 

Anniston Army Depot () 

Ft McClellan (O) 

Camp Sibert (O) 

Huntsville Arsenal (O) 

Redstone Arsenal (O) 

Theodore Naval Ammunition 

Magazine (O) – not shown on map 

AK 

Adak (O) 

Chicagoff Harbor (O) 

Gerstle River Test Center (O) 

AZ 

Navajo Depot Activity (O) 

Yuma Proving Ground (O) 

AR 

Pine Bluff Arsenal () 

CA 

Ft Ord (O) 

Edwards AFB (O) 

CO 

Rocky Mountain Arsenal (O) 

Pueblo Army Depot Activity () 

FL 

Brooksville Army Air Base (O) 

Drew Field (O) 

MacDill AFB (O) 

Withlacoochee (O) 

Dry Tortuga Keys (O) 

Zephyr Hills Gunner Range (O) 

Source: NRC 1996, 2000 

a

post office state abbreviations used 

GA
 

Ft. Gillem (O)
 

Manchester (O)
 

HI 

Kipapa Ammunition Storage Site (O) 

Schofield Barracks (O)
 

IL 

Savanna Army Depot Activity (O) 

IN 

Camp Atterbury (O) 

Naval Weapons Support Center (O) 

KS 

Marysville (O) 

KY 

Blue Grass Army Depot () 

LA 

Ft Polk (O) 

Concord Spur (O) 

MD 

Edgewood Area- Aberdeen Proving 

Grounds () 

MS 

Camp Shelby (O) 

Columbus Army Airfield (O)
 

Horne Island (O) 

NC 

Laurinburg-Maxton Army Air Base 

(O) 

NE 

Nebraska Ordnance Plant (O) 

NV 

Hawthorne Army Ammunition Plant (O) 

NJ 

Raritan Arsenal (O) 

OH 

Ravenna Army Ammunition Plant (O) 

OR 

Umatilla Depot Activity () 

SC 

Charleston Army Depot (O) 

Naval Weapons Center (O)–not shown on map 

SD 

Black Hills Ordnance Depot (O) 

TN 

Defense Depot Memphis (O) 

TX 

Ft Hood (O) 

Camp Stanley Storage Activity (O) 

Camp Bullis (O) 

UT 

Dugway Proving Grounds (O) 

Defense Depot Ogden (O) 

Tooele Army Depot () 

VI 

Ft. Segarra (St. Thomas) (O) 

Other 

Johnston Atoll (S. Pacific)() 
 

SULFUR MUSTARD 127 

5. PRODUCTION, IMPORT/EXPORT, USE, AND DISPOSAL 

5.2 IMPORT/EXPORT 

Sulfur mustard is not imported into or exported from the United States. 

5.3 USE 

The principal use of sulfur mustard was as a vesicant chemical warfare agent. The Germans first used it 

against the British during World War I during the battle of Flanders, near Ypres, Belgium, in 1917 

(Franke 1967; Rosenblatt et al. 1975). It was used by the Allies in 1918 and by the Italians in Ethiopia in 

1936. It has also been used recently in the Iran-Iraq War in 1984–1988 and by Iraq against its Kurdish 

minority in Halabjah in 1988 (Black et al. 1993b; Budiansky 1984). 

Attempts have been made to use sulfur mustard as an antineoplastic agent, although this has not met with 

much success due to its high toxicity. A similar product, nitrogen mustard, has been successfully 

employed as an anticancer agent (IARC 1975). Sulfur mustard has provided a useful model in biological 

studies concerning the behavior of alkylating agents (IARC 1975). Sulfur mustard has also been used 

medicinally to control hyperproliferation of psoratic keratinocytes (SBCCOM 1999). 

5.4 DISPOSAL 

For the past several decades, the United States has stored its stockpile of sulfur mustard at eight Army 

facilities under a policy of total containment (Colburn 1978). The total quantity of sulfur mustard (i.e., H, 

HD, and HT) in the original stockpile was 17,358 tons (34,716,945 pounds) (DOA 2000). The stockpile 

consists of both munitions and 1-ton containers of bulk agent (see Table 5-1; DOA 2000, 2002; NRC 

1994). In addition to sulfur mustard, munitions may contain energetics (e.g., explosives and propellants). 

Public Law (PL) 99-145 (as amended by PL 100-456) and PL 104-484 (October 23, 1992) requires the 

Army to destroy the U.S. stockpile of all lethal unitary chemical agents and munitions by 

December 31, 2004 (DOA 1988; NRC 1994). Some chemical-warfare agents and related material, 

referred to as non-stockpile chemical material (NSCM), were not included in the stockpile inventory, but 

were subsequently added to the chemical demilitarization program in HR 101-822, which accompanied 
 

 

 

 

 

 

 

 

 

 

SULFUR MUSTARD 128 

5. PRODUCTION, IMPORT/EXPORT, USE, AND DISPOSAL 

Table 5-1. Original Stockpile Quantities of Sulfur Mustard as Munitions 

and Bulk Agenta 

Chemical 

munitions or 

bulk agent APG ANAD BAD JAPb

 PBA PUDA TEADc UMDA 

HD 

105-mm 

projectile 68,500 140 1,138,760 5,860 

155-mm 

projectile 206,420 181,260 66,340 3,504,780 

 4.2-inch 

mortar 452,160 116,294 460,340 

M60 

projectile 261,960 

 Ton 

container 3,249,740 185,080 116,294 188,400 11,383,420 

H 

155-mm 

projectile 639,540 

 Ton 

container 4,679,040 

HT

 4.2-inch 

mortar 1,064,600 118,220 363,020 

 Ton 

container 6,249,100 

Total 3,249,740 1,976,760 181,260 578,705 6,437,500 5,222,100 12,391,840 4,679,040 

Percent of 

total sulfur 

mustard 

stockpile 9.4 5.7 0.5 1.7 18.5 15.0 35.7 13.5 

a

Quantities of agent reported in pounds. Original stockpile quantities reflect amounts before the onset of Chemical Stockpile 

Disposal Program. Quantities do not include non-stockpile amounts of sulfur mustard. Up-to-date information about stockpile 

destruction is available at http://www-pmcd.apgea.army.mil/. b

As of the year 2000, the entire stockpile of sulfur mustard at JAP has been destroyed. 

c

As of November 1, 2002, 44% of the agent and 81% of the munitions at TEAD have been destroyed (exact percentage of sulfur 

mustard destruction is unspecified)
 

ANAD = Anniston Army Depot, Alabama; APG = Aberdeen Proving Ground, Maryland; BAD = Blue Grass Army Depot, Kentucky; 

H = undistilled sulfur mustard; HD = distilled sulfur mustard; HT = 60% sulfur mustard + 40% Agent T; JAP = Johnston Atoll, Pacific
 

Ocean; PBA = Pine Bluff Arsenal, Arkansas; PUDA = Pueblo Depot Activity, Colorado; TEAD = Tooele Depot, Utah; 

UMDA = Umatilla Depot Activity, Oregon 

Source: DOA 2000, 2002 
SULFUR MUSTARD 129 

5. PRODUCTION, IMPORT/EXPORT, USE, AND DISPOSAL 

the 1991 Defense Appropriations Act. NSCM includes lethal wastes from past disposal efforts, 

unserviceable munitions, chemically contaminated containers, chemical-production facilities, newly 

located chemical munitions, and known sites containing significant quantities of buried chemical weapons 

and waste (NRC 2000). 

As part of the Chemical Stockpile Disposal Program (CSDP) mandated by Congress, the Army currently 

uses the “baseline system” for destruction of munitions and bulk agents containing sulfur mustard (NRC 

1994). The “baseline system” consists of several steps: (1) storage, transportation, and unloading of 

munitions and containers, (2) disassembly and draining, (3) agent destruction, (4) energetics destruction, 

(5) metal parts decontamination, and (6) dunnage (i.e., other contaminated materials) disposal (NRC 

1994). Munitions are currently stored and monitored in vented igloos; bulk containers are stored in the 

open or in monitored warehouses. The munitions or bulk sulfur mustard are transported to the on-site 

disposal facility and unloaded. Munitions are disassembled, drained of sulfur mustard, and separated into 

streams of bulk liquid agent, metal parts, energetics, and dunnage, all of which contain different amounts 

of sulfur mustard. Liquid agents from drained munitions and bulk containers are fed into a primary 

incinerator preheated to an operating temperature of 2,700 °F (1,480 °C). Exhaust gases from the primary 

incinerator are fed into a secondary incinerator at a temperature of 2,200 °F (1,200 °C) for 2 seconds, 

after which 99.9999% of the agent is destroyed (DOA 2000). The gaseous effluents then flow into 

pollution abatement system before release into the atmosphere. Energetic materials are burned in a 

counterflow rotary kiln and then heated on a discharge conveyor at 1,000 °F (540 °C); the solid waste 

produced is nonhazardous and may be shipped for land disposal. Discharged gases pass through a 

secondary incinerator and a pollution abatement system, and then are released to the atmosphere. Metal 

parts are heated to 1,000 °F for 15 minutes in a fuel-fired metal parts furnace; the heat-treated metal parts 

are then released as scrap metal. Gases discharged pass through a secondary incinerator and a pollution 

abatement system, and then are released to the atmosphere. Dunnage generated during the entire process 

may be either incinerated (with pollution abatement) or shipped for land disposal as hazardous waste. At 

all steps, monitoring for chemical agents is performed to detect concentrations of the agent well below 

those that present an immediate threat to personnel or the surrounding population. There are no 

measurable sulfur mustard effluents leaving the baseline system facilities under normal operating 

conditions (MacNaughton 2001). At present, Johnston Atoll is the first site to destroy its portion of the 

chemical agent and munitions stockpile in the United States. Incineration of sulfur mustard is currently 

underway at Tooele, Utah. Construction of baseline system facilities near Umatilla, Oregon and 

Anniston, Alabama are completed with operational testing in progress at these facilities. As of late 2002, 
 

SULFUR MUSTARD 130 

5. PRODUCTION, IMPORT/EXPORT, USE, AND DISPOSAL 

a baseline system facility at Pine Bluff, Arkansas is near completion with operational testing to be 

conducted afterwards. 

To address growing public concern over incineration, in 1992, Congress directed the Army to evaluate 

alternative disposal methods that might be significantly safer and more cost effective than the baseline 

system (NRC 1994). Two alternatives were accepted by the Army for further development: (1) standalone neutralization followed by incineration and (2) neutralization followed by bio-treatment (NRC 

1996). Neutralization of sulfur mustard is achieved by hydrolysis with hot water (90 °C) and vigorous 

mixing. This process reduces the sulfur mustard concentrations to levels <200 ppb and selectively 

converts 90% of the sulfur mustard to thiodiglycol and hydrochloric acid (Currie et al. 1977; May 1998; 

NRC 1996). Once the reaction is complete, a base (e.g., sodium hydroxide or lime) is added to neutralize 

the acid and adjust the pH of the hydrolysate (i.e., product of hydrolysis). The dilute processing of sulfur 

mustard and the addition of base after completion of the neutralization reaction are designed to minimize 

the production of unwanted byproducts during reaction (NRC 1996). Hydrolysis has been used 

effectively to detoxify over 700 tons of sulfur mustard located at a Canadian defense facility in Cornwall, 

Ontario (Currie et al. 1977). After hydrolysis, the hydrolysate can either be incinerated using the baseline 

system or biotreated. Biotreatment requires adjusting the pH of the hydrolysate to neutral by adding 

sodium bicarbonate buffer and some nutrients. Bacteria oxidize thiodiglycol to carbon dioxide, water, 

and sulfate with high efficiency. During the actual process, approximately 0.8 g of cell mass (dry weight) 

will be produced for every 1 g of organic carbon removed from solution. The biomass is further oxidized 

through aerobic digestion, and then dried and disposed of at a commercial water treatment facility. Any 

volatile organic compounds (VOCs) that are present are condensed and the resulting condensate is 

removed by direct photodegradation and photooxidation by OH radicals. The treated bioresidue is then 

filtered, dried, and sent to landfill (May 1998; NRC 1996). A chemical neutralization facility is currently 

being constructed at Aberdeen, Maryland, where sulfur mustard is stored only as bulk liquid in 1-ton 

containers (NRC 1994). The waste product from this facility will be transported to Dupont’s Chambers 

Works Plant in Deepwater, New Jersey for final treatment at this chemical waste disposal facility. 

Chemical neutralization will also be used to destroy the sulfur mustard stockpile at Pueblo, Colorado. In 

November 2002, the Department of Defense selected neutralization followed by super critical water 

oxidation to destroy the chemical weapons stockpile at the Blue Grass Army Disposal in Kentucky (DOD 

2003). 
 

SULFUR MUSTARD 131 

6. POTENTIAL FOR HUMAN EXPOSURE 

6.1 OVERVIEW 

Sulfur mustard has been identified in at least 3 of the 1,636 hazardous waste sites that have been proposed 

for inclusion on the EPA National Priorities List (NPL) (HazDat 2003). However, the number of sites 

evaluated for sulfur mustard is not known. The frequency of these sites can be seen in Figure 6-1. Of 

these sites, all are located within the United States. 

Sulfur mustard is not a naturally occurring compound and its primary application is in chemical warfare. 

The United States has not produced it since 1968. Chemical agents, such as sulfur mustard, are extremely 

hazardous materials, which is why they were used as weapons. The hazard is increased when the agent is 

contained in explosively configured munitions, an inherent feature of chemical weapons. Since chemical 

weapons no longer have any value as a military deterrent, Congress has mandated that all chemical agents 

and munitions be destroyed by the end of the year 2004 (NRC 1994). However, the destruction of all 

chemical agents and munitions in the United States containing sulfur mustard is likely to continue for 

some unspecified time beyond this date. Sulfur mustard is known to be stored at seven Army bases (see 

Section 5.1) across the continental United States, some of which may also be at NPL sites (DOA 1988). 

Persons working at or living near Army bases where this material is stored or destroyed are at a greater 

risk of exposure. 

Information about other mustard agents (e.g., nitrogen mustard or HN, thickened mustard or HT, and 

lewisite), although related to sulfur mustard, is not included in this document (see Chapter 4). 

6.2 RELEASES TO THE ENVIRONMENT 

During World War I with its use as a chemical warfare agent, sulfur mustard was released directly to the 

atmosphere in countries outside the United States. From World War I until the 1970s, disposal of 

chemical weapons, such as sulfur mustard, at sea was accepted practice. Consequently, sulfur mustard is 

found in ocean waters at several sites around the world. It does not occur naturally, and is no longer 

produced in the United States. Sulfur mustard that was produced for military applications is now being 
SULFUR MUSTARD 132 

6. POTENTIAL FOR HUMAN EXPOSURE 

Figure 6-1. Frequency of NPL Sites with Sulfur Mustard Contamination 

1 

Frequency of

NPL Sites 

Derived from HazDat 2003 
 

SULFUR MUSTARD 133 

6. POTENTIAL FOR HUMAN EXPOSURE 

stored in military depots and storage facilities across the United States (see Section 5.1). Both sulfur 

mustard agent and munitions are currently or will be destroyed on site at these Army facilities. All 

chemical agents maintained in the Army stockpile are now at least 30 years old and some are more than 

50 years old; none were manufactured after 1968 (NRC 1994). There have been almost 1,500 “leaking” 

munitions identified in the stockpile since 1982, some of which are leaking sulfur mustard (NRC 1994). 

In September 1993, a 100-gallon spill from a 1-ton container of sulfur mustard was discovered at Tooele 

Army Depot, Utah (NRC 1994). Other leaks of sulfur mustard have been identified from chemical 

munitions (e.g., 155-mm projectiles) as recently as October 16, 2002 (DOA 2003). Thus, environmental 

releases of sulfur mustard may potentially occur near Army bases where this material is stored and 

destroyed. However, because of the Army’s efforts to mitigate exposure of the general population to 

sulfur mustard (as well as to other stockpile chemical agents), no releases of sulfur mustard have been 

reported beyond the confines of these storage locations. 

6.2.1 Air 

Sulfur mustard may be released to air at stockpile and non-stockpile sites across the United States where 

sulfur mustard is known to be located. However, because of the Army’s efforts to mitigate exposure of 

the general population to sulfur mustard (as well as to other stockpile chemical agents), no releases of 

sulfur mustard to air have been reported beyond the confinement of these facilities. No known releases of 

sulfur mustard to the atmosphere have been reported with the destruction of sulfur mustard by 

incineration (MacNaughton 2001). 

Sulfur mustard has not been identified in air at any of the three NPL hazardous waste sites where it was 

detected in some environmental media (HazDat 2003). 

6.2.2 Water 

From World War I until the 1970s, disposal of sulfur mustard at sea was standard practice. However, 

limited information about this practice is available before the mid-1940s. In 1943, sulfur mustard was 

released into the waters of Bari Harbor, Italy with the sinking of the American freighter, S.S. John Harvey 

(SIPRI 1971). Since the end of World War II, ocean dumping has occurred in many areas, such as the 

Baltic Sea (Mazurek et al. 2001); the coastal waters around Japan (Kurata 1980); the Adriatic Sea near 
 

 

SULFUR MUSTARD 134 

6. POTENTIAL FOR HUMAN EXPOSURE 

Bari, Italy; and the coastal waters of the United States (Brankowitz 1987). Some of the known ocean 

dumping sites off the continental United States are summarized in Table 6-1. 

Sulfur mustard has not been identified in groundwater or surface water at the three NPL hazardous waste 

sites where it was detected in some environmental media (HazDat 2003). 

6.2.3 Soil 

No releases of sulfur mustard to soil have been reported in the literature. However, sulfur mustard is 

currently stored at several sites around the United States and its territories in stockpile and non-stockpile 

quantities (see Figure 5-1). Non-stockpile locations include known sites containing significant quantities 

of buried chemical weapons and wastes. Sulfur mustard is the most frequently identified material at these 

sites (NRC 2000). 

Sulfur mustard has been identified in soil at one site of the three NPL hazardous waste sites where it was 

detected in some environmental media (HazDat 2003). 

6.3 ENVIRONMENTAL FATE 

6.3.1 Transport and Partitioning 

On the basis of its use during warfare and its physical/chemical properties, sulfur mustard should partition 

to and be transported in the atmosphere following release. The vapor pressure of sulfur mustard is 

moderate (0.11 mm Hg at 25 °C), but is high enough for sulfur mustard to be in air in the immediate 

vicinity of liquid droplets (DOA 1996). 

On surface soil, Small (1984) reported that volatilization would be the main route of sulfur mustard loss. 

However, on moist surface soil, hydrolysis would be the main loss pathway. At 25 °C, sulfur mustard 

deposited on a surface soil will evaporate within 30–50 hours (Munro et al. 1999). Meteorologic 

conditions such as temperature and wind will greatly affect the persistence of sulfur mustard on soil; with 

warmer temperatures and stronger winds, persistence of sulfur mustard decreases (Franke 1967). For 

example, sulfur mustard will vaporize 2–3 times faster at 20 °C than at 5 °C (Franke 1967). The freezing 
SULFUR MUSTARD 135 

6. POTENTIAL FOR HUMAN EXPOSURE 

Table 6-1. Location of Historical Dumping Areas for Sulfur Mustard (H) in 

Coastal Waters of the United States 

Location of munitions 

loading Destination Date Munition Quantity 

Attu and Adak, Alaska 12 miles off Chichagoff 1947 Bulk agent Unknown 

Charleston, South Site “Baker” August—October Bombs, Over 7 tons 

Carolina 1946 projectiles, mines, 

bulk 

Colts Neck Naval Pier, 39 ̊ 39’ N, 70 ̊ 57’ W June 15, 1967 Rockets, Bulk 3,890 tons 

Earle, New Jersey 

Colts Neck Naval Pier, 39 ̊ 33’ N, 71 ̊ 02’ W August 7, 1968 Contaminated 2,975 tons 

Earle, New Jersey water 

Edgewood Arsenal, 38 ̊ 30’ N, 72 ̊ 10’ W June 18, 1962 Projectiles, Bulk 3 tons 

Maryland 

Edgewood Arsenal, 38 ̊ 30’ N, 71 ̊ 06’ W August 6–7, 1964 Bulk, Projectiles 65 tons 

Maryland 

Naval Mine Depot, Site “Baker” March 21–25, Projectiles 13 tons 

Yorktown, Virginia 1946 

New Orleans Port of Gulf of Mexico March 1–7, 1946 Projectiles 207 tons 

Entry, Braithwaite, 

Louisiana 

NWS Concord, 37 ̊ 40’ N, 125 ̊ 0’ W April 8–19, 1958 Bulk 9,030 tons 

California 

Theodore Naval Gulf of Mexico July 13, 1946 Bombs (German) 7 tons 

Magazine, Mobile, 

Alabama 

Source: Brankowitz 1987 
SULFUR MUSTARD 136 

6. POTENTIAL FOR HUMAN EXPOSURE 

point of sulfur mustard is between 13 and 15 °C. In temperate regions, sulfur mustard should be a solid 

for half of the year (Munro et al. 1999). Solidified sulfur mustard is less volatile, of lower water 

solubility, and is less reactive than liquified sulfur mustard. A study of persistence under winter 

conditions found that sulfur mustard could be detected after 2 weeks, but was below detection limits (not 

stated) at 4 weeks (Franke 1967). When snowfall covered samples, high recoveries were demonstrated 

even after 4 weeks. This study also showed that persistence was affected by the size of droplets. Larger 

droplets of sulfur mustard increased both stability and recovery (Johnsen and Blanch 1984). Other factors 

that influence vaporization include pH, moisture content, porosity of the surface, and physical 

constituents of the soils (Rosenblatt et al. 1975). Because of its low solubility in water (920 mg/L) and 

ease of hydrolysis once dissolved (see Section 6.3.2.2), sulfur mustard is not transported through soil into 

groundwater (Munro et al. 1999). 

In water, sulfur mustard will volatilize to air, hydrolyze, or remain unchanged. Without turbulence and at 

low temperatures, large quantities of sulfur mustard will persist under water for long periods of time 

(Munro et al. 1999). For example, sulfur mustard disposed of in sea water at several locations around the 

world continues to be brought to the surface where it has injured unsuspecting fisherman (Jorgensen et al. 

1985; Kurata 1980; Mazurek et al. 2001). Volatilization of sulfur mustard from water surfaces is expected 

to be moderate based upon a Henry's law constant of 2.1x10-5 atm⋅m3

/mol (DOA 1996). Using this 

Henry's law constant and an estimation method (Lyman et al. 1990), volatilization half-lives of sulfur 

mustard for a model river and model lake are 36 hours and 503 days, respectively. Hydrolysis of sulfur 

mustard may be slow because of its limited solubility and the fact that sulfur mustard freezes at 14 °C (see 

Section 6.3.2.2). Sulfur mustard is expected to sink to the bottom of the water column because it is 

denser than water (1.27 g/cm3

 at 20 °C; see Table 4-1). 

Sulfur mustard does not bioconcentrate or biomagnify due to its reactivity. It is also unlikely that it is 

transported through the vascular systems of plants since it would almost surely undergo hydrolysis in the 

process (Rosenblatt et al. 1975). 
 

SULFUR MUSTARD 137 

6. POTENTIAL FOR HUMAN EXPOSURE 

6.3.2 Transformation and Degradation 

6.3.2.1 Air 

Sulfur mustard does not absorb ultraviolet (UV) radiation above 290 nm (Rewick et al. 1986); thus, 

photodegradation should not be an important fate process. The rate constant for the vapor-phase reaction 

of mustard with photochemically-produced hydroxyl radicals has been estimated as 

7.82x10-12 cm3

/molecule-s at 25 °C using a structure estimation method (Meylan and Howard 1993). This 

corresponds to an atmospheric half-life of about 2.1 days at an atmospheric concentration of 

5x105 hydroxyl radicals/m3

 (assumed average concentration in non-smog conditions). Under smog 

conditions, reaction with nitrate radicals may be important. 

6.3.2.2 Water 

While hydrolysis of sulfur mustard is relatively rapid in water once dissolved, sulfur mustard dissolution 

is relatively slow (Bartlett and Swain 1949; Clark 1989; Rosenblatt et al. 1975; Small 1984; Stein 1946). 

Dissolved sulfur mustard has a hydrolysis half-life of 4–8 minutes at 25 °C in distilled water (Bartlett and 

Swain 1949). In several studies reviewed by Small (1984), the hydrolysis half-life (first-order rate) of 

dissolved sulfur mustard ranges from 158 minutes at 0.6 °C to ~1.5 minutes at 40 °C. The hydrolysis 

products of sulfur mustard are primarily mustard chlorohydrin, thiodiglycol, and hydrochloric acid; others 

include intermediates such as cyclic sulfonium salts (Rosenblatt et al. 1975, 1996). The hydrolysis of 

mustard chlorohydrin is somewhat faster than the hydrolysis of sulfur mustard. Consequently, mustard 

chlorohydrin does not accumulate to high concentrations. Conditions involving relatively small quantities 

of water give rise to higher concentrations of the cyclic sulfonium salt intermediates, which are rather 

toxic. Hydrolysis pathways of sulfur mustard in the environment are illustrated in Figure 6-2. 

Sufficient levels of chlorine in the water (e.g., salt water) will inhibit the hydrolysis reaction; hydrolysis is 

decreased by a factor of 2.5 in salt water over fresh water (Clark 1989; Rosenblatt et al. 1975, 1996). 

Chloride ions react with the cyclic sulfonium intermediates to reform sulfur mustard. Impurities found in 

sulfur mustard (e.g., polysulfides) might slow the dissolution of the agent, and if they dissolve in water, 

they will react more slowly with water than sulfur mustard (Rosenblatt et al. 1996). One impurity, 

1,2-bis(2-chloroethylthio)ethane, is about 5 times as vesicant as sulfur mustard itself; others, such as 

1,8-dichloro-3-oxa-6-thiaoctane, are probably about as toxic as sulfur mustard. 
Sulfur Mustard 

Source: Munro et al. 1999 

SULFUR MUSTARD 138 

6. POTENTIAL FOR HUMAN EXPOSURE 

Figure 6-2. Primary Hydrolysis Pathways of Sulfur Mustard in the Environment 
SULFUR MUSTARD 139 

6. POTENTIAL FOR HUMAN EXPOSURE 

Because sulfur mustard has limited solubility (920 mg/L in water; Rosenblatt et al. 1996), hydrolysis is 

limited by its slow rate of solution (i.e., 6.77x10-8 g/cm2

⋅s at 10 °C). During the dissolution process, the 

outer surface of a sulfur mustard droplet dissolves and is rapidly hydrolyzed to sulfonium ions and 

thiodiglycol (see Figure 6-2). These compounds then react with sulfur mustard to form 1,2-bis[(2-chloroethyl)thio]ethane and 1,2-dichloroethane or together to form stable sulfonium polymers. Without 

agitation, sulfonium polymers build up, creating a thick boundary layer, which interferes with the transfer 

of sulfur mustard into bulk water. Dissolution of bulk sulfur mustard slows because the driving force for 

diffusion sulfur mustard into the bulk aqueous phase decreases (Rosenblatt et al. 1975, 1996). Without 

agitation, bulk sulfur mustard may persist in water for up to several years (Small 1984). Epstein et al. 

(1973) estimated that a 1-ton lump of sulfur mustard would require 5 years to dissolve in water. 

The addition of water-soluble organic solvents, such as acetone and ethanol, permits greater 

concentrations of sulfur mustard to solubilize in water so as to facilitate hydrolysis (Clark 1989). For 

example, when a small amount of acetone (e.g., 5% solution in water) was used to dissolve sulfur mustard 

in water at 25 °C, the hydrolysis half-life was 9.0 minutes (first-order rate constant =0.00129 s-1). 

Oxidation of sulfur mustard is also known to occur. Reactions with hypochlorite, chlorine water, ozone, 

and hydrogen peroxide yield mustard sulfoxide, which is extremely stable to hydrolysis and slightly toxic. 

Further oxidation under more severe conditions forms mustard sulfone, a relatively nontoxic compound. 

However, in weakly alkaline solution, mustard sulfone is dehydrochlorinated to divinyl sulfone, which is 

highly toxic (Clark 1989; Price and Bullitt 1947; Rosenblatt 1975). 

6.3.2.3 Sediment and Soil 

Natural degradation of sulfur mustard in soil is a result of chemical hydrolysis and biodegradation. The 

major product of chemical hydrolysis is thiodiglycol. Chemical hydrolysis of sulfur mustard and its 

chlorine derivatives in soil depends on soil type and moisture content, degree of contamination, and 

temperature. If the moisture content of soil is <50% of its moisture capacity, then chemical hydrolysis in 

soil does not occur (Medvedeva et al. 2000). With higher temperatures and moisture content, the extent 

of hydrolysis of sulfur mustard increases, but never to 100% completion. Sulfur mustard is known to 

degrade faster in alkaline soils (Franke 1967). If sulfur mustard droplets are considerably below the soil 

surface, then sulfur mustard can persist for several years (Munro et al. 1999; Watson and Griffin 1992). 
 

SULFUR MUSTARD 140 

6. POTENTIAL FOR HUMAN EXPOSURE 

For example, sulfur mustard has been known persist for weeks to decades in military testing areas and 

land dumps where large quantities have been deposited underground. 

Sulfur mustard can be biodegraded in soil via the thioether oxidation pathway, forming bis-(2-chloroethyl)-sulfoxide and corresponding sulfone (U.S. Army Dugway Proving Ground 1985). Recently, 

Wariishi et al. (2002) demonstrated that fungi (e.g., basidiomycetes) are able to degrade sulfur mustard in 

soil by directly cleaving the carbon-sulfur bond and by hydrolytic dechlorination. Sulfur mustard can also 

be biodegraded via reductive dehalogenation and dehydrohalogenation, although these pathways are 

predicted to be slow. 

Degradation of the hydrolysis products of sulfur mustard (e.g., thiodiglycol) proceeds very slowly 

because these compounds are poorly utilized by microorganisms. For example, in a medially 

contaminated peaty gley soil characterized by a high rate of microbiological processes, the concentration 

of thiodiglycol decreased 50% after a year. However in a highly contaminated peaty gley soil, <10% of 

thiodiglycol degraded in a period of a year (Medvedeva et al. 2000). The reduction in microbial activity 

is a consequence of the high toxicity of sulfur mustard to soil microorganisms. 

6.3.2.4 Other Media 

No information was found in the literature regarding transformation and degradation reactions in other 

media. 

6.4 LEVELS MONITORED OR ESTIMATED IN THE ENVIRONMENT 

6.4.1 Air 

No information was found in the literature regarding environmental concentrations of sulfur mustard in 

the ambient atmosphere. Ambient concentrations of sulfur mustard are expected to be zero except near 

military facilities where former production occurred or where current disposal may be in progress. 

During World War I, when sulfur mustard was used, the average and maximum atmospheric 

concentrations in the combat zones were estimated at 3 and 5 ppm, respectively (IARC 1975). 
SULFUR MUSTARD 141 

6. POTENTIAL FOR HUMAN EXPOSURE 

6.4.2 Water 

In 1943, sulfur mustard was released into the waters of Bari Harbor, Italy with the sinking of the 

American freighter, S.S. John Harvey (Mitretek Systems 2002). Since the end of World War II, ocean 

dumping has occurred in many areas (SIPRI 1971), such as the Baltic Sea (Mazurek et al. 2001); the 

coastal waters around Japan (Kurata 1980); the Adriatic Sea near Bari, Italy; and the coastal waters of the 

United States (Brankowitz 1987). Some of the known ocean dumping sites off the continental United 

States are summarized in Table 6-1. No information was located that describes the concentration of 

sulfur mustard at these locations. 

6.4.3 Sediment and Soil 

No information was found in the available literature regarding current soil concentrations of sulfur 

mustard. For some time after World War I, much of the French soil in the region of battle lines was 

contaminated, although it is unlikely to have persisted to the present day (IARC 1975). If any sulfur 

mustard still exists, it would be present only as pockets of liquid, perhaps dissolved in discarded oil, or 

absorbed on an inert anhydrous soil medium (Rosenblatt et al. 1975). Before 1945, sulfur mustard was 

produced at the Rocky Mountain Arsenal in Colorado. Only traces of sulfur mustard have been found in 

soil samples at 3 or 4 locations out of 15,000 sampled during the recent clean-up of this site (Cohn 1999). 

Soils in Fort McClellan, Alabama are highly polluted with sulfur mustard and its many impurities (Dacre 

1994). No additional information was found that quantifies the level of contamination at this site. Other 

sites where sulfur mustard may be present include non-stockpile sites across the United States (see 

Figure 5-1). No information was located that quantifies the concentrations of sulfur mustard at these 

sites. 

6.4.4 Other Environmental Media 

Normal urinary levels of thiodiglycol, a hydrolysis product of sulfur mustard, are <1 ng/mL, but levels up 

to ca. 16 ng/mL are found in blood (Black and Read 1991). The source of this low backgrounds level is 

unknown, but sulfur-rich foods in the diet may be one possibility. No other information was found in the 

available literature regarding concentrations of sulfur mustard in environmental media. 
 

SULFUR MUSTARD 142 

6. POTENTIAL FOR HUMAN EXPOSURE 

6.5 GENERAL POPULATION AND OCCUPATIONAL EXPOSURE 

The general population in the United States is not exposed to sulfur mustard since it is found primarily at 

seven Army bases in stockpiles (Munro et al. 1999) and at 45 non-stockpile sites across the United States 

(see Figure 5-1). Populations located near these sites have a potentially greater risk of exposure to sulfur 

mustard. However, because of the Army’s efforts to mitigate exposure of the general population to sulfur 

mustard (as well as to other stockpile chemical agents), no releases of sulfur mustard have been reported 

beyond the confines of these facilities. Also, since the entire stockpile of sulfur mustard agent and 

munitions is presently being destroyed onsite at several locations around the United States, the risk of 

exposure from accidental leaks and spills of sulfur mustard at these locations is decreasing for the general 

population. In countries where sulfur mustard was released during warfare (e.g., Belgium, Morocco, 

Ethiopia, China, and Iran-Iraq), it is possible that conditions have been favorable to allow small quantities 

to persist (Mitretek Systems 2002). Non-stockpile sites may contain buried munitions or contaminated 

soils containing sulfur mustard, which may be disturbed with excavation activities. Small quantities of 

sulfur mustard may persist at these bases. Populations in these areas are at higher risk than those in areas 

that were never contaminated. 

Occupational exposure may occur for fishermen who inadvertently snare lumps of sulfur mustard in their 

nets. This type of exposure has occurred in areas of historical dumping of sulfur mustard in the seas and 

ocean. Accidents such as this continue to be reported in the Baltic Sea, Adriatic Sea, Pacific Ocean, and 

Japanese coastal waters, and have resulted in several hundred deaths over the past 50 years (Brankowitz 

1987; Kurata 1980; Mazurek et al. 2001; SIPRI 1971). Individuals involved in activities related to the 

storage and destruction of this compound are also occupationally exposed. Construction workers may 

become exposed at Army bases where sulfur mustard was previously released and persisted in the soil or 

in an excavated munitions dump. Laboratory workers may be exposed to sulfur mustard through their 

research activities if they do not take the necessary precautions to prevent exposure. Soldiers may be 

exposed to sulfur mustard with its use as a chemical warfare agent. The most recent report of its use is 

from the Iran-Iraq War in the 1980s when it was detected in the urine of some soldiers (Vycudilik 1985). 

6.6 EXPOSURES OF CHILDREN 

This section focuses on exposures from conception to maturity at 18 years in humans. Differences from 

adults in susceptibility to hazardous substances are discussed in 3.7 Children’s Susceptibility. 
 

 

SULFUR MUSTARD 143 

6. POTENTIAL FOR HUMAN EXPOSURE 

Children are not small adults. A child’s exposure may differ from an adult’s exposure in many ways. 

Children drink more fluids, eat more food, breathe more air per kilogram of body weight, and have a 

larger skin surface in proportion to their body volume. A child’s diet often differs from that of adults. 

The developing human’s source of nutrition changes with age: from placental nourishment to breast milk 

or formula to the diet of older children who eat more of certain types of foods than adults. A child’s 

behavior and lifestyle also influence exposure. Children crawl on the floor, put things in their mouths, 

sometimes eat inappropriate things (such as dirt or paint chips), and spend more time outdoors. Children 

also are closer to the ground, and they do not use the judgment of adults to avoid hazards (NRC 1993). 

Children in the United States are not likely to be exposed to sulfur mustard since it is found only at 

military bases (Munro et al. 1999), and access to these sites is highly restricted. 

6.7 POPULATIONS WITH POTENTIALLY HIGH EXPOSURES 

Since the U.S. stockpile of sulfur mustard is currently found in only at seven storage facilities (Munro et 

al. 1999), the potential for high exposures is limited to these areas and their surrounding communities. 

Exposure at or near these Army storage facilities may occur if the munitions or storage containers explode 

or leak. However, the U.S. Army currently takes corrective and preventive actions to mitigate the risks of 

exposure to the general population. In addition, the stockpile of chemical weapons containing sulfur 

mustard is currently being destroyed and is scheduled to be completed by 2004. Thus, the risk of 

accidental exposure to sulfur mustard is decreasing. 

6.8 ADEQUACY OF THE DATABASE 

Section 104(i)(5) of CERCLA, as amended, directs the Administrator of ATSDR (in consultation with the 

Administrator of EPA and agencies and programs of the Public Health Service) to assess whether 

adequate information on the health effects of sulfur mustard is available. Where adequate information is 

not available, ATSDR, in conjunction with the National Toxicology Program (NTP), is required to assure 

the initiation of a program of research designed to determine the health effects (and techniques for 

developing methods to determine such health effects) of sulfur mustard 
 

 

 

SULFUR MUSTARD 144 

6. POTENTIAL FOR HUMAN EXPOSURE 

The following categories of possible data needs have been identified by a joint team of scientists from 

ATSDR, NTP, and EPA. They are defined as substance-specific informational needs that if met would 

reduce the uncertainties of human health assessment. This definition should not be interpreted to mean 

that all data needs discussed in this section must be filled. In the future, the identified data needs will be 

evaluated and prioritized, and a substance-specific research agenda will be proposed. 

6.8.1 Identification of Data Needs 

Physical and Chemical Properties. The physical and chemical properties of sulfur mustard are available 

(Tables 4-1 and 4-4). Experimental determination of properties for sulfur mustard such as log Kow, log 

Koc, and Henry’s law constant values would be useful to determine its environmental fate. 

Production, Import/Export, Use, Release, and Disposal. Since 1968, sulfur mustard has not 

been produced, imported, or exported by the United States. Future production is not expected since 

international treaties prohibit the manufacture of sulfur mustard. The quantities of sulfur mustard at 

various locations across the United States are known. The entire stockpile of sulfur mustard munitions 

and bulk agent is currently in the process of being destroyed. The destruction of the stockpile, mandated 

by Congress, is to be completed by December 31, 2004. Information on the amounts of sulfur mustard 

being disposed of by each disposal method is available. Sulfur mustard is not used in the home 

environment or workplace. Sulfur mustard is also not present in food, and thus, will not be present as a 

food contaminant. 

Environmental Fate. There is limited information on the environmental fate of sulfur mustard. It is 

known to vaporize and hydrolyze in water (Clark 1989; Rosenblatt et al. 1975; Stein 1946). However, 

sulfur mustard will persist in the environment in both soil and water. Information of the half-life of sulfur 

mustard in the environment is known. Additional environmental fate information (e.g., biodegradation) 

would help to adequately characterize the compound. Information on the fate of sulfur mustard 

degradation products in the environment would also be useful. 

Bioavailability from Environmental Media. Sulfur mustard can be absorbed following inhalation 

(Drasch et al. 1987; Somani and Babu 1989) and dermal (Cullumbine 1946, 1947; Drasch et al. 1987; 

Nagy et al. 1946; Renshaw 1946) exposure from air and soil. This was its intended use and it is well 

studied (see Chapter 3). 
SULFUR MUSTARD 145 

6. POTENTIAL FOR HUMAN EXPOSURE 

Food Chain Bioaccumulation. No information was found regarding the bioconcentration of sulfur 

mustard by plants, animals, and aquatic organisms, or the biomagnification in terrestrial or aquatic food 

chains. However, due to the toxicity and metabolism of sulfur mustard, it is unlikely that it will 

bioconcentrate or biomagnify. 

Exposure Levels in Environmental Media. There are limited reports of sulfur mustard being 

detected in environmental media (e.g., soil and water) at hazardous waste sites, Army chemical weapon 

stockpile and non-stockpile facilities, ocean disposal sites, or other locations. Additional and up-to-date 

information is needed on media concentration levels near former and current facilities where sulfur 

mustard has been produced, stored, or destroyed. This information will be useful in predicting human 

exposure levels at these locations. Additional data on the amount of sulfur mustard at historical ocean 

dumping sites would be useful. 

Exposure Levels in Humans. No estimates have been for human intake of sulfur mustard from 

various environmental media. However, since potential exposure to sulfur mustard is currently limited to 

hazardous waste sites, Army chemical weapon stockpile and non-stockpile facilities, and ocean disposal 

sites, human intake of sulfur mustard by the general population is expected to be very low or none. Sulfur 

mustard metabolites have been detected in the urine and blood of exposed humans after its use as a 

chemical weapon (see Chapter 7). For example, thiodiglycol has been detected in the urine of soldiers 

after an acute exposure to sulfur mustard (Wils et al. 1985). However, the use of levels in urine or other 

biomarkers has not been reported in any other exposed populations. More sensitive methods of detection 

may be useful for assessment of chronic exposure to individuals working at or living near facilities that 

store or destroy sulfur mustard. 

Exposures of Children. Sulfur mustard has been detected in exposed children after its use as a 

chemical weapon (See Chapter 3) during the Iran-Iraq War (Momeni and Aminjavaheri 1994). More 

sensitive methods of detection for sulfur mustard may be useful for assessment of chronic exposure to 

children living near facilities that store or destroy sulfur mustard. 

Child health data needs relating to susceptibility are discussed in Section 3.12.2 Identification of Data 

Needs: Children’s Susceptibility. 

Exposure Registries. There are no exposure registries for sulfur mustard. This compound is not 

currently one of the compounds for which a subregistry has been established in the National Exposure 
SULFUR MUSTARD 146 

6. POTENTIAL FOR HUMAN EXPOSURE 

Registry. The compound will be considered in the future when chemical selection is made for 

subregistries to be established. The information that is amassed in the National Exposure Registry 

facilitates the epidemiological research needed to assess adverse health outcomes that may be related to 

the exposure to this compound. 

6.8.2 Ongoing Studies 

The ongoing studies focusing on environmental fate and human exposure of sulfur mustard are presented 

in Table 6-2 (DTIC 2002; FEDRIP 2002). 
SULFUR MUSTARD 147 

6. POTENTIAL FOR HUMAN EXPOSURE 

Table 6-2. Ongoing Studies on the Environmental Fate of Sulfur Mustard 

Investigator Affiliation Study Sponsor 

Myer, SB Tienzyme, Inc., State 

College, Pennsylvania 

Use of fungal peroxidases for neutralization of 

sulfur mustard 

Army 

Shaw, RW University of Florida, 

Gainesville 

Catalytic oxidation of mustard simulants in 

basic solution 

Army 

Research 

Office 

Sources: DTIC 2002; FEDRIP 2002 

SULFUR MUSTARD 149 

7. ANALYTICAL METHODS 

The purpose of this chapter is to describe the analytical methods that are available for detecting, 

measuring, and/or monitoring sulfur mustard, its metabolites, and other biomarkers of exposure and effect 

to sulfur mustard. The intent is not to provide an exhaustive list of analytical methods. Rather, the 

intention is to identify well-established methods that are used as the standard methods of analysis. Many 

of the analytical methods used for environmental samples are the methods approved by federal agencies 

and organizations such as EPA and the National Institute for Occupational Safety and Health (NIOSH). 

Other methods presented in this chapter are those that are approved by groups such as the Association of 

Official Analytical Chemists (AOAC) and the American Public Health Association (APHA). 

Additionally, analytical methods are included that modify previously used methods to obtain lower 

detection limits and/or to improve accuracy and precision. 

7.1 BIOLOGICAL MATERIALS 

The most common currently used method of analyzing for the presence of sulfur mustard and its 

metabolites in biological and environmental samples is gas chromatography/mass spectrometry (GC/MS). 

Prior to 1987, however, thin-layer chromatography (TLC) with a colorimetric detection system and gas 

chromatography with either flame ionization detector (FID), electron capture detector (ECD), or flame 

photometric detector (FPD) were the most frequently used methods. Sample preparation consists 

primarily of extraction with an organic solvent. Sodium chloride is sometimes added to improve sample 

stability and prevent sulfur mustard breakdown to thiodiglycol and other metabolites. Depending on the 

method used, and the possible interfering compounds present, further cleanup and preparative steps may 

be included. No specific EPA, NIOSH, or AOAC methods were found for this chemical. Table 7-1 

summarizes several representative analytical methods for detecting sulfur mustard and its metabolites in 

biological samples. 

Little information was found on the direct detection of sulfur mustard in biological tissues or fluids. 

However, in two cases of suspected exposure, sodium chloride was first added to the urine samples to 

stabilize any sulfur mustard that might be present. A semi-quantitative analysis by GC/MS detected low 

ppb levels of sulfur mustard in these samples compared to none detected in a control sample of a 

definitely unexposed person (Vycudilik 1985, 1987). The detection limit of the procedure was in the low 
SULFUR MUSTARD 150 

7. ANALYTICAL METHODS 

Table 7-1. Analytical Methods for Determining Sulfur Mustard in Biological 

Samples 

Sample 

Sample Analytical detection Percent 

matrix Preparation method method limit recovery Reference 

Urine Saturate with sodium chloride; GC/MS (EI) 10 ng/μL 20% Vycudilik 

extract with diethyl ether; centrifuge; injected 1985 

isolate organic phase and evaporate; 

redissolve in methylene chloride; 

clean up with silica gel; centrifuge; 

evaporate solvent layer; redissolve in 

methylene chloride 

Urine Hydrolyze sample with helix pomatia GC/MS 1 μg/L 75% Wils et al. 

(enzymatic hydrolysis); clean up on (1 ppb) 1988 

carbon column; add concentrated 

hydrochloric acid to convert thiodiglycol to sulfur mustard; headspace 

analysis7 with collection on Tenax; 

thermally desorb (Thiodiglycol) 

Urine Treat samples with acidic titanium GC-MS-MS 0.1 μg/L 48B56% Black and 

trichloride; final residue dissolved in (0.1 ppb) Read 

acetonitrile and toluene 1995b 

Human fluids Homogenize tissue; extract sample ET-AAS 1.1 mg/L No data Drasch et 

and tissues with dichloromethane; centrifuge; (ppm, al. 1987 

remove dichloromethane layer and body 

evaporate; redissolve in hexane; fluids); 

clean up on TLC; remove sample 0.1 mg/kg 

spots and complex with gold; extract (ppm, 

with toluene body 

tissues) 

EI = electron impact; ET-AAS = electrothermal atomic adsorption spectroscopy; GC = gas chromatography; GCMS-MS = gas chromatography-tandem mass spectroscopy; MS = mass spectroscopy; TLC = thin layer 

chromatography 
SULFUR MUSTARD 151 

7. ANALYTICAL METHODS 

ppb range with inadequate recoveries of about 20%. Sulfur mustard has also been detected in body 

tissues and fluids of an alleged victim (Drasch et al. 1987). In this analysis, abdominal fat samples were 

first qualitatively analyzed by GC/MS. 

Sulfur mustard is generally metabolized rapidly in biological systems. The primary method of analyzing 

for sulfur mustard exposure is by detecting the presence of its hydrolysis metabolites in biological fluids. 

GC/MS has been used for this purpose. The procedure involves conversion of the most common 

hydrolysis metabolite, thiodiglycol, to sulfur mustard by heating with concentrated hydrochloric acid 

(Wils et al. 1985, 1988). The detection limit for this procedure is in the low ppb range (about 1 μg/L) and 

with inclusion of deuterated thiodiglycol as an internal standard, recoveries of 75% are obtained (Wils et 

al. 1988). Unfortunately, thiodiglycol (and thiodiglycol sulphoxide) can exist in the urine of both 

exposed and nonexposed subjects; detection of thiodiglycol in human urine by this procedure at a 

concentration level of 10–100 μg/L does not prove sulfur mustard poisoning (Wils et al. 1985). Other 

methods using GC/MS have determined sulfur mustard in urine of exposed rats and guinea pigs by 

derivatisation of thiodiglycol with heptafluorobutyric anhydride (Jakubowski et al. 1990). Black and coworkers quantified thiodiglycol (and thiodiglycol sulphoxide) in urine of exposed humans using GC/MS 

after formation of bis(pentafluorobenzoyl) derivatives (Black and Read 1991, 1995a, 1995b; Black et al. 

1992a, 1992b, 1994). 

Another recent method for sulfur mustard detection in urine is gas chromatography-tandem mass 

spectrometry (GC-MS-MS) with selected-reaction monitoring. This method was applied to the analysis 

of urinary metabolites of sulfur mustard derived from hydrolysis (i.e., thiodiglycol and its sulfoxide) and 

the glutathione pathway after further metabolism involving the enzyme β-lyase (i.e., 1,1-sulphonylbis­

[2-(methylsulphinyl)ethane] and 1-methylsulphinyl-2-[2-(methylthio)ethylsulphonyl]ethane). The 

procedure involves treatment of samples with acidic titanium trichloride to reduce thiodiglycol sulfoxide 

to thiodiglycol and the two β-lyase metabolites to a single analyte, 1,1-sulphonylbis[2-(2-methylthio)­

ethane]. The detection limit for this procedure is in the sub-ppb range (0.1 μg/L) for detection of β-lyase 

metabolites and in the ppb range (1–12 μg/L) for detection of thiodiglycol. Recoveries, determined in 

normal urine spiked with 1,1-sulphonylbis[2-(2-methythio)ethane] at a concentration of 1 μg/L, ranged 

from 48 to 56%. The advantage of this method is that β-lyase metabolites of sulfur mustard have not 

been observed in normal urine and this method provides an unequivocal biological marker of exposure to 

sulfur mustard (Black and Read 1995b). 
 

SULFUR MUSTARD 152 

7. ANALYTICAL METHODS 

Recently, the detection of DNA adducts formed by the modification of DNA by sulfur mustard in blood 

offers a promising approach for retrospective detection of exposure. For example, Ludlum et al. (1994) 

detected an N7-guanine adduct of DNA using high performance liquid chromatography (HPLC) with 

fluorometric monitoring. In this study, the authors were able to detect one N7-guanine adduct in 

3x105

 DNA nucleotides. Benschop and co-workers (Benschop et al. 1997; Fidder et al. 1996a) were able 

to confirm the exposure to sulfur mustard in samples taken in March 1988 from two Iranians. Exposure 

to sulfur mustard was verified by two independent methods based on immunochemical analysis of the 

N7-guanine adduct in DNA and GC/MS analysis of the N-terminal valine adduct in globin after a 

modified Edman degradation. The adduct levels found were considerably higher than the detection limit 

for the modified Edman procedure (i.e., 0.1 μM sulfur mustard), but just above the detection limit for the 

immunochemical assay (i.e., 0.07 μM sulfur mustard). In another study, Noort et al. (1996) described the 

use of liquid chromatography-tandem mass spectrometry (LC-MS-MS) to identify modified sites in 

human hemoglobin after in vitro exposure to sulfur mustard. They note that hemoglobin is efficiently 

alkylated by sulfur mustard leading to an increase in 104 m/z after hydrolysis. This method is based on 

cleavage of globin by trypsin and micro-LC-MS analysis of the digests. 

7.2 ENVIRONMENTAL SAMPLES 

Table 7-2 presents a summary of several common analytical techniques used to analyze for sulfur mustard 

and its metabolites in environmental samples. 

Until recently, GC with FID, ECD, or FPD were the primary methods of analysis for sulfur mustard and 

its metabolites, with a colorimetric assay utilizing 4-(p-nitrobenzyl) pyridine also frequently used. 

GC/MS is more commonly used for detecting sulfur mustard and its metabolites in environmental 

samples. Separation by TLC, followed by detection with a 4-(p-nitrobenzyl) pyridine procedure, has been 

used qualitatively and quantitatively to detect sulfur mustard in the presence of other vesicant mustards 

(Sass and Stutz 1981; Stutz and Sass 1969). This technique has proved useful in detecting sulfur mustard 

in a variety of complex matrices (water, soil, plants) and has a detection limit of 1 μg/sample spot (Sass 

and Stutz 1981). In addition to being relatively sensitive and selective, it can be scaled up for preparative 

work and down for small samples. This gives it continued usefulness despite the advent of more 

sophisticated GC/MS techniques 
SULFUR MUSTARD 153 

7. ANALYTICAL METHODS 

Table 7-2. Analytical Methods for Determining Sulfur Mustard in 

Environmental Samples 

Analytical Sample Percent 

Sample matrix Preparation method method detection limit recovery Reference 

Air Collect in decalin solvent 

using double trap 

system 

Air Collect in diethyl 

succinate using double 

trap system 

Air Collection in Tenax GC 

in a glass tube; thermal 

desorption into GC 

Water Directly inject sample for 

thiodiglycol detection; 

extract with hexane and 

concentrate for detection 

of other compounds 

(metabolites) 

Water or vapor Extract with hexane 

Standard Dissolve standard of 

solutions and known purity in hexane 

vapors or chloroform (sulfur 

mustard and 

metabolites) 

Soil Extract with chloroform; 

sonicate (sulfur mustard 

and metabolites) 

No data 

Soil, plants, Separation by TLC 

water 

Sulfur mustard Extract with hexane; 

hydrolysate concentrate 

GC/ECD 0.2 ng/μL 

injected 

GC/FPD 0.2 ng/μL 

injected 

GC/FPD 10 ng/m3 

GC/FID 50 μg/L (ppb) 

GC/MS (CI) No data 

GC/FTIR No data 

GC/ECD 160 μg/L 

(water); 1 μg/L 

(vapor) 

GC/ECD About 160 μg/L 

GC/FPD (solution); about 

1 μg/L (vapor) 

GC/MS (CI) 5–10 ng/ 

injection 

GC/MS (EI) No data 

4-(p-nitro- 1 μg/sample 

benzyl) spot 

pyridine 

procedure 

GC/FID No data 

99.5–101.5% Casselman et al. 

1973 

98–101% Gibson et al. 

1974 

No data Fowler and Smith 

1990 

No data D'Agostino et al. 

1989 

D'Agostino et al. 

1989 

D'Agostino et al. 

1989 

No data Fisher et al. 1969 

No data Sass and Steger 

1982 

No data D'Agostino and 

Provost 1988b 

Vycudilik 1985 

No data Sass and Stutz 

1981; Stutz and 

Sass 1969 

No data D'Agostino and 

Provost 1988a 

CI = chemical ionization; ECD = electron capture detector; EI = electron impact; FID = flame ionization detector; 

FPD = flame photometric detector; FTIR = Fourier transform infrared spectroscopy; GC = gas chromatography; 

MS = mass spectrometry 
SULFUR MUSTARD 154 

7. ANALYTICAL METHODS 

GC with either FID, ECD, or FPD was the most common technique of the 1970s and early 1980s for 

determining the presence of sulfur mustard and its metabolites, and is still frequently used. It has been 

used to detect sulfur mustard in air by passing air through a solvent trap. Aliquots of the solvent are 

directly injected into the gas chromatograph to detect sulfur mustard (Casselman et al. 1973; Gibson et al. 

1974). With both ECD and FPD, recoveries were near 100%, and the detection limit was 0.2 ng/μL 

injected. Advantages of both were speed, simplicity, and reliability. However, the solvent producing the 

best results with ECD required ice-bath cooling to prevent solvent and sulfur mustard loss (Casselman et 

al. 1973). The solvent used with FPD had the advantage of allowing room temperature analysis (Gibson 

et al. 1974). 

GC was used to detect sulfur mustard in water (Fisher et al. 1969) and soil (D'Agostino and Provost 

1988a). Using GC/ECD, a minimum detection limit (quantifiable) of 160 μg/L (ppb) for aqueous 

solutions and 1 μg/L for vapor was obtained. The method used was simple, selective, and precise. The 

authors proposed that with appropriate sample preparation, it could be used for a variety of media, 

including soil and biological media (Fisher et al. 1969). Sulfur mustard and metabolites were detected in 

soil by GC/FID by D'Agostino and Provost (1988a), who also analyzed a hydrolysate remaining from the 

destruction of munitions grade mustard, but no details on accuracy, precision, or sensitivity were given. 

A comparison of the various detectors used to analyze for sulfur mustard and its metabolites was 

conducted and showed ECD to be the most sensitive for detecting sulfur mustard in a mixture of mustard 

compounds, followed by FPD and FID (Sass and Steger 1982). The detection limit using ECD and FPD 

was in the mid-ppb range (about 160 μg/L) for solutions and in the low ppb range (about 1 μg/L) for 

vapors. Beck et al. (2001) found that GC-FPD provided a rapid and sensitive method for analysis of 

thiodiglycol (TDG) in soil extracts with a detection limit of 1.1 μg/g soil. Pressurized liquid extraction 

(PLE) with methanol-water (9:1) proved to be the most efficient solvent for TDG extraction with 

recoveries ranging from 12 to 89% of added TDG for various soil types. 

GC/MS has been used to analyze for the presence of sulfur mustard and its metabolites (D'Agostino and 

Provost 1988b; D'Agostino et al. 1989; Munavalli and Jakubowski 1989; Vycudilik 1985). Tests with 

pure substances have supported the sensitivity, selectivity, and reliability of this technique, and analysis 

of pure samples has proved its usefulness. Inclusion of deuterated thiodiglycol as an internal standard 

increases the precision of GC/MS and makes the technique quantitative as opposed to simply semiquantitative. Both chemical ionization (CI) and electron impact (EI) have been used to detect sulfur 

mustard and its characteristic metabolites in samples. Detection of specific mustard metabolites is 

important in determining sulfur mustard exposure since the chemical can degrade rapidly under certain 
SULFUR MUSTARD 155 

7. ANALYTICAL METHODS 

environmental conditions. Testing of several EI and CI techniques showed that MS was a sensitive, 

reliable, and precise detection method for sulfur mustard (Ali-Mattila et al. 1983). This was supported in 

later studies on sample mixtures of vesicant mustards and degradation products, as well as on water and 

soil samples (D'Agostino and Provost 1988b, 1992; D'Agostino et al. 1989; Munavalli and Jakubowski 

1989; Vycudilik 1985). For example, D’Agostino and Provost (1992) used GC/MS for verification of 

sulfur mustard and its hydrolysis products in soil. They used sequential hexane and dichloromethane 

extraction followed by trimethylsilyl derivatization and achieved total recoveries in the 50–90% range for 

most soil types. Wils et al. (1992) used GC/MS to analyze sulfur mustard in rubber and paint samples in 

combination with diesel fuel and aromatic white spirit as a background. Sulfur mustard was isolated by 

extraction with methylene chloride or by dynamic headspace analysis at elevated temperatures. 

Recoveries of sulfur mustard in rubber and paint ranged from 57 to 86%. Black et al. (1993b) analyzed 

soil, bomb casing, and sheep wool samples associated with a chemical weapons agent (CWA) incident 

(obtained from a Kurdish village in the northern part of Iraq in 1988) by GC/MS using headspace 

analysis, solvent extraction, and thermal desorption methods. Using this technique, the presence of sulfur 

mustard and 21 related compounds were successfully confirmed in these samples. 

Sulfur mustard vapor is typically determined in air by bubbling an air sample through a liquid solvent and 

analyzing the solvent for absorbed mustard by colorimetry or by GC. However, the colorimetric 

technique lacks specificity and the solvent entrapment sampling technique possesses a number of 

drawbacks such as limited analyte-trapping efficiency, high detection limits, and degradation of the 

analyte (Fowler and Smith 1990). Rapid and accurate methodologies for the detection of sulfur mustard 

have been developed for use during the demilitarization of mustard stockpiles at U.S. storage sites. These 

procedures are based largely on the Depot Area Air Monitoring System (DAAMS) technology (Smith et 

al. 1982). DAAMS procedures have undergone extensive Precision and Accuracy studies (Smith and 

Fowler 1985) and are methods of choice in current and future demilitarization sites. The sampling and 

analysis process for DAAMS consists of (1) collection of the airborne sample on the sorbent (Tenax GC) 

in a glass tube, (2) transfer to a glass tube containing smaller amounts of the same sorbent using an 

external thermal desorber, and (3) thermal desorption in a specially-modified injection port of a gas 

chromatograph and subsequent analysis using a flame photometric detector (Fowler and Smith 1990; 

Posner 1991). The detection limit of sulfur mustard vapor in air by these procedures is about 10 ng/m3

 (or 

1.5 parts per trillion). 

While GC/MS continues to be the definitive method for assessment of sulfur mustard in environmental 

matrixes, increasing emphasis has been placed on rapid screening procedures such as liquid 
 

SULFUR MUSTARD 156 

7. ANALYTICAL METHODS 

chromatography/mass spectrometry (LC/MS). Although LC/MS methods typically have higher detection 

limits, these techniques allow for more rapid screening of aqueous samples and extracts, with minimum 

sample pretreatment and no requirement for dehydration or derivatization (Burrows 1998). Electrospray 

ionization, thermospray ionization (TSP), and atmospheric pressure chemical ionization (APCI) have 

shown promise as interfaces for the introduction of the liquid solvent stream containing sulfur mustard 

and metabolites into the mass spectrometer (Munavalli et al. 1995; Smith and Shih 2001). For example, 

liquid chromatograph/electrospray-mass spectrometry (LC/ESP-MS) was recently recommended as a 

rapid screening procedure for verification of the presence of traces of the agent in hydrolysis products in 

water without derivatization (Borrett et al. 1996). It has also been successfully applied for the direct 

detection of sulfonium ions formed during the storage and hydrolysis of sulfur mustard (Rohrbaugh and 

Yang 1997). Black and Read (1997) recently demonstrated a rapid screening procedure for sulfur 

mustard, which involves separation by liquid chromatography and detection by atmospheric pressure 

chemical ionization-mass spectrometry (HPLC/APCI-MS). Sulfur mustard and its transformation 

products have been characterized by liquid chromatography/thermospray ionization-mass spectrometry 

(LC/TSP-MS) in methanol. In both positive and negative modes, a rich complex ion chemistry was 

observed for the transformation products of sulfur mustard (Munavalli et al. 1995). 

Other techniques that have been used to characterize sulfur mustard and its metabolites include capillary 

electrophoresis (CE) and secondary ion mass spectrometry (SIMS). CE coupled with MS detection is 

well suited to deal directly with aqueous samples and polar (acidic) degradation products (Hooijschuur et 

al. 2001). SIMS analysis of solid samples has evidenced the presence of sulfonium ion aggregates 

resulting from nucleophilic substitution processes (Groenwold et al. 1995). This method also may 

potentially be able to detect sulfur mustard directly on soil surfaces without the necessity of lengthy 

extraction procedures (Gresham et al. 2001). 

7.3 ADEQUACY OF THE DATABASE 

Section 104(i)(5) of CERCLA, as amended, directs the Administrator of ATSDR (in consultation with the 

Administrator of EPA and agencies and programs of the Public Health Service) to assess whether 

adequate information on the health effects of sulfur mustard is available. Where adequate information is 

not available, ATSDR, in conjunction with the National Toxicology Program (NTP), is required to assure 

the initiation of a program of research designed to determine the health effects (and techniques for 

developing methods to determine such health effects) of sulfur mustard. 
SULFUR MUSTARD 157 

7. ANALYTICAL METHODS 

The following categories of possible data needs have been identified by a joint team of scientists from 

ATSDR, NTP, and EPA. They are defined as substance-specific informational needs that if met would 

reduce the uncertainties of human health assessment. This definition should not be interpreted to mean 

that all data needs discussed in this section must be filled. In the future, the identified data needs will be 

evaluated and prioritized, and a substance-specific research agenda will be proposed. 

7.3.1 Identification of Data Needs 

Methods for Determining Biomarkers of Exposure and Effect. 

Exposure. Available information indicates that sensitive, selective, and reliable methods for determining 

biomarkers of exposure exist for sulfur mustard and its metabolites (Black and Read 1991, 1995a, 1995b; 

Black et al. 1992a, 1992b, 1993b, 1994; Kientz 1998; Ludlum et al. 1994). Available studies emphasize 

detection and quantification of the compound and its metabolites. Further studies that attempt to quantify 

levels in exposed and unexposed populations are useful in assessing the risk associated with sulfur 

mustard and its metabolites. 

Effect. As discussed, sensitive, selective, and reliable methods exist for detecting sulfur mustard and its 

metabolites in biological tissues and fluids. Available studies do not emphasize quantifying the levels of 

these compounds and associating the amounts found with specific biomarkers of effect. Further studies 

associating specific levels in fluids and tissues with known effects are useful in assessing the risk 

associated with sulfur mustard and its metabolites. 

Methods for Determining Parent Compounds and Degradation Products in Environmental Media. 

Sensitive, selective, and reliable methods exist for detecting sulfur mustard and its metabolites in air 

(Casselman et al. 1973; Gibson et al. 1974), water (Fisher et al. 1969; Sass and Stutz 1981; Stutz and Sass 

1969), and soil (D'Agostino and Provost 1988a; Sass and Stutz 1981; Stutz and Sass 1969). No 

information was obtained on the detection of sulfur mustard in other environmental media. The available 

methods emphasize qualitative and quantitative detection. Further studies to improve the detection of 

sulfur mustard and its metabolites will aid in assessing the potential risk of sulfur mustard in the 

environment, especially near hazardous waste facilities and Army storage facilities. 
SULFUR MUSTARD 158 

7. ANALYTICAL METHODS 

7.3.2 Ongoing Studies 

No ongoing studies on the analysis of sulfur mustard in biological and environmental matrixes were 

located in the Federal Research in Progress (FEDRIP) database. 
SULFUR MUSTARD 159 

8. REGULATIONS AND ADVISORIES 

Sulfur mustard is on the list of chemicals appearing in "Toxic Chemicals Subject to Section 313 of the 

Emergency Planning and Community Right-to-Know Act of 1986" (EPA 1987). Available information 

on regulations and standards is presented in Table 8-1. 

ATSDR has derived an acute inhalation MRL of 0.0007 mg/m3

 for sulfur mustard based on a minimal 

LOAEL of 0.06 mg/m3

 for ocular effects in humans that were exposed to sulfur mustard vapors 

8 hours/day, for 3 days (Guild et al. 1941). The LOAEL was duration-adjusted to a time-weighted 

average (TWA) of 0.02 mg/m3 and an uncertainty factor of 30 (3 for use of a minimal LOAEL and 10 for 

human variability) was applied to the TWA minimal LOAEL to derive the MRL (see Appendix A for 

details). 

ATSDR has derived an intermediate-duration inhalation MRL of 0.00002 mg/m3

 for sulfur mustard based 

on a NOAEL of 0.001 mg/m3

 for ocular effects in dogs that were exposed to sulfur mustard vapors 

24 hours/day, 5 days/week, for up to a year (McNamara et al. 1975). The NOAEL was duration-adjusted 

to a daily TWA of 0.0007 mg/m3 and an uncertainty factor of 30 (3 for extrapolation from animals to 

humans and 10 for human variability) was applied to the TWA NOAEL to derive the MRL (see 

Appendix A for details). 

ATSDR has derived an acute oral MRL of 0.0005 mg/kg/day (0.5 μg/kg/day) for sulfur mustard based on 

a LOAEL of 0.5 mg/kg/day for inflamed mesenteric lymph nodes in rat dams and reduced ossification in 

fetuses that were exposed for 10 days (DOA 1987). The test material was administered by gavage in oil 

on gestation days 6–15. An uncertainty factor of 1,000 (10 for use of a LOAEL, 10 for extrapolation 

from animals to humans, and 10 for human variability) was applied to the LOAEL to derive the MRL (see 

Appendix A for details). 

An intermediate-duration oral MRL for sulfur mustard of 0.00007 mg/kg/day (0.07 μg/kg/day) was based 

on a TWA LOAEL of 0.02 mg/kg/day for gastrointestinal effects in rats exposed by gavage for a 21-week 

period (Sasser et al. 1996a). An uncertainty factor of 300 (10 for use of a LOAEL, 3 for extrapolation 

from animals to humans, and 10 for human variability) was applied to the TWA LOAEL to derive the 

MRL (see Appendix A for details). 
 

 

 

 

 

SULFUR MUSTARD 160 

8. REGULATIONS AND ADVISORIES 

Table 8-1. Regulations and Guidelines Applicable to Sulfur Mustard 

Agency Description Information References 

INTERNATIONAL 

Guidelines: 

IARC 

NATIONAL 

Carcinogenicity classification Group 1a

 IARC 2001 

Regulations and 

Guidelines: 

a. Air 

ACGIH TLV-TWA No data 

NIOSH REL No data 

OSHA 

b. Water 

PEL (TWA) No data 

No data 

c. Food No data 

d. Other 

BEA Chemical Weapons Convention 

requirements; schedules of 

chemicals 

 BEA 2001 

15CFR745 

DOS International traffic in arms DOS 2001 

DOT 

regulations; United States 

munitions list; chemical agents 

Hazardous materials table 

22CFR121.7 

DOT 2001 

49CFR172.101 

EPA CERCLA; reportable quantity 500 pounds EPA 2001a 

40CFR355 Appendix 

B 

Groundwater protection standards 

at inactive uranium processing 

sites 

SARA; extremely hazardous 

substance (TPQ) 

RCRA; identification and listing as 

hazardous waste 

500 pounds 

 EPA 2001b 

40CFR192, 

Appendix I 

EPA 2001a 

40CFR355, 

Appendix B 

 EPA 2001c 

40CFR261, 

Appendix VIII 

Toxic chemical release reporting; 

Community Right-to-Know; 

effective date 

01/01/87 EPA 2001d 

40CFR372.65 

NTP 

OSHA 

Carcinogenic classification 

Meets criteria for proposed 

medical records rule

Known to be a 

human carcinogen 

NTP 2001 

 OSHA 1982 

VA Claims based on chronic effects of VA 2001 

exposure 38CFR3.316 
 

 

 

 

SULFUR MUSTARD 161 

8. REGULATIONS AND ADVISORIES 

Table 8-1. Regulations and Guidelines Applicable to Sulfur Mustard 

Agency Description Information References 

STATE 

Regulations and 

Guidelines: 

a. Air 

Colorado 

 Connecticut 

Maryland 

b. Water 

New York 

c. Food 

d. Other 

Alabama 

Arkansas 

California 

Colorado 

District of Columbia 

Delaware 

Florida 

Georgia 

Illinois 

Kentucky 

Louisiana 

Maine 

Massachusetts 

Massachusetts 

Maryland 

Air contaminant emission notice 

HAP 

Toxic air pollutant 

Water regulation 

TPQ 

RQ 

Identification and listing of 

hazardous waste 

Identification and listing of 

hazardous waste 

Chemical known to cause cancer 

or reproductive toxicity; initial 

appearance of chemical on list 

Hazardous substance list 

Identification and listing of 

hazardous waste 

Identification and listing of 

hazardous waste 

Reportable quantity 

Toxic substances in the workplace 

Regulated substance and soil 

concentration that trigger 

notification 

Identification and listing of 

hazardous waste 

Extremely hazardous substance 

(TPQ) 

Identification and listing of 

hazardous waste 

Hazardous waste 

Identification and listing of 

hazardous waste 

Containers adequately labeled 

pursuant to federal law 

Oil and hazardous material list 

Identification and listing of 

hazardous waste 

Known human 

carcinogen 

1 pound 

1 pound 

No data 

02/27/87 

1 pound 

500 pounds 

BNA 2001 

BNA 2001 

BNA 2001 

BNA 2001 

 BNA 2001 

 BNA 2001 

BNA 2001 

BNA 2001 

 BNA 2001 

 BNA 2001 

BNA 2001 

BNA 2001 

 BNA 2001 

 BNA 2001 

BNA 2001 

 BNA 2001 

BNA 2001 

 BNA 2001 

 BNA 2001 

BNA 2001 

 BNA 2001 
 

SULFUR MUSTARD 162 

8. REGULATIONS AND ADVISORIES 

Table 8-1. Regulations and Guidelines Applicable to Sulfur Mustard 

Agency Description Information References 

STATE (cont.) 

Michigan Identification and listing of BNA 2001 

hazardous waste 

Minnesota Hazardous constituent BNA 2001 

Nebraska Hazardous constituent BNA 2001 

New Jersey Discharge of oil and other BNA 2001 

hazardous substances

North Dakota Identification and listing of BNA 2001 

hazardous waste 

Ohio Toxic release inventory rules BNA 2001 

Oregon Toxic use reduction and BNA 2001 

hazardous reduction regulations 

South Carolina Identification and listing of BNA 2001 

hazardous waste 

Tennessee Identification and listing of BNA 2001 

hazardous waste 

Vermont Hazardous waste management BNA 2001 

regulation 

Washington Dangerous waste regulations BNA 2001 

Wisconsin Identification and listing of BNA 2001 

hazardous waste 

Wyoming Identification and listing of BNA 2001 

hazardous waste 

a

Group 1: Carcinogenic to humans 

ACGIH = American Conference of Governmental Industrial Hygienists; BEA = Bureau of Export Administration; 

BNA = Bureau of National Affairs; CERCLA = Comprehensive Environmental Response, Compensation, and Liability 

Act; CFR = Code of Federal Regulations; DOS = Department of State; DOT = Department of Transportation; 

EPA = Environmental Protection Agency; HAP = hazardous air pollutant; IARC = International Agency for Research 

on Cancer; NIOSH = National Institute of Occupational Safety and Health; NTP = National Toxicology Program; 

OSHA = Occupational Safety and Health Administration; PEL = permissible exposure limit; RCRA = Resource 

Conservation and Recovery Act; REL = relative exposure limit; RQ = reportable quantity; SARA = Superfund 

Amendments and Reauthorization Act; TPQ = threshold planning quantity; TLV = threshold limit values; TWA = timeweighted average; VA = Department of Veteran Affairs 
SULFUR MUSTARD 163 

8. REGULATIONS AND ADVISORIES 

ATSDR has not derived a chronic oral MRL for sulfur mustard because a chronic bioassay was not 

located. 

The acute exposure guideline levels (AEGLs) for sulfur mustard, which were developed by the National 

Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, are presented in 

Table 8-2. A more detailed discussion of these AEGLs is presented in Appendix D. 

The Army has recommended sulfur mustard airborne exposure limits for agent workers (WPL) and the 

general population (GPL) for chronic exposures to provide adequate protection during the limited time of 

potential exposure prior to the completion of the Chemical Stockpile Demilitarization Program 

(USACHPPM 2000a, 2003). For the general population, a sulfur mustard GPL of 0.00002 mg/m3

 as a 

24-hour TWA, 7 days/week, has been established. For agent workers, the WPL established for sulfur 

mustard as an 8-hour TWA, 5 days/week, is 0.0004 mg/m3

. In addition, the Army has established a Short 

Term Exposure Limit (STEL) of 0.003 mg/m3

 and an Immediately Dangerous to Life and Health (IDLH) 

value of 2.0 mg/m3

 for sulfur mustard agents. Previously established airborne exposure limits for sulfur 

mustard agents were promulgated by the Centers for Disease Control and Prevention (CDC) in 1988 

(DHHS 1988). 

The International Agency for Research on Cancer (IARC) has classified sulfur mustard as carcinogenic to 

humans (Group 1), based on sufficient evidence for carcinogenicity to humans and limited evidence for 

carcinogenicity to animals (IARC 1975, 1987, 2001). 

The U.S. Army has derived health-based environmental screening levels (HBESLs) for sulfur mustard 

(USACHPPM 1999) as shown in Table 8-3. Ongoing evaluations of alternative approaches for 

quantitatively estimating noncancer and cancer risk may result in changes to these values (USACHPPM 

2000a). 
SULFUR MUSTARD 164 

8. REGULATIONS AND ADVISORIES 

Table 8-2. Acute Exposure Guideline Level (AEGL) Values for Sulfur Mustard 

(ppm [mg/m3]) 

End point 

Classification 10-minute 30-minute 1-hour 4-hour 8-hour (reference) 

AEGL-1 0.06 ppm 0.02 ppm 0.01 ppm 0.003 ppm 0.001 ppm Conjunctival injection 

(0.40) (0.13) (0.067) (0.017) (0.008) and minor discomfort 

with no functional 

decrement in 

volunteers (Anderson 

1942) 

AEGL-2 0.09 ppm 0.03 ppm 0.02 ppm 0.004 ppm 0.002 ppm Well-marked 

(0.60) (0.20) (0.10) (0.025) (0.013) generalized 

conjunctivitis, edema, 

photophobia, and eye 

irritation in volunteers 

(Anderson 1942) 

AEGL-3 0.59 ppm 0.41 ppm 0.32 ppm 0.08 ppm 0.04 ppm Lethality estimate in 

(3.9) (2.7) (2.1) (0.53) (0.27) mice (Kumar and 

Vijayaraghavan 1998) 

Source: NAC/AEGL 2001 
SULFUR MUSTARD 165 

8. REGULATIONS AND ADVISORIES 

Table 8-3. U.S. Army Toxicity Values for Sulfur Mustard 

Parameter Value Units 

Oral reference dose 0.000007 mg/kg/day 

Inhalation reference dose 0.00003 mg/kg/day 

Cancer potency oral slope factor 7.7 (mg/kg/day)-1 

Cancer potency inhalation unit risk 0.085 (μg/m3

)

-1 

Cancer potency inhalation slope factor 300 (mg/kg/day)-1 

Source: USACHPPM 1999 
SULFUR MUSTARD 166 

8. REGULATIONS AND ADVISORIES 

On October 17, 1986, the President signed into law the Superfund Amendments and Reauthorization Act 

of 1986 (SARA). This act amended the Comprehensive Environmental Response, Compensation and 

Liability Act of 1980 (CERCLA), commonly known as "Superfund". The Emergency Planning and 

Community Right-to-Know Act of 1986 (EPCRA) was included under Title III of SARA. 

EPA has established a reportable quantity (RQ) for sulfur mustard of 500 pounds under the CERCLA 

section 103, codified at 40 CFR part 302, in addition to the requirements of 40 CFR part 355, and 

regulates it as a hazardous constituent of waste under the Resource Conservation and Recovery Act 

(RCRA, 40 CFR 261). 

EPA regulates sulfur mustard under the SARA, subjecting it to reporting requirements. Emergency 

response plans are required under SARA if the threshold planning quantity (TPQ) of 500 pounds is 

exceeded. 

Under EPCRA, release of sulfur mustard must be reported according to EPA toxic chemical release 

reporting regulations (40 CFR 372.65). 

Sulfur mustard is included as a constituent regulated under the groundwater protection standards for 

inactive uranium processing sites (40 CFR 192). 

OSHA regulates sulfur mustard under the Hazard Communication Standard and as a chemical hazard in 

laboratories. 

The Department of Veterans Affairs regulates compensation based on chronic effects of exposure to 

sulfur mustard (38 CFR 3.316). 
 

_______________________ 

SULFUR MUSTARD 167 

9. REFERENCES 

Aasted A, Darre E, Wulf HC. 1987. Mustard gas clinical toxicological and mutagenic aspects based on 

modern experience. Ann Plast Surg 19:330-333. 

*Aasted A, Wulf HC, Darre E, et al. 1985. [Fishermen exposed to mustard gas. Clinical experience and 

evaluation of the cancer risk.] Ugeskrift for Laeger 147:221-2216. (Dutch) 

Abe Y, Sugisaki K, Dannenberg AM. 1996. Rabbit vascular endothelial adhesion molecules: ELAM-1 

is most elevated in acute inflammation, whereas VCAM-1 and ICAM-1 predominate in chronic 

inflammation. J Leukoc Biol 60:692-703. 

Abramowicz M. 2002. Prevention and treatment of injury from chemical warfare agents. The Medical 

Letter: On drugs and therapeutics 44(1121):1-4. 

*Adinolfi M. 1985. The development of the human blood-CSF-brain barrier. Dev Med Child Neurol 

27:532-537. 

*Adlercreutz H. 1995. Phytoestrogens: Epidemiology and a possible role in cancer protection. Environ 

Health Perspect Suppl 103(7):103-112. 

*Agency for Toxic Substances and Disease Registry. 1989. Decision guide for identifying substancespecific data needs related to toxicological profiles: Notice. Fed Regist 54(174):37618-37634. 

*Agency for Toxic Substances and Disease Registry. 1990. Biomarkers of organ damage or dysfunction 

for the renal, hepatobiliary, and immune systems. Subcommittee on Biomarkers of Organ Damage and 

Dysfunction. 

*Alexander SF. 1947. Medical report of the Bari Harbor mustard casualties. Military Surgeon 101:1-17. 

*Ali-Mattila E, Siivinen K, Kenttamaa H, et al. 1983. Mass spectrometric methods in structural analysis 

of some vesicants. Int J Mass Spectrom Ion Phys 47:371-374. 

*Allon N, Gilat E, Amir A, et al. 1993. Sulfur mustard inhalation induced respiratory lesions in guinea 

pigs: Physiological, biochemical and histological study. In: Proceedings of the medical defense 

bioscience review (1993) held in Baltimore, Maryland on 10-13 May 1993. Volume 1. Springfield, VA: 

US Department of Commerce, 133-139 

*Altman PL, Dittmer DS. 1974. In: Biological handbooks: Biology data book. Vol. III. 2nd ed. 

Bethesda, MD: Federation of American Societies for Experimental Biology, 1987-2008, 2041. 

Altus Biologics Inc. 2000. Stabilized crystalline OPAA-2 for additive in topical skin protectant. 

ADB261408. 

*Amalric P, Bessou P, Farenc M. 1965. [Delayed relapsing mustard gas keratitis.] Bull Soc Ophtal 

Franc 65:101-106. (French) 

*Cited in text 
SULFUR MUSTARD 168 

9. REFERENCES 

Amir A, Chapman S, Gozes Y, et al. 1998. Protection by extracellular glutathione against sulfur mustard 

induced toxicity in vitro. Hum Exp Toxicol 17:652-660. 

*Andersen ME, Krishnan K. 1994. Relating in vitro to in vivo exposures with physiologically based 

tissue dosimetry and tissue response models. In: Salem H, ed. Animal test alternatives: Refinement, 

reduction, replacement. New York: Marcel Dekker, Inc., 9-25. 

*Andersen ME, Clewell HJ III, Gargas ML, et al. 1987. Physiologically based pharmacokinetics and the 

risk assessment process for methylene chloride. Toxicol Appl Pharmacol 87:185-205. 

*Anderson JS. 1942. The effect of mustard gas vapour on eyes under Indian hot weather conditions. 

CDRE (India)- Report No. 241. 

Anderson DR, Byers SL, Clark CR, et al. 1997. Biochemical alterations in rat lung lavage fluid 

following acute sulfur mustard inhalation. Inhal Toxicol 9:43-51. 

Anderson DR, Yourick JJ, Moeller RB, et al. 1996. Pathologic changes in rat lungs following acute 

sulfur mustard inhalation. Inhal Toxicol 8:285-297. 

Andrew DJ, Lindsay CD. 1998. Protection of human upper respiratory tract cell lines against sulphur 

mustard toxicity by hexamethylenetetramine (HMT). Hum Exp Toxicol 17:373-379. 

Anft M. 1988. Burnt offerings: A generation of chemical weapons is scheduled to go up in smoke. 

Environmental Action 11-13. 

*Angelov A, Belchev L, Angelov G. 1996a. Study of some toxic effects of sulfur mustard gas on broiler 

chickens. Vet Archiv 66:27-34. 

Angelov A, Belchev L, Angelov G. 1996b. Experimental sulfur mustard gas poisoning and protective 

effect of different medicines in rats and rabbits. Indian Vet J 73:546-551. 

*Anslow WP, Houck CR. 1946. Systemic pharmacology and pathology of sulfur and nitrogen mustards. 

In: Chemical warfare agents and related chemical problems. Part 4. Chapter 22. U.S. Office of 

Scientific Research and Development. Washington, DC: National Defense Research Committee, 440­

478. 

*Arroyo CM, Schafer RJ, Carmichael AJ. 2000. Reactivity of chloroethyl sulfides in the presence of a 

chlorinated prophylactic: a kinetic study by EPR/spin trapping and NMR techniques. J Appl Toxicol 

20:S7-S12. 

Arroyo CM, Schafer RJ, Kurt EM, et al. 1999. Response of normal human keratinocytes to sulfur 

mustard (HD): Cytokine release using a non-enzymatic detachment procedure. Hum Exp Toxicol 18:1­

11. 

*Ashby J, Tinwell H, Callander RD, et al. 1991. Genetic activity of the human carcinogen sulphur 

mustard towards salmonella and the mouse bone marrow. Mutat Res 257:307-311. 

Atkinson R. 1987. A structure-activity relationship for the estimation of rate constants for the gas-phase 

reactions of OH radicals with organic compounds. Int J Chem Kinet 19:799-828. 
SULFUR MUSTARD 169 

9. REFERENCES 

*Auerbach C. 1947. The induction by mustard gas of chromosomal instabilities in Drosophila 

melanogaster. Proc R Soc Edinb 62B:307-320. 

Auerbach C, Robson JM. 1946. Tests of chemical substances for mutagenic action. 1946/1947 

Proceedings of the Royal Society Edinburgh, Section B 62:284-291. 

Augerson WS, Sivak A, Marley WS. 1986. Chemical casualty treatment protocol developmenttreatment approaches. Vol II-IV. Cambridge, MA: Arthur D. Little, Inc. 

Axelrod DJ, Hamilton JG. 1947. Radio-autographic studies of the distribution of lewisite and mustard 

gas in skin and eye tissues. Am J Pathol 23:389-411. 

*Azizi F, Amini M, Arbab P. 1993. Time course of changes in free thyroid indices, rT3, TSH, and 

ACTH following exposure to sulfur mustard. Exp Clin Endocrinol 101:303-306. 

*Azizi F, Keshavarz A, Roshanzamir F, et al. 1995. Reproductive function in men following exposure to 

chemical warfare with sulphur mustard. Med War 11:34-44. 

Back KC, Thomas AA, MacEwen JD. 1972. Reclassification of material listed as transportation health 

hazards. Office of Hazardous Materials of the Assistant Secretary for Safety and Consumer Affairs, 

Department of Transportation. TSA-2072-3, PB214270. 

*Balali-Mood M. 1986. First report of delayed toxic effects of yperite poisoning in Iranian fighters. In: 

Heyndricks B, ed. Terrorism: Analysis and detection of explosives. Proceedings of the Second World 

Congress on new compounds in biological and chemical warfare. Gent: Rijksuniversiteit. 489-495. 

*Ball CR, Roberts JJ. 1971/72. Estimation of interstrand DNA cross-linking resulting from mustard gas 

alkylation of HeLa cells. Chem Biol Interact 4:297-303. 

*Barnes DG, Dourson M. 1988. Reference dose (RfD): Description and use in health risk assessments. 

Regul Toxicol Pharmacol 8:471-486. 

*Bartlett PD, Swain CG. 1949. Kinetics of hydrolysis and displacement reactions of β,β'-dichlorodiethyl 

sulfide (mustard gas) and of β-chloro-β'-hydroxydiethyl sulfide (mustard chlorohydrin). J Am Chem Soc 

71:1406-1415. 

*Baskin SI, Prabhaharan V, Bowman JD, et al. 2000. In vitro effects of anionic sulfur compounds on the 

spectrophotometric properties of native DNA. J Appl Toxicol 20:S3-S5. 

Battista SP, McSweeney ES Jr. 1965. Approaches to a quantitative method for testing eye irritation. J 

Soc Cosmet Chem 16:119-131. 

*BEA. 2001. Chemical Weapons Convention requirements. Schedules of chemicals. U.S. Bureau of 

Export Administration. Code of Federal Regulations. 15 CFR 745. 

http://ecfr.access.gpo.gov/otcgi/cfr/otfilter.cgi?DB=...andI&QUERY=8180&RGN=BAPPCT&SUBSET= 

SUBSET&FROM=1&ITEM=1. May 24, 2001. 

*Beck NV, Carrick WA, Cooper DB, et al. 2001. Extraction of thiodiglycol from soil using pressurized 

liquid extraction. J Chromat 907:221-227. 
SULFUR MUSTARD 170 

9. REFERENCES 

*Beebe GW. 1960. Lung cancer in World War I veterans: Possible relation to mustard gas injury and 

1918 influenza epidemic. J Natl Cancer Inst 25:1231-1252. 

Belcher DW. 1977. Spray drying of war gas residue. CEP 101-104. 

*Benschop HP, van der Schans GP, Noort D, et al. 1997. Verification of exposure to sulfur mustard in 

two casualties of the Iran-Iraq Conflict. J Anal Toxicol 21:249-251. 

Berenblum I. 1931. The anti-carcinogenic action of dichlorodiethylsulphide (mustard gas). J Pathol 

Bacteriol 34:731-746. 

Berenblum I. 1935. Experimental inhibition of tumor induction by mustard gas and other compounds. J 

Pathol Bacteriol 40:549-558. 

*Berger GS. 1994. Epidemiology of endometriosis. In: Berger GS, ed. Endometriosis: Advanced 

management and surgical techniques. New York, NY: Springer-Verlag. 

*Bhat KR, Benton BJ, Rosenthal DS, et al. 2000. Role of poly (ADP-ribose) polymerase (PARP) in 

DNA repair in sulfur mustard-exposed normal human epidermal keratinocytes (NHEK). J Appl Toxicol 

20:S13-S18. 

Bhattacharya R, Rao LPV, Pant SC, et al. 2001. Protective effects of amifostine and its analogues on 

sulfur mustard toxicity in vitro and in vivo. Toxicol Appl Pharmacol 176:24-33. 

*Bide RW, Sawyer TW, DiNinno VL, et al. 1993. Skin decontamination of G, V, H & L agents by 

Canadian reactive skin decontamination lotion. In: Proceedings of the medical defense bioscience 

review (1993) held in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, VA: US 

Department of Commerce, 379-387. 

*Black RM, Read RW. 1991. Methods for the analysis of thiodiglycol sulphoxide, a metabolite of 

sulphur mustard, in urine using gas chromatography-mass spectrometry. J Chromatogr 558:393-404. 

*Black RM, Read RW. 1995a. Biological fate of sulphur mustard, 1,1'-thiobis(2-chloroethane): 

Identification of β-lyase metabolites and hydrolysis products in human urine. Xenobiotica 25(2):167-173. 

*Black RM, Read RW. 1995b. Improved methodology for the detection and quantization of urinary 

metabolites of sulphur mustard using gas chromatography-tandem mass spectrometry. J Chromatogr 

665:97-105. 

*Black RM, Read RW. 1997. Application of liquid chromatography-atmospheric pressure chemical 

ionization mass spectrometry, and tandem mass spectrometry, to the analysis and identification of 

degradation products of chemical warfare agents. J Chromatogr 759:79-92. 

*Black RM, Brewster K, Clarke RJ, et al. 1992a. Biological fate of sulphur mustard, 1,1'-thiobis(2­

chloroethane): Isolation and identification of urinary metabolites following intra peritoneal 

administration to rat. Xenobiotica 22(4):405-418. 

Black RM, Brewster K, Clarke RJ, et al. 1993a. Metabolism of thiodiglycol (2,2'-thiobis-ethanol): 

Isolation and identification of urinary metabolites following intra peritoneal administration to rat. 

Xenobiotica 23(5):473-481. 
 

 

SULFUR MUSTARD 171 

9. REFERENCES 

*Black RM, Clarke RJ, Cooper DB, et al. 1993b. Application of head space analysis, solvent extraction, 

thermal desorption and gas chromatography-mass spectrometry to the analysis of chemical warfare 

samples containing sulphur mustard and related compounds. J Chromatogr 637:71-81. 

*Black RM, Clarke RJ, Harrison JM, et al. 1997a. Biological fate of sulphur mustard: Identification of 

valine and histidine adducts in hemoglobin from casualties of sulphur mustard poisoning. Xenobiotica 

27(5):499-512. 

*Black RM, Clarke RJ, Read RW. 1991. Analysis of 1,1'-sulphonylbis[2-(methylsulphinyl)ethane] and 

1-methylsulphinyl-2-[2-(methylthio)ethylsulphonyl]ethane, metabolites of sulphur mustard, in urine using 

gas chromatography-mass spectrometry. J Chromatogr 558:405-414. 

*Black RM, Clarke RJ, Read RW, et al. 1994. Application of gas chromatography-mass spectrometry 

and gas chromatography-tandem mass spectrometry to the analysis of chemical warfare samples, found to 

contain residues of the nerve agent sarin, sulphur mustard and their degradation products. J Chromatogr 

662:301-321. 

*Black RM, Hambrook JL, Howells DJ, et al. 1992b. Biological fate of sulfur mustard, 1,1'-thiobis(2­

chloroethane). Urinary excretion profiles of hydrolysis products and β-lyase metabolites of sulfur 

mustard after cutaneous application in rats. J Anal Toxicol 16:79-84. 

*Black RM, Harrison JM, Read RW. 1997b. Biological fate of sulphur mustard: In vitro alkylation of 

human hemoglobin by sulphur mustard. Xenobiotica 27(1):11-32. 

Blair A, Kazerouni N. 1997. Reactive chemicals and cancer. Cancer Causes Control 8:473-490. 

*Blank JA, Lane LA, Olson CT. 1996. Protein alterations in weanling pig skin following percutaneous 

sulfur mustard exposure. Medical Research and Evaluation Facility. Columbus, OH. 

*BNA. 2001. Environment and Safety Library on the Web States and Territories. Washington, D.C. 

Bureau of National Affairs, Inc. http://www.esweb.bna.com/. February 23, 2001. 

Bodell WJ, Gerosa M, Aida T, et al. 1985. Investigation of resistance to DNA cross-linking agents in 9L 

cell lines. Cancer Res 45:3460. 

Bongiovanni R, Millard CB, Schultz SM, et al. 1993. Estimation of neutrophil infiltration into hairless 

guinea pig skin treated with 2,2'-dichlorodiethyl sulfide. In: Proceedings of the medical defense 

bioscience review (1993) held in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, VA: US 

Department of Commerce, 389-395. 

*Borak J, Sidell F. 1992. Agents of chemical warfare: Sulfur mustard. Anal Emerg Med 21:303-308. 

Borges HT, Faust RA, Watson AP, et al. 1996. Preliminary data analysis and derivation of an estimated 

reference dose (RfD) for sulfur mustard (HD). Toxicologist 30(1 part 2):149. 

Boronin AM, Ermakova IT, Sakharovsky VG, et al. 2000. Ecologically safe destruction of the 

detoxification products of mustard-lewisite mixtures from the Russian chemical stockpile. J Chem 

Technol Biotechnol 15:82-88. 
SULFUR MUSTARD 172 

9. REFERENCES 

*Borrett VT, Matthews RJ, Colton R, et al. 1996. Verification of the United Nations Chemical Weapons 

Convention: the application of electrospray mass spectrometry. Rapid Commun Mass Spectrom 

10:1114-118. 

Bossle PC, Ellzy MW, Martin JJ. 1992. Detection of thiodiglycol and its sulfoxide and sulfone 

analogues in environmental waters by high performance liquid chromatography. In: Abstracts of papers, 

part 1, 203rd ACS national meeting, 0-8412-2210-X. San Francisco, CA: American Chemical Society. 

Boublik T, Fried V, Hala E. 1984. The vapor pressures of the temperature dependence of the vapor 

pressures of some pure substances in the normal and low pressure region. 2nd ed. Amsterdam, Oxford, 

New York, Tokyo: Elsevier. 

*Boursnell JC, Cohen JA, Dixon M, et al. 1946. Studies on mustard gas (ββ'-dichlorodiethyl sulphide) 

and some related compounds. 5. The fate of injected mustard gas (containing radioactive sulphur) in the 

animal body. Biochem J 40:757-764. 

*Bowden E. 1943. Median detectable concentrations by odor of plant run mustard, plant run lewisite and 

pilot plant ethyl nitrogen mustard. TDMR 615. Chemical Warfare Service. 

*Brankowitz WR. 1987. Chemical weapons movement. History compilation. Aberdeen Proving 

Ground, MD: Office of the Program Manager for chemical munitions (demilitarization and binary), 

ADA193348. 

Brimfield AA. 1995. Possible protein phosphatase inhibition by bis(hydroxyethyl)sulfide, a hydrolysis 

product of mustard gas. Toxicol Lett 78:43-48. 

Brown RFR, Rice P. 1997. Histopathological changes in Yucatan minipig skin following challenge with 

sulphur mustard. A sequential study of the first 24 hours following challenge. Int J Exp Pathol 78:9-20. 

*Budavari S, O’Neil MJ, Smith A, et al., eds. 1996. The Merck index. An encyclopedia of chemicals, 

drugs and biologicals. 12th ed. Whitehouse Station, NJ: Merck & Co. Inc., 1082. 

*Budiansky S. 1984. Chemical weapons: "United Nations accuses Iraq of military use." Nature 

308:483. 

Bullman T, Kang H. 1994. The effects of mustard gas, ionizing radiation, herbicides, trauma, and oil 

smoke on U.S. military personnel: The results of veteran studies. Annu Rev Public Health 15:69-90. 

*Bullman T, Kang H. 2000. A fifty year mortality follow-up study of veterans exposed to low level 

chemical warfare agent, mustard gas. Ann Endocrinol (Paris) 10(5):333-338. 

*Burrows EP. 1998. Analysis of chemical warfare agents and their transformation products. Govt 

Reports Announcements & Index (GRA&I), Issue 05. 

Byrne MP, Broomfield CA, Stites WE. 1996. Mustard gas cross linking of proteins through preferential 

alkylation of cysteines. J Protein Chem 15(2):131-136. 

Calabrese EJ, Baldwin LA, Leonard DA, et al. 1995. Decrease in hepatotoxicity by lead exposure is not 

explained by its mitogenic response. J Appl Toxicol 15(2):129-132. 
SULFUR MUSTARD 173 

9. REFERENCES 

*Calvet JH, Coste A, Levame M, et al. 1996. Airway epithelial damage induced by sulfur mustard in 

guinea pigs, effects of glucocorticoid. Hum Exp Toxicol 15:964-971. 

Calvet JH, D'Ortho MP, Jarreau PH, et al. 1994a. Glucocorticoid inhibit sulfur mustard-induced airway 

muscle hyperresponsiveness to substance P. J Appl Physiol 77(5):2325-2332. 

Calvet JH, Gascard JP, Delamanche S, et al. 1999a. Airway epithelial damage and release of 

inflammatory mediators in human lung parenchyma after sulfur mustard exposure. Hum Exp Toxicol 

18:77-81. 

Calvet JH, Jarreau PH, Levame M, et al. 1994b. Acute and chronic respiratory effects of sulfur mustard 

intoxication in guinea pig. J Appl Toxicol 76(2):681-688. 

Calvet JH, Planus E, Rouet P, et al. 1999b. Matrix metalloproteinase gelatinases in sulfur mustardinduced acute airway injury in guinea pigs. Am J Physiol 276:L754-L762. 

*Calvet JH, Trouiller G, Harf A. 1993. Acute and chronic respiratory lesions induced by sulfur mustard 

in guinea pigs: Role of Tachykinins. In: Proceedings of the medical defense bioscience review (1993) 

held in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, VA: US Department of 

Commerce, 123-132. 

*Cameron GR, Gaddum JH, Short RHD. 1946. The absorption of war gasses by the nose. J Pathol 

Bacteriol 58:449-455. 

*Capizzi RL, Papirmeister B, Mullins JM, et al. 1974. The detection of chemical mutagens using the 

L5178Y/Asn-murine leukemia in vitro and in a host-mediated assay. Cancer Res 34:3073-3082. 

Capizzi RL, Smith WJ, Field R, et al. 1973. A host-mediated assay for chemical mutagens using 

L5178Y/Asn murine leukemia. Mutat Res 21:6. 

Carrick WA, Cooper DB, Muir B. 2001. Retrospective identification of chemical warfare agents by 

high-temperature automatic thermal desorption-gas chromatography-mass spectrometry. J Chromatogr A 

925:241-249. 

Carter CA, Yvette H, Ludlum DB. 1988. Release of 7-alkylguanines from haloethylnitrosourea-treated 

DNA by E. coli 3-methyladenine-DNA Glycosylase II. Biochem Biophys Res Comm 155:1261-1265. 

*Case RA, M, Lea AJ. 1955. Mustard gas poisoning, chronic bronchitis, and lung cancer: An 

investigation into the possibility that poisoning by mustard gas in the 1914-18 war might be a factor in the 

production of neoplasia. Br J Prev Soc Med 9:62-72. 

*Casillas RP, Smith KJ, Castrejon LR, et al. 1996. Effect of topically applied drugs against HD-induced 

cutaneous injury in the mouse ear edema model. Med Def Biosci Rev. 2:801-809. 

*Casselman AA, Gibson NCC, Bannard RAB. 1973. A rapid, sensitive, gas-liquid chromatographic 

method for the analysis of bis(2-chloroethyl) sulfide collected from air in hydrocarbon solvents. J 

Chromatogr 78:317-322. 

Chakrabarti AK, Ray P, Broomfield CA, et al. 1998. Purification and characterization of protease 

activated by sulfur mustard in normal human epidermal keratinocytes. Biochem Pharmacol 56:467-472. 
 

SULFUR MUSTARD 174 

9. REFERENCES 

*Chauhan RS, Murty LVR. 1997. Effect of topically applied sulphur mustard on guinea pig liver. J 

Appl Toxicol 17:415-419. 

*Chauhan RS, Murthy LVR, Arora U, et al. 1996. Structural changes induced by sulphur mustard in 

rabbit skin. J Appl Toxicol 16:491-495. 

*Chauhan RS, Murthy LVR, Malhotra RC. 1993a. Effect of sulphur mustard on mouse skin-an electron 

microscopic evaluation. Bull Environ Contam Toxicol 51:374-380. 

*Chauhan RS, Murthy LVR, Pandey M. 1993b. Histomorphometric study of animal skin exposed to 

sulphur mustard. Bull Environ Contam Toxicol 51:138-145. 

*Chauhan RS, Murthy LVR, Pant SC. 1995. Electron microscopic study of guinea pig skin exposed to 

sulphur mustard. Bull Environ Contam Toxicol 55:50-57. 

CHEMFATE. 2001. Di-2-chloroethyl sulfide. Syracuse Research Corp. http://esc.syrres.com/efdb/ 

Chemfate.htm. May 29, 2001. 

Cheng TC, Kolakowski JE, Harvey SP. 1993. Bioprocessing of industrial and agricultural waste 1: 

Advances in the biodegradation of chemical warfare agents and related materials. J Cell Biochem Suppl 

21A:41. 

*Chilcott RP, Jenner J, Carrick W, et al. 2000. Human skin absorption of bis-2-(chloroethyl)sulphide 

(sulphur mustard) in vitro. J Appl Toxicol 20:349-355. 

*Chilcott RP, Jenner J, Hotchkiss SAM, et al. 2001. In vitro skin absorption and decontamination of 

sulphur mustard: comparison of human and pig-ear skin. J Appl Toxicol 21:279-283. 

*Clark DN. 1989. Review of reactions of chemical agents in water. Final report. Fort Detrick, 

Frederick, Maryland: U.S. Army Medical Research and Development Command. 88PP8847, 39-43. 

*Clark E, Smith WJ. 1993. Activation of poly (ADP-RIBOSE) polymerase by sulfur mustard in hela cell 

cultures. In: Proceedings of the medical defense bioscience review (1993) held in Baltimore, Maryland 

on 10-13 May 1993. Vol. 1. Springfield, VA: US Department of Commerce 199-205. 

Clark CR, Smith JR, Shih ML. 1999. Development of an in vitro screening method for evaluating 

decontamination of sulfur mustard by reactive dermal formulations. J Appl Toxicol 19:S77-S81. 

Clemedson CJ, Kristoffersson H, Sorbo B, et al. 1963. Whole body autoradiographic studies of the 

distribution of sulphur 35-labelled mustard gas in mice. Acta Radiol Ther Phys Biol 1:314-320. 

*Clewell HJ III, Andersen ME. 1985. Risk assessment extrapolations and physiological modeling. 

Toxicol Ind Health 1(4):111-131. 

Code of Maryland Regulations (COMAR). 1990. State of Maryland 26.11.15. Toxic Air Pollutants. 

The Bureau of National Affairs, Inc., Washington, D.C. 

Cohen B. 1946. Kinetic reactions of sulfur and nitrogen mustards. In: Chemical warfare agents and 

related problems parts III-IV. Summary technical report of Division 9, NRDC. Washington, DC: Office 

of Scientific Research and Development. PB158508, 415-424. 
SULFUR MUSTARD 175 

9. REFERENCES 

Cohen AM, Prabhaker H. 1983. Carcinogen induced DNA damage in isolated rat liver nuclei. Cancer 

Lett 18:163-167. 

*Cohn JP. 1999. A make over for rocky mountain arsenal. Bioscience 49(4):273-277. 

*Colburn EF. 1978. Monitoring the disposal of hazardous materials. 4th ed. Joint Conference on 

Sensing of Environmental Pollutants, New Orleans, LA, 1977. Washington, DC: American Chemical 

Society, 489-492. 

*Colborn T, Clement C. 1992. Chemically induced alterations in sexual and functional development. 

The Wildlife/Human Connection. In: Advances in modern environmental toxicology. Volume XXI. 

Princeton, NJ: Princeton Scientific Publishing Co. 

Corsini E, Galli CL. 1998. Cytokines and irritant contact dermatitis. Toxicol Lett 102-103:277-282. 

*Coutelier JP, Lison D, Simon O, et al. 1991. Effect of sulfur mustard on murine lymphocytes. Toxicol 

Lett 58:143-148. 

*Cowan FM, Anderson DR, Broomfield CA, et al. 1997. Biochemical alterations in rat lung lavage fluid 

following acute sulfur mustard inhalation: II. Increases in proteolytic activity. Inhal Toxicol 9:53-61. 

*Cowan FM, Yourick JJ, Hurst CG, et al. 1993. Sulfur mustard-increased proteolysis following in vitro 

and in vivo exposures. In: Proceedings of the medical defense bioscience review (1993) held in 

Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, MA: US Department of Commerce,49­

55. 

Crathorn AR, Roberts JJ. 1965. Reactions of cultured mammalian cells of varying radiosensitivity with 

the radiomimetic alkylating agent, mustard gas. Prog Biochem Pharmacol 1:320-326. 

Crathorn AR, Roberts JJ. 1966. Mechanism of the cytotoxic action of alkylating agents in mammalian 

cells and evidence for the removal of alkylated groups from deoxyribonucleic acid. Nature 211:150-153. 

Creasy WR, Brickhouse MD, Morrissey KM, et al. 1999. Analysis of chemical weapons 

decontamination waste from old ton containers from Johnston Atoll using multiple analytical methods. 

Environ Sci Technol 33:2157-2162. 

Creasy WR, Stuff JR, Williams B, et al. 1997. Identification of chemical-weapons-related compounds in 

decontamination solutions and other matrices by multiple chromatographic techniques. J Chromatogr 

774:253-263. 

*Cullumbine H. 1946. The mode of penetration of the skin by mustard gas. Br J Dermatol 58:291-294. 

*Cullumbine H. 1947. Medical aspects of mustard gas poisoning. Nature 4031:151-153. 

Culp SJ, Gaylor DW, Sheldon WG, et al. 1998. A comparison of the tumors induced by coal tar and 

benzo[a]pyrene in a 2-year bioassay. Carcinogenesis 19(1):117-124. 

*Currie DJ, Weaver RS, Cameron BG. 1977. Disposal of WW II mustard gas hydrolysate by burning. 

Proc Annu Meet Air Pollut Control Assoc 70:1-11. 
 

SULFUR MUSTARD 176 

9. REFERENCES 

*CWC. 1993. Chemical Weapons Convention Treaty. http://www.cwc.gov/treaty/cwcIndex_html. 

August 22, 2003. 

*Dabney BJ. 1991. Mustard gas MEDITEXT medical management. In: Hall AH, Rumack BH, eds. 

TOMES Plus Information System, Micromedex, Inc., Denver, CO. 

Dabrowska MI, Becks LL, Lelli JL, et al. 1996. Sulfur mustard induces apoptosis and necrosis in 

endothelial cells. Toxicol Appl Pharmacol 141:568-583. 

Dachir S, Fishbeine E, Meshulam Y, et al. 2002. Potential anti-inflammatory treatments against 

cutaneous sulfur mustard injury using the mouse ear vesicant model. Hum Exp Toxicol 21:197-203. 

*Dacre JC. 1994. Hazard evaluation of army compounds in the environment. Drug Metab Rev 26:649­

662. 

*Dacre JC, Goldman M. 1996. Toxicology and pharmacology of the chemical warfare agent sulfur 

mustard. Pharmacol Rev 48(2):289-326. 

*Dacre JC, Beers R, Goldman M, et al. 1995. Toxicology and pharmacology of the chemical warfare 

agent sulfur mustard - A review. Govt Reports Announcements & Index. No. 23. ADA294927. 

*D'Agostino PA, Provost LR. 1988a. Capillary column isobutane chemical ionization mass spectrometry 

of mustard and related compounds. Biomed Environ Mass Spectrom 15:553-564. 

*D'Agostino PA, Provost LR. 1988b. Gas chromatographic retention indices of sulfur vesicants and 

related compounds. J Chromatogr 436:399-411. 

*D'Agostino PA, Provost LR. 1992. Determination of chemical warfare agents, their hydrolysis products 

and related compounds in soil. J Chromatogr 589:287-294. 

*D'Agostino PA, Provost LR, Hansen AS, et al. 1989. Identification of mustard related compounds in 

aqueous samples by gas chromatography/mass spectrometry. Biomed Environ Mass Spectrom 18:484­

491. 

*Dahl H, Gluud B, Vangsted P, et al. 1985. Eye lesions induced by mustard gas. Acta Ophthalmol 

[Suppl] (Copenh) 173:30-31. 

Dangi RS, Jeevaratnam K, Sugendran K, et al. 1994. Solid-phase extraction and reversed-phase highperformance liquid chromatographic determination of sulphur mustard in blood. J Chromatogr 

661:341-345. 

*Dannenberg AM, Tsuruta J. 1993. Role of cytokines and reactive oxygen intermediates in the 

inflammatory response produced by sulfur mustard. A progress report. In: Proceedings of the medical 

defense bioscience review (1993) held in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, 

VA: US Department of Commerce, 58-65. 

Dannenberg AM Jr, Pula PJ, Liu LH, et al. 1985. Inflammatory mediators and modulators released in 

organ culture from rabbit skin lesions produced in vivo by sulfur mustard: I. Quantitative histopathology, 

polymorphonuclear leukocyte, basophil, and mononuclear cell survival, and unbound (serum) protein 

content. Am J Pathol 121:15-27. 
 

 

SULFUR MUSTARD 177 

9. REFERENCES 

Davis KG, Aspera G. 2001. Exposure to liquid sulfur mustard. Ann Emerg Med 37(6):653-656. 

*Davison C, Rozman RS, Smith PK. 1961. Metabolism of bis-B-chloroethyl sulfide. Biochem 

Pharmacol 7:65-74. 

Demek MM, Davis GT, Dennis WH Jr, et al. 1970. Behavior of chemical agents in seawater. Edgewood 

Arsenal, MD: Department of the Army Edgewood Arsenal. AD873242. 

*Detheux M, Jijakli H, Lison D. 1997. Effect of sulphur mustard on the expression of urokinase in 

cultured 3T3 fibroblasts. Arch Toxicol 71:243-249. 

De Young LM, Mufson RA, Boutwell RK. 1977. An apparent inactivation of initiated cells by the potent 

inhibitor of two-stage mouse skin tumorigenesis, bis(2-chloroethyl)sulfide. Cancer Res 37:4590-4594. 

*D’Halluin F, Roels H. 1984. Autopsy observations in an Iranian soldier exposed to war gases. Arch 

Belges (Suppl):284-290. 

*DHHS. 1988. Final recommendations for protecting the health and safety against potential adverse 

effects of long-term exposure to low doses of agents: GA, GB, VX, mustard agent (H, HD, T), and 

lewisite (L). Fed Regist 53(50):8504-8507. 

DOA. 1985. Protection against the acute and delayed toxicity of mustards and mustard-like compounds: 

Annual report. Frederick, MD: U.S. Army Medical Research and Development Command, Department 

of the Army. AD-A182 468. 

*DOA. 1987. Teratology studies of lewisite and sulfur mustard agents: Effects of sulfur mustard in rats 

and rabbits: Final Report: Frederick, MD: U.S. Army Medical Research and Development Command, 

Department of the Army. AD-A187 495. 

*DOA. 1988. Chemical stockpile disposal program: Final programmatic environmental impact 

statement. Aberdeen Proving Ground, MD: Department of the Army V-IX, 1-6. 

DOA. 1989. Toxicology studies on lewisite and sulfur mustard agents: Subchronic toxicity study on 

lewisite in rats: Final report. Frederick, MD: U.S. Army Medical Research and Development 

Command, Department of the Army. ADA217886. 

DOA. 1994a. Environmental chemistry and fate of chemical warfare agents: Draft: Final report. San 

Antonio, TX: Corps of Engineers. Huntsville Division. Department of the Army. SwRI Project 01­

5864. 

DOA. 1994b. Mechanism of cutaneous vesication. Frederick, MD: U.S. Army Medical Research, 

Development, Acquisition and Logistics Command, Department of the Army. ADA283085. 

DOA. 1995. Host factors contributing to disability following sulfur mustard exposure. Frederick, MD: 

U.S. Army Medical Research and Material Command, Department of the Army. ADA294497. 

*DOA. 1996. Health risk assessment for sulfur mustard (HD): draft report. Oak Ridge, TN: U.S. Army 

Environmental Center, Department of the Army. 1769-1769-A1. 
 

SULFUR MUSTARD 178 

9. REFERENCES 

DOA. 1998. Characterization and modulation of proteins involved in sulfur mustard vesication. 

Frederick, MD: U.S. Army Medical Research and Material Command, Department of the Army. 

ADA366 664. 

*DOA. 2000. Anniston chemical agent disposal facility. Department of the Army. 

http://www.pmcd.apgea.army.mil/CSDP/IP/FS/QF/ANCA/index.asp. March 8, 2001. 

*DOA. 2003. News release. Mustard leak detected at Deseret Chemical Depot. U.S. Department of the 

Army. http://www.pmcd.army.mil/. August 27, 2003. 

*DOD. 2003. Blue Grass Army Depot, Kentucky. Chemical weapons disposal in Kentucky. U.S. 

Department of Defense. http://www.pmacwa.army.mil/ky/cw_disposal_Ky.htm. August 27, 2003. 

*Doebler JA. 2002. Blockade of sulfur mustard cytotoxicity in vitro. U.S. Army Medical Research 

Institute of Chemical Defense, Neurotoxicology Branch, Pharmacology Division. Aberdeen Proving 

Ground, MD. 

*DOS. 2001. International traffic in arms. United States munitions list. Chemical agents. U.S. 

Department of State. Code of Federal Regulations. 22 CFR 121.7. 

http://ecfr.access.gpo.gov/otcgi/cfr/otfilter.cgi...TI&QUERY=1682&RGN=BSECCT&SUBSET=SUBSE 

T&FROM=1&ITEM=1. May 24, 2001. 

*DOT. 2001. Hazardous materials table. U.S. Department of Transportation. Code of Federal 

Regulations. 49 CFR 172.101. 

http://ecfr.access.gpo.gov/otcgi/cfr/otfilter.cgi?DB=...I&QUERY=971312&RGN=BSECCT&SUBSET=S 

UBSET&FROM=1&ITEM=1. May 24, 2001. 

Dowlati A, Pierard GE. 1993. Epidermal hyperplasia with or without atypia in patients exposed to 

mustard gas. Arch Dermatol 129:245. 

*Drasch G, Kretschmer E, Pahrm M, et al. 1987. Concentrations of mustard gas bis-2-chloroethylsulfide 

in the tissue of a victim of a vesicant exposure. J Forensic Sci 32:1788-1793. 

*Dreisbach RH, Robertson WO. 1987. Handbook of poisoning: Prevention, diagnosis and treatment. 

12th ed. Norwalk, CT: Appleton and Lange. 

*DTIC. 2002. DTIC research summaries. Defense Technical Information Center. Ft. Belvoir, VA. 

October 22, 2002. 

Dube SN, Husain K, Sugendran K, et al. 1998. Dose response of sulphur mustard: Behavioral and toxic 

signs in rats. Indian J Physiol Pharmacol 42(3):389-394. 

Dumez H, Guetens G, De Boeck G, et al. 2001. Quantitation of suspensions (MESED). Application of 

MESED-GC/MS in the quantitation of ifosfamide mustard in erythrocytes, plasma, and plasma water. J 

Sep Sci 24(2):123-128. 

*Easton DF, Peto J, Doll R. 1988. Cancers of the respiratory tract in mustard gas workers. Br J Ind Med 

45:652-659. 

Ebtekar M, Hassan ZM. 1993. Effect of immunomodulators pyrimethamine and cimetidine on 

immunosuppression induced by sulfur mustard in mice. Immunopharmacology 15(4):533-541. 
SULFUR MUSTARD 179 

9. REFERENCES 

*Eisenmenger W, Drasch G, von Clarmann M, et al. 1991. Clinical and morphological findings on 

mustard gas [bis(2-chloroethyl)sulfide] poisoning. J Forensic Sci 36(6):1688-1698. 

*Eldad A, Meir PB, Breiterman S, et al. 1998a. Superoxide dismutase (SOD) for mustard gas burns. 

Burns 24:114-119. 

*Eldad A, Weinberg A, Breiterman S, et al. 1998b. Early nonsurgical removal of chemically injured 

tissue enhances wound healing in partial thickness burns. Burns 24:166-172. 

*Ellenhorn MJ, Barceloux DG. 1988. Medical toxicology. New York, NY: Elsevier Science Publishing 

Company. 

*Emad A, Rezaian GR. 1997. The diversity of the effects of sulfur mustard gas inhalation on respiratory 

system 10 years after a single, heavy exposure. Analysis of 197 cases. Chest 112(3):734-738. 

Emad A, Rezaian GR. 1999a. Characteristics of broncho alveolar lavage fluid in patients with sulfur 

mustard gas-induced asthma or chronic bronchitis. Am J Med 106:625-628. 

Emad A, Rezaian GR. 1999b. Immunoglobulins and cellular constituents of the BAL fluid of patients 

with sulfur mustard gas-induced pulmonary fibrosis. Chest 115:1346-1351. 

Emison ES, Smith WJ. 1997. Cytometric analysis of DNA damage in cultured human epithelial cells 

after exposure to sulfur mustard. J Am Coll Toxicol 15:S9-S18. 

English F, Brisbane WT, Bennett Y. 1990. The challenge of mustard-gas keratopathy. Med J Aust 

152:55-56. 

EPA. 1987a. US Environmental Protection Agency. Code of Federal Regulations. 40 CFR 355, 

Appendix A. 

EPA. 1987b. US Environmental Protection Agency. Fed Regist 52:21152. 

EPA. 1987c. Recommendations for and documentation of biological values for use in risk assessment. 

Cincinnati, OH: U.S. Environmental Protection Agency, Office of Research and Development, Office of 

Health and Environmental Assessment, Environmental Criteria and Assessment Office. EPA ECAOCIN-554. 

EPA. 1988. US Environmental Protection Agency. Code of Federal Regulations. 40 CFR 261, 

Appendix VIII. 

EPA. 1989. Interim methods for development of inhalation reference doses. Washington, DC: U.S. 

Environmental Protection Agency, Office of Health and Environmental Assessment. EPA888066F. 

*EPA. 1990. Interim methods for development of inhalation reference concentrations. Washington, DC: 

U.S. Environmental Protection Agency, Office of Health and Environmental Assessment, Office of 

Research and Development, Environmental Criteria and Assessment Office. EPA600890066A. 

EPA. 1991. Upper-bound quantitative cancer risk estimate for populations adjacent to sulfur mustard 

incineration facilities. Washington, DC: Human Health Assessment Group, Office of Health and 
SULFUR MUSTARD 180 

9. REFERENCES 

Environmental Assessment, Office of Research and Development. U.S. Environmental Protection 

Agency. EPA600891053. 

EPA. 1994. Methods for derivation of inhalation reference concentrations and application of inhalation 

dosimetry. Washington, DC: U.S. Environmental Protection Agency, Office of Health and 

Environmental Assessment, Office of Research and Development, Environmental Criteria and 

Assessment Office. EPA600890066F. 

*EPA. 1997. Special report on environmental endocrine disruption: An effects assessment and analysis. 

Washington, DC: U.S. Environmental Protection Agency, Risk Assessment Forum. EPA630R96012. 

*EPA. 2001a. Health and environmental protection standards. U.S. Environmental Protection Agency. 

Code of Federal Regulations. 40 CFR 192. http://esweb.bna.com/cgibin/om_isa...tID=109873&softpage=es_menu_fedral. February 22, 2001. 

*EPA. 2001b. Identification and listing of hazardous waste. U.S. Environmental Protection Agency. 

Code of Federal Regulations. 40 CFR 261. http://esweb.bna.com/cgibin/om_isa...tID=109873&softpage=es_menu_fedral. February 22, 2001. 

*EPA. 2001c. Reportable quantities. U.S. Environmental Protection Agency. Code of Federal 

Regulations. 40 CFR 355. http://esweb.bna.com/cgibin/om_isa...tID=109873&softpage=es_menu_fedral. February 22, 2001. 

*EPA. 2001d. Toxic chemical release reporting community right-to-know. U.S. Environmental 

Protection Agency. Code of Federal Regulations. 40 CFR 372.65. http://esweb.bna.com/cgibin/om_isa...tID=109873&softpage=es_menu_fedral. February 22, 2001. 

*Epstein J, Rosenblatt DH, Gallacio A, et al. 1973. Summary report on a data base for predicting 

consequences of chemical disposal operation. ADB955399. 

Epstein SS, Arnold E, Andrea J, et al. 1972. Detection of chemical mutagens: Dominant lethal assay in 

the mouse. Toxicol Appl Pharmacol 23:288-325. 

*Fahmy OG, Fahmy MJ. 1971. Mutability at specific euchromatic and heterochromatic loci with 

alkylating and nitroso compounds in Drosophila melanogaster. Mutat Res 13:19-34. 

*Fahmy OG, Fahmy MJ. 1972. Mutagenic selectivity for the RNA-forming genes in relation to the 

carcinogenicity of alkylating agents and polycyclic aromatics. Cancer Res 32:550-557. 

*Fan L, Bernstein IA. 1991. Effect of bis(β-chloroethhyl)sulfide (BCES) on base mismatch repair of 

DNA in monkey kidney cells. Toxicol Appl Pharmacol 111:233-241. 

*FEDRIP. 2002. Federal Research In Progress Database. National Technical Information Service, 

Springfield, VA. 

Ferguson LR, Turner PM. 1988. Mitotic crossing-over by anti-cancer drugs in Saccharomyces cerevisiae 

strain D5. Mutat Res 204:239-250. 

*Fidder A, Moes GWH, Scheffer AG, et al. 1994. Synthesis, characterization, and quantization of the 

major adducts formed between sulfur mustard and DNA of calf thymus and human blood. Chem Res 

Toxicol 7:199-204. 
 

SULFUR MUSTARD 181 

9. REFERENCES 

*Fidder A, Noort D, de Jong AL, et al. 1996a. Monitoring of in vitro and in vivo exposure to sulfur 

mustard by GC/MS determination of the N-terminal valine adduct in hemoglobin after a modified edman 

degradation. Chem Res Toxicol 9:788-792. 

*Fidder A, Noort D, de Jong LPA, et al. 1996b. N7-(2-hydroxyethylthioethyl)-guanine: A novel urinary 

metabolite following exposure to sulphur mustard. Arch Toxicol 70:854-855. 

Firooz A, Komeile A, Dowlati Y. 1999. Eruptive melanocytic nevi and cherry angiomas secondary to 

exposure to sulfur mustard gas. J Am Acad Dermatol 40(4):646-647. 

*Fisher TL, Jaskot M, Sass S. 1969. Trace estimation and differentiation of some mustards employing 

gas-liquid chromatography. Edgewood Arsenal technical report. Edgewood Arsenal, Maryland: 

Department of the Army, Edgewood Arsenal, Research Laboratories, Chemical Research Laboratory. 

EATR 4321. 

*Fomon SJ. 1966. Body composition of the infant: Part I: The male “reference infant.” In: Falkner F, 

ed. Human development. Philadelphia, PA: WB Saunders, 239-246. 

*Fomon SJ, Haschke F, Ziegler EE, et al. 1982. Body composition of reference children from birth to 

age 10 years. Am J Clin Nutr 35:1169-1175. 

Foussereau J, Benezra C, Maibach HI, et al. 1982. Occupational contact dermatitis, clinical and chemical 

aspects. Philadelphia, PA: W.B. Saunders Company, 171-176. 

*Fowler WK, Smith JE. 1990. Solid sorbent collection and gas chromatographic determination of bis(2­

chloroethyl)sulfide in air at trace concentrations. J Chromatogr Sci 28:118-122. 

Fox M, Scott D. 1980. The genetic toxicology of nitrogen and sulfur mustard. Mutat Res 75:131-168. 

Frank AL. 1982. The epidemiology and etiology of lung cancer. Clin Chest Med 3:219-228. 

Frank AL. 1987. Occupational cancers of the respiratory system. Seminars in Occupational Medicine 

2:257-266. 

*Franke S. 1967. [Textbook of military chemistry.] Vol. I, 2nd ed. Berlin, West Germany: Military 

Publisher of the German Democratic Republic. (German-English translation by the U.S. Army Medical 

Intelligence and Information Agency), 114-122, 132-133, 168-178. 

*Freitag L, Firusian N, Stamatis G, et al. 1991. The role of bronchoscopy in pulmonary complications 

due to mustard gas inhalation. Chest 100:1436-1441. 

*Friedberg K, Mengel K, Schlick E. 1983. The action of azimexone on the cells of the hempopietic 

system in mice, especially after the damage with x-rays. Radiation and Environ Biophy 22:117-131. 

Friedenwald JS, Buschke W. 1948. Nuclear fragmentation produced by mustard and nitrogen mustards 

in the corneal epithelium. Bull Johns Hopkins Hosp 82:161-177. 

Friedenwald JS, Scholz RO, Snell Jr A, et al. 1948. Primary reaction of mustard with the corneal 

epithelium. Bull Johns Hopkins Hosp 82:102-120. 
 

 

 

SULFUR MUSTARD 182 

9. REFERENCES 

Fritsche U, Koenig A. 1982. [Luminometric determination of S-lost with sodium hypobromite.] 

Mikrochim Acta 1:349. (German) 

*Gates M, Moore S. 1946. Mustard gas and other sulfur mustards. In: Chemical warfare agents, and 

related chemical problems, Parts I-II. Summary technical report of Division 9, NDRC, Volume 1, 

Chapter 5, 30-58. 

Gaylor DW, Gold LS. 1995. Quick estimate of the regulatory virtually safe dose based on the maximum 

tolerated dose for rodent bioassays. Regul Toxicol Pharmacol 22:57-63. 

Geeraets WJ, Abedi S, Blanke RV. 1977. Acute corneal injury by mustard gas. South Med J 70(3):348­

350. 

Ghanei M, Vosoghi AA. 2002. An epidemiologic study to screen for chronic myelocytic leukemia in 

war victims exposed to mustard gas. Environ Health Perspect 110(5):519-521. 

Ghotbi L, Hassan Z. 2002. The immunostatus of natural killer cells in people exposed to sulfur mustard. 

Int Immunopharm 2:981-985. 

*Gibson NCC, Casselman AA, Bannard RAB. 1974. An improved gas-liquid chromatographic method 

for the analysis of bis(2-chloroethyl) sulfide collected from air by solvent entrapment. J Chromatogr 

92:162-165. 

Gilbert RM, Rowland S, Davison CL, et al. 1975. Involvement of separate pathways in the repair of 

mutational and lethal lesions induced by a mono-functional sulfur mustard. Mutat Res 28:257-276. 

Gililland J, Weinstein L. 1983. The effects of cancer chemotherapeutic agents on the developing fetus. 

Obstet Gynecol Surv 38:6-13. 

Gilman MR. 1982. Skin and eye testing in animals. In: Hayes AW, ed. Principles and methods of 

toxicology. New York: Raven Press, 209-222. 

*Giwercman A, Carlsen E, Keiding N, et al. 1993. Evidence for increasing incidence of abnormalities of 

the human testis: A review. Environ Health Perspect Suppl 101(2):65-71. 

Gold MB, Scharf BA. 1995. Hematological profile of the euthymic hairless guinea pig following sulfur 

mustard vesicant exposure. J Appl Toxicol 15:433-438. 

Gold MB, Bongiovanni R, Scharf BA, et al. 1993. Hypochlorite solution as a decontaminant in sulfur 

mustard contaminated skin defects in the euthymic hairless guinea pig. In: Proceedings of the medical 

defense bioscience review (1993) held in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, 

VA: US Department of Commerce, 369-378. 

*Gold MB, Bongiovanni R, Scharf BA, et al. 1994. Hypochlorite solution as a decontaminant in sulfur 

mustard contaminated skin defects in the euthymic hairless guinea pig. Drug Chem Toxicol 17(4):499­

527. 

*Goldfrank LR, Flomenbaum NE, Lewin NA, et al. 1990. Goldfrank's toxicologic emergencies. 4th ed. 

Norwalk, CT: Appleton and Lange. 
 

SULFUR MUSTARD 183 

9. REFERENCES 

Goldstein LS. 1984. Use of in vitro technique to detect mutations induced by antineoplastic drugs in 

mouse germ cells. Cancer Treat Rep 68:855-856. 

Gottschall EB. 2002. Occupational and environmental thoracic malignancies. J Thorac Imaging 17:189­

197. 

*Graef I, Karnofsky DA, Jager VB, et al. 1948. The clinical and pathologic effects of the nitrogen and 

sulphur mustards in laboratory animals. Am J Pathol 24:1-47. 

*Graham JS, Bryant MA, Braue EH. 1994. Effect of sulfur mustard on mast cells in hairless guinea pig 

skin. J Toxicol Cutaneous Ocul Toxicol 13(1):47-54. 

Graham JS, Schomacker KT, Glatter RD, et al. 2002. Bioengineering methods employed in the study of 

wound healing of sulphur mustard burns. Skin Res Tech 8:57-69. 

Gray PJ. 1995. Sulphur mustards inhibit binding of transcription factor AP2 in vitro. Nucl Acids Res 

23(21):4378-4382. 

Gray PJ, Phillips DR. 1993. Effect of alkylating agents on initiation and elongation of the lac UV5 

promoter. Biochemistry 32:12471-12477. 

*Gresham GL, Groenewold GS, Appelhans AD, et al. 2001. Static secondary ionization mass 

spectrometry and mass spectrometry/mass spectrometry (MS2

) characterization of the chemical warfare 

agent HD on soil particle surfaces. Int J Mass Spectrom 208:135-145. 

Groenewold GS, Appelhans AD, Ingram JC, et al. 1998. Detection of 2-chloroethyl ethyl sulfide on soil 

particles using ion trap-secondary ion mass spectrometry. Talanta 47:981-986. 

*Groenewold GS, Ingram JC, Appelhans AD, et al. 1995. Detection of 2-chloroethyl ethyl sulfide and 

sulfonium ion degradation products on environmental surfaces using static SIMS. Environ Sci Technol 

29:2107-2111. 

*Gross CL, Smith WJ. 1993. Pretreatment of isolated human peripheral blood lymphocytes with Loxothiazolidine 4-carboxylate reduces sulfur mustard cytotoxicity. In: Proceedings of the medical 

defense bioscience review (1993) held in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, 

VA: US Department of Commerce, 141-147. 

*Guild WJF, Harrison KP, Fairley A, et al. 1941. The effect of mustard gas vapour on the eyes. 

Chemical Board, Physiological Sub-Committee and Panel of Ophthalmic Specialists. Porton Report No. 

2297. Great Britain. 

Guittin P, Schorch F, Fontaine J-J, et al. 1989. Experimental pathology induced in rat by a single skin 

application of mustard gas. Pathol Res Pract 185:68-69. 

*Guzelian PS, Henry CJ, Olin SS. 1992. Similarities and differences between children and adults: 

Implications for risk assessment. Washington, DC: International Life Sciences Institute Press. 

*Haddad LM, Winchester JF. 1990. Clinical management of poisoning and drug overdose. 2nd ed. 

Philadelphia, PA: W.B. Saunders Company. 
SULFUR MUSTARD 184 

9. REFERENCES 

*Hambrook JL, Harrison JM, Howells DJ, et al. 1992. Biological fate of sulphur mustard (1,1'-thiobis(2­

chloroethane)): Urinary and fecal excretion of 35S by rat after injection or cutaneous application of 35Slabeled sulphur mustard. Xenobiotica 22(1):65-75. 

*Hambrook JL, Howells DJ, Schock C. 1993. Biological fate of sulphur mustard (1,1'-thiobis(2­

chloroethane)): Uptake, distribution and retention of 35S in skin and in blood after cutaneous application 

of 35S-sulphur mustard in rat and comparison with human blood in vitro. Xenobiotica 23(5):537-561. 

Hancock JR, McAndless JM, Hicken RP. 1991. A solid adsorbent based system for the sampling and 

analysis of organic compounds in air: An application to compounds of chemical defense interest. J 

Chromatogr Sci 29:40-45. 

Hart BW, Schlager JJ. 1996. G2/M phase cell cycle block by sulfur mustard in normal human 

keratinocytes. Med Def Biosci Rev 2:835-843. 

*Hart BW, Schlager JJ. 1997. Okadaic acid and calyculin a reverse sulfur mustard-induced G2/M cellcycle block in human keratinocytes. J Am Coll Toxicol 15(Suppl. 2):S36-S42. 

Hartmann HM. 2002. Evaluation of risk assessment guideline levels for the chemical warfare agents 

mustard, GB, and VX. Regul Toxicol Pharmacol 35:347-356. 

Harvey SP, Szafraniec LL, Beaudry WT. 1998a. Hydrolysis and biodegradation of the vesicant agent 

HT: two potential approaches. Biorem J 2(3&4):191-203. 

Harvey SP, Szafraniek LL, Beaudry WT. 1998b. Neutralization and biodegradation of sulfur mustard. 

In: Bioremediation. Aberdeen Proving Ground, MD 21010-5423: U.S. Army Edgewood Research, 

Development and Engineering Center, 615-636. 

Hassan ZM, Ebtekar M. 2001. Modeling for immunosupression by sulfur mustard. Int Immunopharm 

1:605-610. 

Hassan ZM, Ebtekar M. 2002. Immunological consequence of sulfur mustard exposure. Immunol Lett 

83:151-152. 

Hay A. 1993. Effects on health of mustard gas. Nature 366:398-399. 

*HazDat. 2003. Agency for Toxic Substances and Disease Registry (ATSDR), Atlanta, GA. 

Helmke B, Starz H, Bachter D, et al. 2002. Metastasising porocarcinoma following exposure to poison 

gas. Lancet 359(9318):1685. 

Hemminki K, Kallama S, Falck K. 1983. Correlations of alkylating activating and mutagenicity in 

bacteria of cytostatic drugs. Acta Pharmacol Toxicol 53:421-428. 

Heston WE. 1950. Carcinogenic action of the mustards. J Natl Cancer Inst 11:415-423. 

*Heston WE. 1953a. Occurrence of tumors in mice injected subcutaneously with sulfur mustard and 

nitrogen mustard. J Natl Cancer Inst 14:131-140. 

*Heston WE. 1953b. Pulmonary tumors in Strain A mice exposed to mustard gas. Proceedings of the 

Society for Experimental Biology and Medicine 82:457-460. 
SULFUR MUSTARD 185 

9. REFERENCES 

*Heully F, Gruinger M, et al. 1956. [Collective intoxication caused by the explosion of a mustard gas 

shell.] Annales de Medecine Legale 36:195-204. (French) 

*Heyndrickx A, Heyndrickx B. 1984. Treatment of Iranian soldiers attacked by chemical and 

microbiological war gases. Arch Belges (Supplement):S157-S159. 

*Hobson DW, Snider TH, Korte DW. 1993. Evaluation of the effects of hypochlorite solutions in the 

decontamination of wounds exposed to either VX or sulfur mustard. Columbus, OH: Battelle Memorial 

Institute. 

*Hoel DG, Davis DL, Miller AB, et al. 1992. Trends in cancer mortality in 15 industrialized countries, 

1969-1986. J Natl Cancer Inst 84(5):313-320. 

Hooijschuur EWJ, Keintz CE, Brinkman UAT. 1999. Determination of the sulfur mustard hydrolysis 

product thiodiglycol by microcolumn liquid chromatography coupled on-line with sulfur flame 

photometric detection using large-volume injections and peak compression. J Chromatogr 849:433-444. 

*Hooijschuur EWJ, Kientz CE, Brinkman UAT. 2001. Application of microcolumn liquid 

chromatography and capillary electrophoresis with flame photometric detection for the screening of 

degradation products of chemical warfare agents in water and soil. J Chromatogr A 928:187-199. 

Hopkins AR, Lewis NS. 2001. Detection and classification characteristics of arrays of carbon 

black/organic polymer composite chemiresistive vapor detectors for the nerve agent simulants 

dimethylphophonate and diisopropylmethylphosponate. Anal Chem 73:884-892. 

Horwitz EP, Dietz ML, Fisher DE. 1991. Separation and preconcentration of strontium from biological, 

environmental, and nuclear waste samples by extraction chromatography using a crown ether. Anal 

Chem 63:522-525. 

*Hosseini K, Moradi A, Mansouri A, et al. 1989. Pulmonary manifestations of mustard gas injury: a 

review of 61 cases. Iran J Med Sci 14(2):20-26. 

*HSDB. 2002. Hazardous Substances Data Bank. National library of Medicine, National Toxicology 

Information Program, Bethesda, MD. 

Hu J, Mao Y, White K, et al. 2002. Renal cell carcinoma and occupational exposure to chemicals in 

Canada. Occup Med 52(3):157-164. 

Hua A, Daniel R, Jasseron MP, et al. 1993. Early cytotoxic effects induced by Bis-chloroethyl sulphide 

(sulphur mustard): Ca2

 rise and time-dependent inhibition of B77 fibroblast serum response. J Appl 

Toxicol 13(3):161-168. 

*Hughes WF Jr. 1942. Mustard gas injuries to the eyes. Arch Ophthamol 27:582-601. 

Hughes WF Jr. 1945. The importance of mustard burns of the eye as judged by World War I statistics 

and recent accidents. In: National Research Council, Division of Medical Sciences, Committee on 

Treatment of Gas Casualties. Fasciculus on chemical warfare medicine. Vol. 1, Eye. Washington, DC: 

Prepared for the Committee on Medical Research of the Office of Scientific Research and Development, 

79-90. 
 

SULFUR MUSTARD 186 

9. REFERENCES 

Hur GH, Kim YB, Choi DS, et al. 1998. Apoptosis as a mechanism of 2-chloroethylethyl sulfideinduced cytotoxicity. Chem Biol Interact 110:57-70. 

*Husain K, Dube SN, Sugendran K, et al. 1996. Effect of topically applied sulphur mustard on 

antioxidant enzymes in blood cells and body tissues of rats. J Appl Toxicol 16:245-248. 

*IARC. 1975. Mustard gas. IARC monographs on the evaluation of the carcinogenic risk of chemicals 

to humans. International Agency for Research on Cancer. 9:181-207. 

*IARC. 1987. IARC monographs on the evaluation of carcinogenic risks to humans. Overall 

evaluations of carcinogenicity: International Agency for Research on Cancer. An updating of IARC 

monographs, Volumes 1 to 42, Supplement 7:67. 

*IARC. 2001. IARC monographs on the evaluation of carcinogenic risks to humans. International 

Agency for Research on Cancer. http://www.iarc.fr/pageroot/top1.html. February 22, 2001. 

*Ichinotsubo D, Mower HF, Setliff J, et al. 1977. The use of rec- bacteria for testing of carcinogenic 

substances. Mutat Res 46:53-61. 

*Inada S, Hiragun K, Seo K, et al. 1978. Multiple Bowens disease observed in former workers of a 

poison gas factory in Japan with special reference to mustard gas exposure. J Dermatol 5:49-60. 

*IRIS. 2003. Mustard gas. Integrated Risk Information System. U.S. Environmental Protection 

Agency. http://www.epa.gov/iris/subst/index.htm. January 28, 2003. 

Jackson R, Adams RH. 1973. Horrifying basal cell carcinoma: A study of 33 cases and a comparison 

with 435 nonhorror cases and a report on 4 metastatic cases. J Surg Oncol 5:431-463. 

*Jakubowski EM, Sidell FR, Evans RA, et al. 2000. Quantification of thiodiglycol in human urine after 

an accidental sulfur mustard exposure. Toxicol Meth 10:143-150. 

*Jakubowski EM, Woodard CL, Mershon MM, et al. 1990. Quantification of thiodiglycol in urine by 

electron ionization gas chromatography-mass spectrometry. J Chromatogr 528:184-190. 

*Johanson CE. 1980. Permeability and vascularity of the developing brain: Cerebellum vs cerebral 

cortex. Brain Res 190:3-16. 

*Johnsen BA, Blanch JH. 1984. Analysis of snow samples contaminated with chemical warfare agents. 

Proceedings of the First World Congress, Med Soc Hyg Chem Warfare Toxicol Eval Pt 22:22-30. 

*Johnson MA. 1998. Written communication (July 21, 1999) to Nancy Crowe, Bureau of Export 

Administration, Regulatory Policy Division, Office of Exporter Services, regarding proposed chemical 

weapons convention regulations. Fed Regist 64:39194. 

*Jorgenson B, Olesen B, Berntsen O. 1985. [Accidents with mustard gas near Bornholm.] Ugeskrift for 

Laeger 147:2251-2254. (Dutch) 

Jones TD, Walsh PJ, Watson AP, et al. 1988. Chemical scoring by a rapid screening of hazard (RASH) 

method. Risk Anal 8(1):99-118. 
SULFUR MUSTARD 187 

9. REFERENCES 

Ju Fang W. 1984. Biological detection of chemical warfare agents. Arch Belg Med Soc Hyg Med Trav 

Med Leg Suppl:74-80. 

Kadar T, Turetz J, Fishbine E, et al. 2001. Characterization of acute and delayed ocular lesions induced 

by sulfur mustard in rabbits. Curr Eye Res 22(1):42-53. 

Kam CM, Selzler J, Schulz SM, et al. 1997. Enhanced serine protease activities in the sulfur mustardexposed homogenates of hairless guinea pig skin. Int J Toxicol 16:625-638. 

Karaer F. 1996. Environmental pollution and carcinogenic risk. J Environ Pathol Toxicol Oncol 

15(2-4):105-113. 

Karlsson JO, Nguyen NV, Foland LD, et al. 1985. (2-Alkynylethenyl)ketenes: A new benzoquinone 

synthesis. J Am Chem Soc 107:3392-3393. 

Khordagui HK. 1995. Fate and control of nerve chemical warfare agents in the desalination industry of 

the Arabian-Persian Gulf. Environ Int 21(4):363-379. 

Khordagui H, Al-Ajimi D. 1994. Potential fate of blistering chemical warfare agents in the coastal 

waters of kuwait. J Environ Sci Health A29:687-700. 

*Kientz CE. 1998. Chromatography and mass spectrometry of chemical warfare agents, toxins and 

related compounds: State of the art and future prospects. J Chromatogr 814:1-23. 

*Kindred JE. 1947. Histological changes occurring in the hemopoietic organs of albino rats after single 

injections of 2-chloroethyl vesicants: A quantitative study. Arch of Path 43:253-295. 

*Kircher M, Brendel M. 1983. DNA alkylation by mustard gas in yeast Saccharomyces-cerevisiae 

strains of different repair capacity. Chem-Biol Interact 44:27-39. 

Kjellstrom BT, Persson JKE, Runn P. 1997. Surgical treatment of skin lesions induced by sulfur mustard 

("mustard gas")-An experimental study in the guinea pig. Ann Acad Med Singapore 26:30-36. 

*Klain GJ, Omaye ST, Schuschereba ST, et al. 1991. Ocular toxicity of systemic and topical exposure to 

butyl 2-chloroethyl sulfide. J Toxicol Cutaneous Ocul Toxicol 10(4):289-302. 

*Klehr N. 1984. [Cutaneous late manifestations in former mustard gas workers]. Z Hautkr 59:1161­

1170. (German) 

Koepke SR, Kroeger-Koepke MB, Bosan W, et al. 1988. Alkylation of DNA in rats by N-nitrosomethyl­

(2-hydroxyethyl)amine: Dose response and persistence of the alkylated lesions in vivo. Cancer Res 

48:1537-1542. 

*Komori M, Nishio K, Kitada M, et al. 1990. Fetus-specific expression of a form of cytochrome P-450 

in human livers. Biochemistry 29:4430-4433. 

*Koper O, Lucas E, Klabunde KJ. 1999. Development of reactive topical skin protectants against sulfur 

mustard and nerve agents. J Appl Toxicol 19:S59-S70. 

Kosson. 2000. Obstacles to closure of the Johnston atoll chemical agent disposal system. 

http://www.4.nationalacademies.org/cets/dmst.nsf. May 4, 2000. 
 

SULFUR MUSTARD 188 

9. REFERENCES 

*Krishnan K, Andersen ME. 1994. Physiologically based pharmacokinetic modeling in toxicology. In: 

Hayes AW, ed. Principles and methods of toxicology. 3rd ed. New York, NY: Raven Press, Ltd., 149­

188. 

*Krishnan K, Andersen ME, Clewell HJ III, et al. 1994. Physiologically based pharmacokinetic 

modeling of chemical mixtures. In: Yang RSH, ed. Toxicology of chemical mixtures: Case studies, 

mechanisms, and novel approaches. San Diego, CA: Academic Press, 399-437. 

Kroes R, Galli C, Munro I, et al. 2000. Threshold of toxicological concern for chemical substances 

present in the diet: A practical tool for assessing the need for toxicity testing. Food Chem Toxicol 

38:255-312. 

Kumar O, Vijayaraghavan R. 1997. Effect on physiological variables & urinary metabolites following a 

single dermal application of sulphur mustard in rats. Def Sci J 47(3):389-394. 

*Kumar O, Vijayaraghavan R. 1998. Effect of sulphur mustard inhalation exposure on some urinary 

variables in mice. J Appl Toxicol 18:257-259. 

Kumar O, Sugendran K, Vijayaraghavan R. 2001. Protective effect of various antioxidants on the 

toxicity of sulphur mustard administered to mice by inhalation or percutaneous routes. Chem Biol 

Interact 134:1-12. 

*Kumar P, Sharma US, Vijayaraghavan R. 1991. Study of the efficacy of CC-2 and Fuller's Earth 

Combination as a decontaminant against sulphur mustard (Mustard Gas) dermal intoxication in mice. Def 

Sci J 41(4):363-366. 

Kumar P, Vijayaraghavan R, Kulkarni AS, et al. 2002. In vivo protection by amifostine and DRDE-07 

against sulphur mustard toxicity. Hum Exp Toxicol 21:371-376. 

Kuperman R, Dunn C. 1994. Ecological effects of soil contamination at Aberdeen Proving Ground, 

Maryland. Bull Ecol Soc Am 75(1):118-119. 

*Kurata H. 1980. Lessons learned from the destruction of the chemical weapons of the Japanese 

Imperial Forces. In: Stockholm International Peace Research Institute. Chemical weapons: Destruction 

and conversion. London: Taylor and Francis, 77-93. 

Kurozumi S, Haradi Y, Sugimoto Y, et al. 1977. Airway malignancy in poisonous gas workers. 

J Laryngol Otol 91:217-226. 

*Kurt E, Schafer RJ, Arroyo CM. 1998. Effects of sulfur mustard on cytokines released from cultured 

human epidermal keratinocytes. Int J Toxicol 17:223-229. 

Kurt EM, Schafer RJ, Broomfield CA, et al. 1997. Immunologic cytokine expression in human 

keratinocytes after exposure to sulfur mustard. J Am Coll Toxicol 15(Suppl. 2):S32-S35. 

*Kwong CD, Segers DP. 1996. Antivesication by simultaneous prophylaxis and detoxification. Govt 

Reports Announcements & Index. ADA230926. 

Lal J, Kumar V, Gupta RC. 2002. LC determination of a sulphur mustard decontaminant CC-2 in rat 

serum. J Pharm Biomed Anal 29:609-615. 
SULFUR MUSTARD 189 

9. REFERENCES 

*Langenberg JP, van der Schans GP, Spruit HET, et al. 1998. Toxicokinetics of sulfur mustard and its 

DNA-adducts in the hairless guinea pig. Drug Chem Toxicol 21(Suppl. 1):131-147. 

Lardot C, Dubois V, Lison D. 1999. Sulfur mustard upregulates the expression of interleukin-8 in 

cultured human keratinocytes. Toxicol Lett 110:29-33. 

*Laughlin RC. 1944a. Correlation of eye changes in rabbits with CT exposure to HD. MRL (EA) 

Report No. 23. 

*Laughlin RC. 1944b. Continued exposure of human eyes to H vapor, MIT subjects. MRL (EA) Report 

No. 9. 

*Laughlin RC. 1944c. Eye examination of factory workers handling H, CN and CG. MRL (EA) Report 

18. 

Lawley PD, Brookes P. 1965. Molecular mechanism of the cytotoxic action of difunctional alkylating 

agents and of resistance to this action. Nature 206:480-483. 

*Leeder JS, Kearns GL. 1997. Pharmacogenetics in pediatrics: Implications for practice. Pediatr Clin 

North Am 44(1):55-77. 

Lefkowitz LJ, Smith WJ. 2002. Sulfur mustard-induced arachidonic acid release is mediated by 

phospholipase D in human keratinocytes. Biochem Biophys Res Commun 295:1062-1067. 

Leggett DC. 1987. Persistence of chemical agents on the winter battlefield. Part 1. Literature review 

and theoretical evaluation. Defense Technical Information Center, U.S. Army Cold Regions Res Eng 

Lab: CRREL Report # 87-12. 

Lemen RA. 1986. Occupationally induced lung cancer epidemiology. Occup Respir Dis 629-656. 

*Leung H-W. 1993. Physiologically-based pharmacokinetic modeling. In: Ballentine B, Marro T, 

Turner P, eds. General and applied toxicology. Vol. 1. New York, NY: Stockton Press, 153-164. 

*Lüning KG. 1952. Studies on the origin of apparent gene mutations in Drosophila melanogaster. Acta 

Zool 33:193. 

Lewis DFV, Bird MG, Jacobs MN. 2002. Human carcinogens: An evaluation study via the COMPACT 

and Hazard Expert procedures. Hum Exp Toxicol 21:115-122. 

Li Q, Laval J, Lundlum DB. 1997. Fpg protein releases a ring-opened N-7 guanine adduct from DNA 

that has been modified by sulfur mustard. Carcinogenesis 18(5):1035-1038. 

Lieske C, Gross C. 1992. Reply from the authors. Immunol Lett 34(2):175-176. 

Lieske C, Klopcic R, Gross C, et al. 1992. Development of an antibody that binds sulfur mustard. 

Immunol Lett 31:117-122. 

*Lin P, Bernstein IA, Vaughan FL. 1994. Failure to observe a relationship between 

bis-(β-chloroethyl) sulfide-induced NAD depletion and cytotoxicity in the rat keratinocyte culture. J 

Toxicol Environ Health 42:393-405. 
SULFUR MUSTARD 190 

9. REFERENCES 

*Lin P, Bernstein IA, Vaughan FL. 1996a. Bis(2-chloroethyl)sulfide (BCES) disturbs the progression of 

rat keratinocytes through the cell cycle. Toxicol Lett 84:23-32. 

*Lin P, Vaughan FL, Bernstein IA. 1996b. Formation of interstrand DNA cross-links by bis-(2-chloroethyl)sulfide (BCES): A possible cytotoxic mechanism in rat keratinocytes. Biochem Biophys Res 

Commun 218:556-561. 

Lindsay C, Rice P. 1995. Changes in connective tissue macromolecular components of Yucatan minipig skin following the application of sulfur mustard vapor. Hum Exp Toxicol 14:341-348. 

Lindsay CD, Hambrook JL. 1997. Protection of A549 cells against the toxic effects of sulphur mustard 

by hexamethylenetetramine. Hum Exp Toxicol 16:106-114. 

Lindsay CD, Hambrook JL. 1998. Diisopropylglutathione ester protects A549 cells from the cytotoxic 

effects of sulphur mustard. Hum Exp Toxicol 17:606-612. 

Lindsay CD, Upshall DG. 1995. The generation of a human dermal equivalent to assess the potential 

contribution of human dermal fibroblasts to the sulphur mustard-induced vesication response. Hum Exp 

Toxicol 14:580-586. 

Lindsay CD, Hambrook JL, Lailey AF. 1997. Monoisopropylglutathione ester protects A549 cells from 

the cytotoxic effects of sulphur mustard. Hum Exp Toxicol 16:636-644. 

Lindsay CD, Hambrook JL, Smith CN, et al. 1996. Histological assessment of the effects of the 

percutaneous exposure of sulfur mustard in an in vitro human skin system and the therapeutic properties 

of the protease inhibitors. Med Def Biosci Rev 2:899-908. 

*Liu DK, Wannemacher RW, Snider TH, et al. 1999. Efficacy of the topical skin protectant in advanced 

development. J Appl Toxicol 19:S41-S45. 

*Livingston, AL. 1978. Forage plant estrogens. J Toxicol Environ Health 4:301-324. 

Lodhi IJ, Sweeney JF, Clift RE, et al. 2001. Nuclear dependence of sulfur mustard-mediated cell death. 

Toxicol Appl Pharmacol 170:69-77. 

Logan TP, Millard CB, Shutz M, et al. 1999. Cutaneous uptake of 14C-HD vapor by the hairless guinea 

pig. Drug Chem Toxicol 22(2):375-387. 

Lohs K. 1975. Delayed toxic effects of chemical warfare agents. Stockholm International Peace 

Research Institute Monograph. Stockholm: Almqvist & Wilksell International. 

*Ludlum DB, Austin-Ritchie P, Hagopian M, et al. 1994. Detection of sulfur mustard-induced DNA 

modifications. Chem Biol Interact 91:39-49. 

Lundy PM, Sawyer TW, Hand BT, et al. 1998. Effects of bis(2-chloroethyl)sulfide on ATP receptormediated responses of the rat vas deferens: Possible relationship to cytotoxicity. J Pharmacol Exp Ther 

285(1):299-306. 

*Lyman WJ, Reehl WF, Rosenblatt DH. 1990. Handbook of chemical property estimation methods. 2nd 

ed. Washington, DC: American Chemical Society. 
SULFUR MUSTARD 191 

9. REFERENCES 

*MacNaughton, MG. 2001. Monitoring information for sulfur mustard. Southwest Research Institute. 

*Maisonneuve A, Callebat I, Debordes L, et al. 1993. Biological fate of sulphur mustard in rat: 

Toxicokinetics and disposition. Xenobiotica 23(7):771-780. 

*Maisonneuve A, Callebat I, Debordes L, et al. 1994. Distribution of [4

C]sulfur mustard in rats after 

intravenous exposure. Toxicol Appl Pharmacol 125:281-287. 

*Mandl H, Freilinger G. 1984. First report on victims of chemical warfare in the Gulf War treated in 

Vienna. Arch Belges (Supplement):330-340. 

*Mann I. 1944. A study of eighty-four cases of delayed mustard gas keratitis fitted with contact lenses. 

Br J Ophthal 28:441-447. 

*Mann I, Pullinger BD. 1944. A study of mustard gas lesions on the eyes of rabbits and men. Am J 

Ophthmol 26:1253-1277. 

*Manning KP, Skegg DCG, Stell PM, et al. 1981. Cancer of the larynx and other occupational hazards 

of mustard gas workers. Clin Otolaryngol 6:165-170. 

*Marrs TC, Maynard RL, Sidell FR. 1996. Chemical warfare agents. John Wiley & Sons, New York. 

Martens ME. 1997. In vitro studies of glucose metabolism in human epidermal keratinocytes exposed to 

sulfur mustard. J Am Coll Toxicol 15(Suppl. 2):S19-S31. 

*Martens ME, Smith WJ. 1993. Mechanisms of sulfur mustard-induced metabolic injury. FASEB J 

8(3):A408. 

Marzulli FN, Simmon ME. 1971. Eye irritation from topically applied drugs and cosmetics: preclinical 

studies. Am J Ophthalmol 48:61-79. 

*Masta A, Gray PJ, Phillips DR. 1996. Effect of sulphur mustard on the initiation and elongation of 

transcription. Carcinogenesis 17(3):525-532. 

Matijasevic Z, Precopio ML, Snyder JE, et al. 2001. Repair of sulfur mustard-induced DNA damage in 

mammalian cells measured by a host cell reactivation assay. Carcinogenesis 22(4):661-664. 

*Matijasevic Z, Stering A, Ludlum DB. 1996. Toxicity of sulfur mustard for human fibroblasts grown in 

cell culture. Med Def Biosci Rev 2:635-50. 

*Maumenee AE, Scholz RO. 1948. The histopathology of the ocular lesions produced by sulfur and 

nitrogen mustards. Bull John Hopkins Hosp 82:121-147. 

Maurice DM, Giardini AA. 1951. A simple optical apparatus for measuring the corneal thickness, and 

the average thickness of the human cornea. Br J Ophthalmol 35:169-177. 

*May WG. 1998. Effluents from alternative demilitarization technologies. Netherlands: Kluwer 

Academic Publishers. 
 

 

SULFUR MUSTARD 192 

9. REFERENCES 

*Mayr U, Butsch A, Schneider S. 1992. Validation of two in vitro test systems for estrogenic activities 

with zearalenone, phytoestrogens and cereal extracts. Toxicology 74:135-149. 

Mazumder PK, Sugendran K, Vijayaraghavan R. 1998. Protective efficacy of calcium channel blockers 

in sulphur mustard poisoning. Biomed Environ Sci 11:363-369. 

*Mazurek M, Witkiewicz Z, Popiel S, et al. 2001. Capillary gas chromatography-atomic emission 

spectroscopy-mass spectrometry analysis of sulphur mustard and transformation products in a block 

recovered from the Baltic Sea. J Chromatogr A 919:133-145. 

*McAdams AJ Jr. 1956. A study of mustard vesication. J Invest Derm 26:317-326. 

McCann J, Choi E, Yamasaki E, et al. 1975. Detection of carcinogens as mutagens in the 

Salmonella/microsome test: Assay of 300 chemicals. Proc Natl Acad Sci 72:5135-5170. 

*McNamara BP, Owens EJ, Christensen MK, et al. 1975. Toxicological basis for controlling levels of 

mustard in the environment. Edgewood Arsenal Special Publication. Aberdeen Proving Ground, 

Maryland: Department of the Army. EB-SP-74030. 

*Medvedeva N, Polyak Y, Zaytceva T, et al. 2000. Microbiological destruction of mustard in soil. 

Environ Sci Pollut Control Series (bioremediation of contaminated soils) 32:151-176. 

Meier HL, Johnson JB. 1992. The determination and prevention of cytotoxic effects induced in human 

lymphocytes by the alkylating agent 2,2'-dichlorodiethyl sulfide (sulfur mustard, HD). Toxicol Appl 

Pharmacol 113:234-239. 

*Meier HL, Kelly SA. 1993. The identification and ranking of poly (ADP-RIBOSE) polymerase 

inhibitors as protectors against sulfur mustard induced decrease in cellular energy and viability in vitro 

assays with human lymphocytes. In: Proceedings of the medical defense bioscience review (1993) held 

in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, VA: US Department of Commerce, 

227-236. 

Meier HL, Millard CB. 1998. Alterations in human lymphocyte DNA caused by sulfur mustard can be 

mitigated by selective inhibitors of poly(ADP-ribose) polymerase. Biochem Biophys Acta 1404:367-376. 

*Meier HL, Clayson ET, Kelly SA, et al. 1996. Effect of sulfur mustard (HD) on ATP levels of human 

lymphocytes cultured in vitro. In Vitro Toxicol 9(2):135-139. 

*Meier HL, Gross CL, Graham LM, et al. 1987. The prevention of 2,2-dichlorodiethyl sulfide (sulfur 

mustard, HD) cytotoxicity in human lymphocytes by inhibitors of the poly(ADP-ribose) polymerase. In: 

Proceedings of the 6th Chemical Defense Bioscience Review, Frederick, MD, 313-315. 

Meisenberg BR, Melaragno AJ, Monroy RL. 1993. Granulocyte colony stimulating factor (G-CSF) for 

mustard-induced bone marrow suppression. Mil Med 158:470-474. 

Mellor SG, Rice P, Cooper GJ. 1991. Vesicant burns. Brit J Plastic Surg 44:434-437. 

Mesilaakso MT. 1997. Application of NMR spectroscopy to environmental analysis: detection of trace 

amounts of chemical warfare agents and related compounds in organic extract, water, and sand. Environ 

Sci Technol 31:518-522. 
SULFUR MUSTARD 193 

9. REFERENCES 

*Meylan WM, Howard PH. 1993. Computer estimation of the atmospheric gas-phase reaction rate of 

organic compounds with hydroxyl radicals and ozone. Chemosphere 26:2293-2299. 

*Michaelson S. 2000. DNA fragmentation pattern induced in thymocytes by sulphur mustard. Chem 

Biol Interact 125:1-15. 

Millard CB, Bongiovanni R, Broomfield CA. 1997. Cutaneous exposure to bis-(2-chloroethyl)sulfide 

results in neutrophil infiltration and increased solubility of 180,000 Mτ subepidermal collagens. Biochem 

Pharmacol 53:1405-1412. 

Millard CB, Meier HL, Broomfield CA. 1994. Exposure of human lymphocytes to bis-(2-chloroethyl)sulfide solubilizes truncated and intact core histones. Biochem Biophys Acta 1224:389-394. 

Mishima S, Hedbys BO. 1968. Measurement of corneal thickness with the haag-streit pachometer. Arch 

Ophthalmol 80:710-713. 

*Mitretek Systems. 2002. Chemistry of H (mustard). 

http://www.mitretek.org/home.nsf/homelandsecurity/Mustard. 

*Mol MAE, DeVries R, Kluivers AW. 1991. Effects of nicotinamide on biochemical changes and 

microblistering induced by sulfur mustard in human skin organ cultures. Toxicol Appl Pharmacol 

107:439-449. 

*Mol MAE, Van De Ruit ABC, Kluivers AW. 1989. NAD+ levels and the glucose uptake of cultured 

human epidermal cells exposed to sulfur mustard. Toxicol and Applied Pharm 98:159-165. 

*Momeni AZ, Aminjavaheri M. 1994. Skin manifestations of mustard gas in a group of 14 children and 

teenagers: A clinical study. Int J Dermatol 33(3):184-187. 

*Momeni AZ, Enshaeih S, Meghdadi M, et al. 1992. Skin manifestations of mustard gas. Arch 

Dermatol 128:775-780. 

Moore AM, Rockman JB. 1950. A study of human hypersensitivity to compounds of the mustard gas 

type. Can J Res 28E:169-176. 

*Morgenstern P, Koss FR, Alexander WW. 1947. Residual mustard gas bronchitis; effects of prolonged 

exposure to low concentrations. Ann Intern Med 26:27-40. 

*Morselli PL, Franco-Morselli R, Bossi L. 1980. Clinical pharmacokinetics in newborns and infants: 

Age-related differences and therapeutic implications. Clin Pharmacokin 5:485-527. 

*Munavalli S, Jakubowski EW. 1989. Thermospray liquid chromatography/mass spectrometry of 

mustard and its metabolites. Aberdeen Proving Ground, MD: U.S. Army Medical Research Institute of 

Chemical Defense, U.S. Armament Munitions Chemical Command. CRDEC-TR-066. 

*Munavalli S, Jakubowski EM, Durst HD. 1995. Liquid chromatography/thermospray mass 

spectrometry of mustard and its metabolites. J Mass Spectrom 30:1716-1722. 

*Munro NB, Talmage SS, Griffin GD, et al. 1999. The sources, fate, and toxicity of chemical warfare 

agent degradation products. Environ Health Perspect 107(12):933-973. 
 

SULFUR MUSTARD 194 

9. REFERENCES 

Murphy ML. 1959. Comparison of the teratogenic effects of five polyfunctional alkylating agent on the 

rat fetus. Pediatrics 23:231-244. 

Murphy RJ. 1979. Air pollution aspects of hazardous material disposal. Proc Annu WWEMA Ind Pollut 

Conf 7:163-170. 

*Murray VS, Volans GN. 1991. Management of injuries due to chemical weapons. Br Med J. 

19:302(6769):129-30. 

*NAC/AEGL. 2001. Acute exposure guideline levels (AEGLs) for sulfur mustard (Agent HD). Final 

acute exposure guideline levels (AEGLs). National Advisory Committee on Exposure Guideline Levels 

for Hazardous Substances. 

*Nagy SM, Columbic D, Stein WH, et al. 1946. The penetration of vesicant vapors into human skin. J 

Gen Physiol 29:441-445. 

*Nakamura T. 1956. [Studies on the warfare gas-injury in Japan. Report I: On the general condition of 

the poison gas island.] Hiroshima Med J 4:1141-1149. (Japanese) 

*NAS/NRC. 1989. Biologic markers in reproductive toxicology. National Academy of 

Sciences/National Research Council. Washington, DC: National Academy Press, 15-35. 

Needham DM, Cohen JA, Barrett AM. 1947. The mechanism of damage to the bone marrow in systemic 

poisoning with mustard gas. Biochemistry 41:631-639. 

Nersessians AK. 1992. Activity of human carcinogens in the salmonella and rodent bone marrow 

cytogenetic tests. Mutat Res 281:239-243. 

Newman-Taylor AJ, Morris AJR. 1991. Experience with mustard gas casualties. Lancet 337:242. 

*NIOSH. 2003. Mustard Emergency Response Card. National Institute for Occupational Safety and 

Health. http://www.bt.cdc.gov/agent/mustardgas/erc505-60-2pr.asp. March 20, 2003. 

*Nishimoto Y, Burrows B, Miyanishi S, et al. 1970. Chronic obstructive lung disease in Japanese 

poisoning gas workers. Am Rev Resp Disease 102:173-179. 

Nishimoto Y, Yamakido M, Ishioka S, et al. 1988. Epidemiological studies of lung cancer in Japanese 

mustard gas workers. In: Miller RW, et al. Unusual occurrences as clues to cancer etiology. Tokyo: 

Japan Science Society Press, 95-101. 

*Nishimoto Y, Yamakido M, Shigenobu T, et al. 1983. Long term observation of poison gas workers 

with special reference to respiratory cancers. J UOEH 5:89-94. 

*Niu T, Matijasevic Z, Austin-Ritchie P, et al. 1996. A 32P-postlabeling method for the detection of 

adducts in the DNA of human fibroblasts exposed to sulfur mustard. Chem Biol Interact 100:77-84. 

*Noort D, Hulst AG, de Jong LPA, et al. 1999. Alkylation of human serum albumin by sulfur mustard in 

vitro and in vivo: Mass spectrometric analysis of a cysteine adduct as a sensitive biomarker of exposure. 

Chem Res Toxicol 12:715-721. 
 

SULFUR MUSTARD 195 

9. REFERENCES 

*Noort D, Hulst AG, Trap HC, et al. 1997. Synthesis and mass spectrometric identification of the major 

amino acid adducts formed between sulphur mustard and hemoglobin in human blood. Arch Toxicol 

71:171-178. 

*Noort D, Verheij ER, Hulst AG, et al. 1996. Characterization of sulfur mustard induced structural 

modifications in human hemoglobin by liquid chromatography-tandem mass spectrometry. Chem Res 

Toxicol 9:781-787. 

*Norman JE Jr. 1975. Lung cancer mortality in World War I veterans with mustard gas injury 1919­

1965. J Natl Cancer Inst 54:311-318. 

*NRC. 1985. Possible long-term health effects of short-term exposure to chemical agents. Volume 3. 

Current health status of test subjects. Govt Reports Announcements & Index (GRA&I). NTIS/AD-A163 

614/1. Washington, DC: National Academy of Sciences, National Research Council, National Academy 

Press. 

*NRC. 1993. Pesticides in the diets of infants and children. National Research Council. Washington, 

DC: National Academy Press. 

*NRC. 1994. Recommendations for the disposal of chemical agents and munitions. National Research 

Council. Washington, DC: National Academy Press. 

*NRC. 1996. Review and evaluation of alternative chemical disposal technologies. National Research 

Council. Washington, DC: National Academy Press. 

*NRC. 1997. Review of acute human toxicity estimates for selected chemical-warfare agents. 

Committee on Toxicology, National Research Council, Washington, DC. 

http://books.nap.edu/books/0309057493/html/59.html. 

*NRC. 1999a. Review and evaluation of alternative technologies for demilitarization of assembled 

chemical weapons. National Research Council. Washington, DC: National Academy Press. 

*NRC. 1999b. Review of the U.S. Army’s health risk assessments for oral exposure to six chemicalwarfare agents. National Research Council, Washington, DC. National Academy Press. 

*NRC. 2000. Review of the U.S. Army's health risk assessments for oral exposure to six chemicalwarfare agents. National Research Council. Washington, DC: National Academy Press. 

*NRC. 2003. Acute exposure guideline levels for selected airborne chemicals. Volume 3. 

Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, National Research 

Council. Washington, DC: National Academy Press. 

*NRL. 1945. Chamber tests with human subjects. IX. Basic tests with H vapor. Naval Research 

Laboratory, Washington, DC. AD396275. 

NTP. 1989. Fifth annual report on carcinogens. Summary NTP Publication No. 89-239. US 

Department of Health and Human Services. Public Health Service. National Toxicology Program. 

Research Triangle Park, NC. 

*NTP. 2001. National Toxicology Program. http://ntp-server.niehs.nih.gov/. February 27, 2001. 
SULFUR MUSTARD 196 

9. REFERENCES 

Nyska A, Lomnitski L, Maronpot R, et al. 2001. Effects of iodine on inducible nitric oxide synthase and 

cyclooxygenase-2 expression in sulfur mustard-induced skin injury in guinea pigs. Arch Toxicol 74:768­

774. 

*Oak Ridge National Laboratory. 1996. Health risk assessment for sulfur mustard (HD). Appendix E. 

Draft Report. 

Ohmine H, Fujita M, Goriki K, et al. 1984. A study of the genetic effects of occupational exposure to 

mustard gas 2. Jpn J Hum Genet 29:237-238. 

*OPCW. 2001. Organization for the prohibition of chemical weapons, decontamination of chemical 

warfare agents. http://www.opcw.nl/chemhaz/decon.htm. March 13, 2001. 

*Opresko DM, Young RA, Faust RA, et al. 1998. Chemical warfare agents: Estimating oral reference 

doses. Oakridge, TN: Rev Environ Contam Toxicol 56:1-183. 

*Opresko DM, Young RA, Watson AP, et al. 2001. Chemical warfare agents: Current status of oral 

reference doses. Rev Environ Contam Toxicol 172:65-85. 

Orma PS, Middleton RK. 1992. Aerosolized atropine as an antidote to nerve gas. Ann Pharmacother 

26:937-938. 

*OSHA. 1982. Occupational Safety and Health Administration. Federal Register. 47:30420. 

*Owen GM, Brozek J. 1966. Influence of age, sex and nutrition on body composition during childhood 

and adolescence. In: Falkner F, ed. Human development. Philadelphia, PA: WB Saunders, 222-238. 

*Pant SC, Vijayaraghavan R. 1999. Histomorphological and histochemical alterations following shortterm inhalation exposure to sulfur mustard on visceral organs of mice. Biomed Environ Sci 12:201-213. 

*Papirmeister B. 1993. Excitement in vesicant research – yesterday, today, and tomorrow. In: 

Proceedings of the medical defense bioscience review (1993) held in Baltimore, Maryland on 10-13 May 

1993. Vol. 1. Springfield, VA: US Department of Commerce, 1-14. 

*Papirmeister B, Feister AF, Robinson SI, et al. 1991. Medical defense against mustard gas: Toxic 

mechanisms and pharmacological implications. CRC Press, Boca Raton, FL. 

*Papirmeister B, Gross CL, Meier HL, et al. 1985. Molecular basis for mustard-induced vesication. 

Fundam Appl Toxicol 5:S134-S149. 

*Papirmeister B, Gross CL, Petrali JP, et al. 1984a. Pathology produced by sulfur mustard in human skin 

grafts on athymic nude mice: 1. Gross and light microscopic changes. J Toxicol Cutaneous Ocul 

Toxicol 3:371-392. 

*Papirmeister B, Gross CL, Petrali JP, et al. 1984b. Pathology produced by sulfur mustard in human 

skin grafts on athymic nude mice: 2. Ultrastructural changes. J Toxicol Cutaneous Ocul Toxicol 3:393­

408. 

*Pauser G, Aloy A, Caravan M, et al. 1984. Lethal intoxication by war gases on Iranian soldiers. 

Therapeutic interventions on survivors of mustard gas and mycotoxin immersion. Archives Belges:S341­

S351. 
SULFUR MUSTARD 197 

9. REFERENCES 

Pearson GS. 1993. Chemical complications. Nature 365(3443):218. 

Pechura CM. 1993. The health effects of mustard gas and lewisite. JAMA 269:453. 

*Pechura CM, Rall DP. 1993. Veterans at risk: The health effects of mustard gas and lewisite. 

Washington DC: National Academy Press, 117-118. 

http://nap.edu/openbook/030904832X/html/R1.html. July 10, 2001. 

Peters RA. 1947. Biochemical research at Oxford upon mustard gas. Nature 4031:149-153.
 

Petrali JP, Oglesby-Megee S. 1997. Toxicity of mustard gas in skin lesions. Microsc Res Tech 37:221­

228. 

*Pierard GE, Dowlati A, Dowlati Y, et al. 1990. Chemical warfare casualties and yperite-induced 

xerodermoid. Am J Dermatopathol 12(6):565-570. 

*Platteborze PL. 2000. The effects of sulfur mustard on transcription in human epidermal keratinocytes: 

Analysis at early time points through DNA arrays. Toxicol Meth 10:151-163. 

Pleyer U, Sherif Z, Baatz H, et al. 1999. Delayed mustard gas keratopathy: Clinical findings and 

confocal microscopy. Am J Ophthalmol 128:506-507. 

Pons F, Calvet J-H, Haag M, et al. 2001. Altered expression of lung cytochrome P450 3A1 in rat after 

exposure to sulfur mustard. Pharmacol Toxicol 88:40-44. 

*Posner JC. 1991. Evaluation of sorbents for the collection and analysis of trace levels of airborne 

vapors: Bis(2-chloroethyl)sulfide (mustard). A case study. Chemosphere 22:461-472. 

*Pour-Jafari H. 1992. Fetal deaths and parental exposure to chemical warfare agents. Med J Islamic Rep 

Iran 6:87-88.
 

*Pour-Jafari H. 1994a. Secondary sex ratios in progenies of Iranian chemical victims. Vet Hum Toxicol 

36:475-476. 

*Pour-Jafari H. 1994b. Congenital malformations in the progenies of Iranian chemical victims. Vet 

Human Toxicol 36(6):562-563. 

*Pour-Jafari H, Moushtaghi A. 1992. Alterations of libido in gassed Iranian men. Vet Hum Toxicol 

34(6):547. 

*Prentiss AN. 1937. Chemicals in war. New York: McGraw-Hill. 

*Price CC, Bullitt IH. 1947. Hydrolysis and oxidation of mustard gas and related compounds in aqueous 

solution. J Org Chem 12:238-248. 

Price CC, Wakefield LB. 1947. Reactions and analysis of B-chloroethyl sulfide in water. J Org Chem
 

12:232-237. 

Probst GS, Hill LE, Bewsey BJ. 1980. Comparison of 3 in vitro assays for carcinogen-induced DNA 

damage. J Toxicol Environ Health 6:333-349. 
 

 

SULFUR MUSTARD 198 

9. REFERENCES 

Probst GS, McMahon RE, Hill CZ, et al. 1981. Chemically-induced unscheduled DNA synthesis in 

primary rat hepatocyte cultures: A comparison with bacterial mutagenicity using 218 compounds. 

Environ Mutagen 3:11-32. 

*Pu Y, Lin P, Vaughan FL, et al. 1995. Appearance of interleukin 1α relates DNA interstrand cross-links 

and cytotoxicity in cultured human keratinocytes exposed to bis-(2chloroethyl)sulfide. J Appl Toxicol 

15:477-482. 

*Rao PVL, Vijayaraghavan R, Bhaskar ASB. 1999. Sulphur mustard induced DNA damage in mice 

after dermal and inhalation exposure. Toxicology 139:39-51. 

Ray P, Chakrabarti AK, Broomfield CA, et al. 2002. Sulfur mustard-stimulated protease: a target for 

antivesicant drugs. J Appl Toxicol 22:139-140. 

Ray R, Benton BJ, Anderson DR, et al. 1999. Poly(ADP-ribose) polymerase (PARP) mediated 

mechanisms of sulphur mustard (SM) toxicity and its protection. FASEB J 13(7):A1341. 

Ray R, Legere RH, Majerus BJ, et al. 1995. Sulfur mustard-induced increase in intracellular free calcium 

level and arachidonic acid release from cell membrane. Toxicol Appl Pharmacol 131:45-52. 

*Ray R, Majerus BJ, Munavalli GS, et al. 1993. Sulfur mustard-induced increase in intracellular 

calcium: A mechanism of mustard toxicity. In: Proceedings of the medical defense bioscience review 

(1993) held in Baltimore, Maryland on 10-13, May 1993. Vol. 1. Springfield, VA: US Department of 

Commerce, 267-276. 

Reddy PMK, Dubey DK, Kumar P, et al. 1996. Evaluation of CC-2 as a decontaminant at various time 

intervals against topically applied sulphur mustard in mice. Indian J Pharmacol 28:227-231. 

*Reed CI. 1918. The minimum concentration of mustard gas effective for man. Preliminary Report. 

War Department, Medical Division, Pharmacological Research Section, American University Experiment 

Station, Washington, DC. Report 318. 

Reed CI, Hopkins EF, Weyand CF. 1918. The minimum concentration of mustard gas effective for man. 

Final Report. War Department, Medical Division, Pharmacological Research Section, American 

University Experiment Station, Washington, DC. Report 329. 

Reed CI. 1920. The minimum concentration of dichlorethylsulfide (mustard gas) effective for man. J 

Pharmacol Exp Ther 15:77-80. 

Rees J, Harper P, Ellis F. 1991. Mustard gas casualties. Lancet 337:430. 

Reid BD, Walker IG. 1969. The response of mammalian cells to alkylating agents. II. On the 

mechanism of the removal of sulfur-mustard-induced cross-links. Biochem Biophys Acta 179:179-182. 

*Renshaw B. 1946. Mechanisms in production of cutaneous injuries by sulfur and nitrogen mustards. 

In: Chemical warfare agents and related chemical problems. Vol. 4. Chapter 23, Washington, DC: U.S. 

Office of Scientific Research and Development, National Defense Research Committee, 479-518. 

Renwick AG, Lazarus NR. 1998. Human variability and noncancer risk assessment-an analysis of the 

default uncertainty factor. Regul Toxicol Pharmacol 27:3-20. 
 

 

SULFUR MUSTARD 199 

9. REFERENCES 

Requena L, Requena C, Sanchez G, et al. 1988. Chemical warfare. Cutaneous lesions from mustard gas. 

J Am Acad Dermatol 19:529-536. 

*Rewick RT, Schumacher ML, Haynes DL. 1986. The UV absorption spectra of chemical agents and 

stimulants. Appl Spectrosc 40(2):152-156. 

*Ribeiro PL, Mitra RS, Bernstein IA. 1991. Assessment of the role of DNA damage and repair in the 

surviving cultures of rat cutaneous keratinocytes exposed to bis(2-chloroethyl) sulfide. Toxicol Appl 

Pharmacol 111(2):342-51. 

Rikimaru T, Nakamura M, Yano T, et al. 1991. Mediators, initiating the inflammatory response, released 

in organ culture by full-thickness human skin explants exposed to the irritant, sulfur mustard. J Invest 

Dermatol 96:888-897. 

Riviere JE, Brooks JD, Williams PL, et al. 1995. Toxicokinetics of tropical sulfur mustard penetration, 

disposition, and vascular toxicity in isolated perfused porcine skin. Toxicol Appl Pharmacol 135:25-34. 

Riviere JE, Monteiro-Riviere NA, Baynes RE, et al. 2002. Gulf war related exposure factors influencing 

topical absorption of 14C-permethrin. Toxicol Lett 135:61-71. 

Riviere JE, Smith CE, Budsaba K, et al. 2001. Use of methyl salicylate as a simulant to predict the 

percutaneous absorption of sulfur mustard. J Appl Toxicol 21:91-99. 

*Roberts JJ, Warwick GP. 1963. Studies of the mode of action of alkylating agents-VI. The metabolism 

of bis-β-chloroethylsulfide (mustard gas) and related compounds. Biochem Pharmacol 12:1239-1334. 

*Rohrbaugh DK, Yang YC. 1997. Liquid chromatography/electrospray mass spectrometry of mustardrelated sulfonium ions. J Mass Spectrom 32:1247-1252. 

Rohrbaugh DK, Yang Y-C, Ward JR. 1988. Identification of degradation products of 2-chloroethyl ethyl 

sulfide by gas chromatography-mass spectrometry. J Chromatogr 447:165-169. 

Romano Jr JA, King JM. 2001. Psychological casualties resulting from chemical and biological 

weapons. Mil Med 166:21-22. 

Rommerim RL, Hackett PL. 1986. Evaluation of the teratogenic potential of the mustards. Teratology 

33:70C. 

*Rosenblatt DH, Miller TA, Dacre JC, et al. 1975. Problem definition studies on potential environmental 

pollutants. II. Physical, chemical, toxicological, and biological properties of 16 substances. Fort Detrick, 

MD: U.S. Army Medical Bioengineering Research Development Laboratory. TR-7509. 

*Rosenblatt DH, Small MJ, Kimmell TA, et al. 1996. Background chemistry for warfare agents and 

decontamination processes in support of delisting waste streams at the U.S. Army Dugway Proving 

Ground, Utah. 

Rosenthal DS, Simbulan-Rosenthal CM, Liu WF, et al. 2001. PARP determines the mode of cell death 

in skin fibroblasts, but not keratinocytes, exposed to sulfur mustard. J Invest Dermatol 117:1566-1573. 
SULFUR MUSTARD 200 

9. REFERENCES 

*Rosenthal DS, Simbulan-Rosenthal CMG, Spoonde SIA, et al. 1998. Sulfur mustard induces markers 

of terminal differentiation and apoptosis in keratinocytes via a Ca2+-calmodulin and capase-dependent 

pathway. J Invest Dermatol 111:64-71. 

*Rozmiarek H, Capizzi RL, Papirmeister B, et al. 1973. Mutagenic activity in somatic and germ cells 

following chronic inhalation of sulfur mustard. Mutat Res Sect Environ Mutag Relat Sub 21:13-14. 

Ruhl CM, Park SJ, Danisa O, et al. 1994. A serious skin sulfur mustard burn from an artillery shell. 

J Emerg Med 12(2):159-166. 

Safaei A, Saluti R, Kumar PV. 2001. Conjunctival dysplasia in soldiers exposed to mustard gas during 

the Iraq-Iran war. Acta Cytol 45(6):909-913. 

Safarinejad MR. 2001. Testicular effect of mustard gas. Urology 58:90-94. 

Safarinejad MR, Moosavi SA, Montazeri B. 2001. Ocular injuries caused by mustard gas: diagnosis, 

treatment, and medical defense. Mil Med 166(1):67-70. 

Sage GW, Howard PH. 1989. Environmental fate assessments of chemical agents: HD and VX. 

Chemical Hazard Assessment Division. Syracuse, NY: Syracuse Research Corporation. 

*Sandelowsky I, Simon GA, Barak R, et al. 1992. N1

-(2-hydroxyethylthioethyl)-4-methyl imidazole (4­

met-1-imid-thiodiglycol) in plasma and urine: A novel metabolite following dermal exposure to sulphur 

mustard. Arch Toxicol 66:296-297. 

*Sass S, Steger RJ. 1982. Gas chromatographic differentiation and estimation of some sulfur and 

nitrogen mustards using a multidetector technique. J Chromatogr 238:121-132. 

*Sass S, Stutz MH. 1981. Thin-layer chromatography of some sulfur and nitrogen mustards. 

J Chromatogr 213:173-176. 

Sasser LB, Cushing JA, Dacre JC. 1990. Dominant lethal effect of sulfur mustard in rats. Toxicologist 

10(1):225. 

*Sasser LB, Cushing JA, Dacre JC. 1993. Dominant lethal study of sulfur mustard in male and female 

rats. J Appl Toxicol 13(5):359-368. 

*Sasser LB, Cushing JA, Dacre JC. 1996a. Two-generation reproduction study of sulfur mustard in rats. 

Reprod Toxicol 10(4):311-319. 

*Sasser LB, Miller RA, Kalkwarf DR, et al. 1996b. Subchronic toxicity evaluation of sulfur mustard in 

rats. J Appl Toxicol 16(1):5-13. 

*Sawyer TW. 1998. Characterization of the protective effects of L-nitroarginine methyl ester (L-NAME) 

against the toxicity of sulphur mustard in vitro. Toxicology 131:21-32. 

*Sawyer TW. 1999. Synergistic protective effects of selected arginine analogues against sulphur 

mustard toxicity in neuron culture. Toxicol Appl Pharmacol 155:169-176. 

Sawyer TW, Risk D. 2000. Effects of selected arginine analogues on sulphur mustard toxicity in human 

and hairless guinea pig skin keratinocytes. Toxicol Appl Pharmacol 163:75-85. 
SULFUR MUSTARD 201 

9. REFERENCES 

*Sawyer TW, Hancock JR, D'Agostino PA. 1998. L-Thiocitrulline: A potent protective agent against 

the toxicity of sulphur mustard in vitro. Toxicol Appl Pharmacol 151:340-346. 

*Sawyer TW, Lundy PM, Weiss MT. 1996. Protective effect of an inhibitor of nitric oxide synthase on 

sulphur mustard toxicity in vitro. Toxicol Appl Pharmacol 141:138-144. 

*Sax IN, Lewis RJ. 1989. Dangerous properties of industrial materials. Volume II. 7th ed. New York: 

Van Nostrand Reinhold, 477. 

*SBCCOM. 1999. Distilled mustard (HD). Material safety data sheet. U.S. Army Soldier and 

Biological Chemical Command. http://in1.apgea.army.mil/RDA/msds/hd.htm. July 12, 2001. 

*SBCCOM. 2001. M291 Skin decontamination kit. U.S. Army Soldier and Biological Chemical 

Command. http://www.sbccom.apgea.army.mil/products/m291.htm. March 14, 2001. 

*SBCCOM. 2002. Biological and chemical agent quick reference tables. U.S. Army Soldier and 

Biological Chemical Command. http://www.sbccom.apgea.army.mil/products/m291.htm. March 12, 

2002. 

Schlager JJ, Hart BW. 2000. Stress gene activity in HepG2 cells after sulfur mustard exposure. J Appl 

Toxicol 20:395-405. 

*Scholz RO. 1945. Clinical and pathological studies of ocular mustard gas burns. Fasciculus on 

Chemical Warfare Medicine. Volume I, Eye. Washington, DC: National Research Council, Division of 

Medical Sciences, Committee on Treatment of Gas Casualties, 155-191. 

*Scholz RO, Woods AC. 1945. Relapsing and chronic mustard gas lesions of the eyes. Fasciculus on 

Chemical Warfare Medicine. Volume I, Eye. Washington, DC: National Research Council, Division of 

Medical Sciences, Committee on Treatment of Gas Casualties, 260-278. 

Scott D, Marshall RR. 1977. Relationships between DNA repair chromosome aberrations and survival in 

mammalian cells. Mutat Res 46:154-155. 

*Scott D, Fox M, Fox BW. 1974. The relationship between chromosomal aberrations, survival, and 

DNA repair in tumor cell lines of differential sensitivity to x-rays and sulphur mustard. Mutat Res 

22:207-221. 

*Seidell A. 1941. Solubilities of organic compounds. A compilation of quantitative solubility data from 

the periodical literature. Vol. 11, 3rd Edition. New York: D. Van Nostrand Company, Inc. 241-242. 

*Setchell BP, Waites GMH. 1975. The blood-testis barrier. In: Creep RO, Astwood EB, Geiger SR, 

eds. Handbook of physiology: Endocrinology V. Washington, DC: American Physiological Society. 

Shahin S, Cullinane C, Gray PJ. 2001. Mitochondrial and nuclear DNA damage induced by sulphur 

mustard in keratinocytes. Chem Biol Interact 138:231-245. 

Shakil FA, Kuramoto A, Yamakido M, et al. 1993. Cytogenetic abnormalities of hematopoietic tissue in 

retired workers of the Ohkunojima poison gas factory. Hiroshima J Med Sci 42(4):159-165. 
SULFUR MUSTARD 202 

9. REFERENCES 

Sherer RA, Price PS. 1993. The effect of cooking processes on PCB levels in edible fish tissue. Qual 

Assur Good Prac Reg Law 2(4):396-407. 

Shih ML, Korte WD, Smith JR, et al. 1999a. Analysis and stability of the candidate sulfur mustard 

decontaminant S-330. J Appl Toxicol 19:S89-S95. 

Shih ML, Korte WD, Smith JR, et al. 1999b. Reactions of sulfides with S-330, a potential 

decontaminant of sulfur mustard in formulations. J Appl Toxicol 19:S83-S88. 

Shimkin MB, McClelland JN. 1949. Induced pulmonary tumors in mice. IV. Analysis of dose response 

data with methyl-cholanthrene. J Natl Cancer Inst 10:597-603. 

Sidell FR, Hurst CG. 1992. Clinical considerations in mustard poisoning. In: Somani AM ed. 

Chemical warfare agents. New York: Academic Press, 51-67. 

*Sinclair DC. 1948. The clinical features of mustard-gas poisoning in man. Br Med J 290-294. 

*Sinclair DC. 1950. Disability produced by exposure of skin to mustard-gas vapor. Br Med J 346-348. 

SIPRI. 1975. Delayed toxic effects of chemical warfare agents: A SIPRI monograph. Stockholm: 

Stockholm International Peace Research Institute. 

*SIPRI. 1971. The Problem of chemical and biological warfare: A study of the historical, technical, 

military, legal, and political aspects of CBW, and possible disarmament measures. Stockholm 

International Peace Research Institute. Stockholm, Sweden: Almqvist & Wiksell, 125-305. 

Sklyar VI, Mosolova TP, Kuchernko IA, et al. 1999. Anaerobic toxicity and biodegradability of 

hydrolysis products of chemical warfare agents. Appl Biochem Biotech 81:107-117. 

*Small MJ. 1984. Compounds formed from the chemical decontamination of HD, GB, and VX and their 

environmental fate. U.S. Army Research and Development Command. Frederick, Maryland. 

Smith CN, Lindsay CD. 2001a. Kojic acid reduces the cytotoxic effects of sulfur mustard on cultures 

containing human melanoma cells in vitro. J Appl Toxicol 21:435-440. 

Smith CN, Lindsay CD. 2001b. Stimulation of C32 and G361 melanoma cells using oleoyl acetyl 

glycerol and its effect on sulphur mustard cytotoxicity. Hum Exp Toxicol 20:418-425. 

*Smith JE, Fowler WK. 1985. Analytical methods development. Final report. Contract DAAK 11-82­

C-0162. 

*Smith JR, Shih ML. 2001. Analysis of the degradation compounds of chemical warfare agents using 

liquid chromatography/mass spectrometry. J Appl Toxicol 21:S27-S34. 

Smith WJ, Dunn MA. 1991. Medical defense against blistering chemical warfare agents. Arch Dermatol 

127:1207-1213. 

Smith WJ, Gross CL. 2002. Sulfur mustard medical countermeasures in a nuclear environment. Mil 

Med 167:101-102. 
 

SULFUR MUSTARD 203 

9. REFERENCES 

Smith C, Lindsay C, Upshall D. 1997. Presence of methenamine/glutathione mixtures reduces the 

cytotoxic effect of sulfur mustard on cultured SVK-14 human keratinocytes in vitro. Hum Exp Toxicol 

16:247-253. 

Smith CN, Lindsay CD, Hambrook JL. 2001. An in vitro comparison of the cytotoxicity of sulphur 

mustard in melanoma and keratinocyte cell lines. Hum Exp Toxicol 20:483-490. 

*Smith HW, Clowes GHA, Marshall JV. 1919. On dichloroethylsulfide (mustard gas). IV. The 

mechanism of absorption by the skin. J Pharmacol Exp Ther 13:1-30. 

*Smith JE, Boyd WB, Mason DW. 1982. Depot Area Air Monitoring System and VX Study. Final 

Report. Contract DAAK 11-77-c-0087. Task orders 6 and 7. Report # ARCS-CR-82052. 

*Smith KJ, Graham JS, Hamilton TA, et al. 1997a. Immunohistochemical studies of basement 

membrane proteins and proliferation and apoptosis markers in sulfur mustard induced cutaneous lesions 

in weanling pigs. J Dermatol Sci 15:173-182. 

Smith KJ, Hamilton T, Smith WJ, et al. 1996. Immunohistochemical staining of basement membrane 

proteins after topical exposure of human skin to nitrogen and sulfur mustard. In: 1996 Medical defense 

bioscience review: Proceedings. Vol. II. 12-16 May. Aberdeen, MD; N: U.S. Army Medical Research 

Institute of Chemical Defense; 1093-1103. 

Smith KJ, Hurst CG, Moeller RB, et al. 1995. Sulfur mustard: Its continuing threat as a chemical 

warfare agent, the cutaneous lesions induced, progress in understanding its mechanism of action, its longterm health effects, and new developments for protection and therapy. J Am Acad Dermatol 32:765-778. 

*Smith KJ, Skelton HG, Martin JL, et al. 1997b. CO2 laser debridement of sulphur mustard (bis-2­

chloroethyl sulphide) induced cutaneous lesions accelerates production of a normal epidermis with 

elimination of cytological atypia. Br J Dermatol 137:590-594. 

*Smith PH, Nadkarni MV, Trams EG, et al. 1958. Distribution and fate of alkylating agents. Ann NY 

Acad Sci 68:834-852. 

*Smith WJ, Baskin SI, Filbert MG, et al. 2000. Editorial. Introduction to vesicant supplement of Journal 

of Applied Toxicology. J Appl Toxicol 20(Suppl 1):661. 

Smith WJ, Gross CL, Chan P, et al. 1990a. The use of human epidermal keratinocytes in culture as a 

model for studying the biochemical mechanisms of sulfur mustard toxicity. Cell Biol Toxicol 6(3):285­

291. 

Smith WJ, Gross CL, Chan P, et al. 1990b. Use of human epidermal keratinocytes in culture as a model 

for studying the biochemical mechanisms of sulfur mustard toxicity. Govt Reports Announcements & 

Index. NTIS/AD-A230 926/8. 

*Smith WJ, Martens ME, Gross CL, et al. 1998. Biochemical and flow cytometric studies of the 

mechanism of action of sulfur mustard using human cells in culture. In: Salem H, Katz SA, eds. 

Advances in animal alternatives for safety and efficacy testing. Washington, DC: Taylor and Francis 99­

101. 

*Smith WJ, Sanders KM, Ruddle SE, et al. 1993a. Cytometric analysis of DNA changes induced by 

sulfur mustard. J Toxicol Cutaneous Ocul Toxicol 12(4):337-347. 
 

SULFUR MUSTARD 204 

9. REFERENCES 

Smith WJ, Sanders KM, Ruddle SE, et al. 1993b. Cytometric analysis of DNA changes induced by 

sulfur mustard. In: Proceedings of the medical defense bioscience review (1993) held in Baltimore, 

Maryland on 10-13 May 1993. Vol. 1. Springfield, VA: US Department of Commerce, 189-198. 

Snider TH, Blank JA, Reid FM, et al. 1996. Evaluation of the weanling pig as a model for sulfur 

mustard induced microvesication. In: 1996 Medical defense bioscience review: Proceedings. Vol. II. 

12-16 May. Columbus, OH: Medical Research and Evaluation Facility, 1121-1128. 

Snyder RE, Schulte BE, Mangoba L, et al. 1983. Research and development of hazardous/toxic waste 

analytical screening procedures: Available field methods for rapid screening of hazardous waste 

materials at waste sites. Final report. Fort Detrick, Frederick, MD: U.S. Army Medical Research and 

Development Command. DAMD17-78-C-8075. 

Sokal JE, Lessman EM. 1960. Effects of cancer chemotherapeutic agents on the human fetus. J Am 

Med Assoc 172:1765-1771. 

*Solberg Y, Alcalay M, Belkin M. 1997. Ocular injury by mustard gas. Surv Ophthalmol 41(6):461­

466. 

*Somani SM. 1992. Toxicokinetics and toxicodynamics of mustard. In: Chemical warfare agents. San 

Diego, CA: Academic Press Inc., 13-50. 

*Somani SM, Babu SR. 1989. Toxicodynamics of sulfur mustard. Int J Clin Pharmacol Ther Toxicol 

27:419-435. 

*Sonbati EM, Auerbach C. 1960. The brood pattern for intragenic and intergenic changes after mustard 

gas treatment of Drosophila males. Zeitschrift fur Vererbungslehre 91:253-258. 

Spencer PS, Daniels J, Kisby G. 2000. Mustard warfare agents and related substances. In: Spencer PS, 

Schaumburg HH, Ludolph AC, eds. Experimental and clinical neurotoxicology. 2nd Ed. New York, NY: 

Oxford University Press, 837-848. 

Spoo JW, Monteiro-Riviere NA, Riviere JE. 1995. Detection of sulfur mustard bis (2-chloroethyl) 

sulfide and metabolites after topical application in the isolated perfused porcine flap. Life Sci 

56(17):1385-1394. 

*Stein WH. 1946. Chemical reactions of sulfur and nitrogen mustards. Chemical warfare agents and 

related chemical problems. Parts III-IV. Summary technical report of Division 9, NRDC, 389-414. 

Stein WH, Moore S, Bergmann M. 1946. Chemical reactions of mustard gas and related compounds. J 

Org Chem 11:664-674. 

*Sterri SH. 1993. Effect of s-mustard on stress response. In: Proceedings of the medical defense 

bioscience review (1993) held in Baltimore, Maryland on 10-13 May 1993. Vol. 1. Springfield, MA: 

US Department of Commerce, 285-292. 

Stewart DL, Sass EJ, Fritz LK, et al. 1989. Toxicology studies on lewisite and sulfur mustard agents: 

Mutagenicity of sulfur mustard in the Salmonella histidine reversion assay. Final Report, PNL-6873. 

Pacific Northwest Laboratories, Richland, WA. ADA213102. 
SULFUR MUSTARD 205 

9. REFERENCES 

*Stutz MH, Sass S. 1969. Qualitative thin-layer chromatography of some mustards (HD, Q, HN-1, HN2, HN-3, and T). Edgewood Arsenal technical report. Edgewood Arsenal, Maryland: Department of the 

Army, Edgewood Arsenal, Research Laboratories, Chemical Research Laboratories. EATR 4283. 

*Sugendran K, Jeevaratnam K, Vijayaraghavan R, et al. 1994. Therapeutic efficacy of saline and 

glucose-saline against dermally applied sulphur mustard intoxication in mice. Def Sci J 44(1):21-23. 

Sulzberger MB, Baer RL, Kanof A, et al. 1945. Skin sensitization to vesicant agents of chemical 

warfare. Fasciculus on chemical warfare medicine. Ithaca NY: Cornell University, 16-66. 

*Sulzberger MB, Baer RL, Kanof A, et al. 1947. Skin sensitization to vesicant agents of chemical 

warfare. J Invest Dermatol 8:365-393. 

Suryanarayana MVS, Shrivastava RK, Pandey D, et al. 2001. Simple time weighted average level airmonitoring method for sulfur mustard in work places. J Chromatogr A 907:229-234. 

SwRI. 2001. Ensuring environmental safety. Southwest Research Institute. 

http://www.swri.com/3pubs/ttoday/summer98/safe.htm. March 17, 2001. 

Taher AA. 1992. Cleft lip and palate in Tehran. Cleft Palate Craniofac J 29:15-16. 

Takeshima Y, Inai K, Bennett WP, et al. 1994. Accelerated paper, p53 mutations in lung cancers from 

Japanese mustard gas workers. Carcinogenesis 15(10):2075-2079. 

ten Berge WF, Zwart A, Appelman LM. 1986. Concentration-time mortality response relationship of 

irritant and systematically acting vapours and gases. J Hazard Mater 13(3):301-309. 

*Thomsen AB, Eriksen J, Smidt-Nielsen K. 1998. Chronic neuropathic symptoms after exposure to 

mustard gas: A long-term investigation. J Am Acad Dermatol 39:187-190. 

*Tokuoka S, Hayashi Y, Inai K, et al. 1986. Early cancer and related lesions in the bronchial epithelium 

in former worker of mustard gas factory. Acta Pathologica Japonica 36:533-542. 

TRI00. 2003. Toxic Chemical Release Inventory. National Library of Medicine, National Toxicology 

Information Program, Bethesda, MD. http://www.epa.gov/triexplorer/chemical.htm. August, 2003. 

*Uhde G, Dunphy EB. 1946. The effect of oily drops on eyes exposed to mustard vapor. Intelligence 

Division Report No. 2981. Great Britain. 

*Uhrig HT. 1962. Some medical aspects of chemical agents. J M A Alabama 32:144-150. 

United States Army Chemical Activity WESTCOM. 1989. Environmental Laboratory Section 

Operations. SOP No ELS-3. 

*USACHPPM. 1999. Derivation of health-based environmental screening levels for chemical warfare 

agents. A technical evaluation. U.S. Army Center for Health Promotion and Preventive Medicine. 

*USACHPPM. 2000a. Evaluation of airborne exposure limits for sulfur mustard: occupational and 

general population exposure criteria. U.S. Army Center for Health Promotion and Preventive Medicine. 

Technical Report 47-EM-3767-01. 
 

SULFUR MUSTARD 206 

9. REFERENCES 

*USACHPPM. 2000b. Recommendations regarding chronic toxicological criteria for chemical warfare 

compounds. Memo for Office of the Surgeon General. 

*USACHPPM. 2003. Chemical Warfare Agent Standards Derivation. Environmental Medicine 

Program. U.S. Army Center for Health Promotion and Preventive Medicine. http://chppmwww.apgea.army.mil/doem/EMP.asp. 

U.S. Army. 1973. Medical aid for toxic adent victims. Washington, DC: Foreign Science and 

Technology Center, U.S. Army. FSTC-HT-23-1074-73. 

*U.S. Army. 1995. Treatment of chemical agent casualties and conventional military chemical injuries. 

Washington, DC: Department of the Army, FM 8-285. http://www.adtdl.army.mil/cgibin/atdl.dll/query/info/FM+8-285. March 22, 2001. 

*U.S. Army Dugway Proving Ground. 1985. Technical report: Toxic chemicals in the soil environment: 

Volume 2. Interactions of some toxic chemicals/chemical warfare agents and soils. Technical Analysis 

and Information Office, Dugway, Utah. 2-CO-210-049-041. ADA158215. 

*USCWCR. 1999. Chemical weapons convention regulations. U.S. Chemical Weapons Convention 

Regulations. Department of Commerce, Bureau of Export Administration. Federal Register:64:250. 15 

CFR Parts 710 through 722. December 30, 1999. 

*VA. 2001. Claims based on chronic effects of exposure. Veterans Affairs. Code of Federal 

Regulations. 38 CFR 3.316. http://www.acess.gpo.gov/nara/cfr/cfr-table-search.html. June 3, 2001. 

van Delft JHM, van Weert EJM, Schellekens MM, et al. 1991. The isolation of monoclonal antibodies 

selected for the detection of imidazole ring-opened N7-ethylguanine in purified DNA and in cells in situ. 

Cross reaction with methyl, 2-hydroxyethyl and sulphur mustard adducts. Carcinogenesis 12(6):1041­

1049. 

van der Schans GP, Noort D, Mars-Groenendijk RH, et al. 2002. Immunochemical detection of sulfur 

mustard adducts with keratins in the stratum corneum of human skin. Chem Res Toxicol 15:21-25. 

*van der Schans GP, Scheffer AG, Mars-Groenendijk RH, et al. 1994. Immunochemical detection of 

adducts of sulfur mustard to DNA of calf thymus and human white blood cells. Chem Res Toxicol 7:408­

413. 

*Venitt S. 1968. Inter strand cross link in the DNA of Escherichia coli B-R and B-S-1 and their removal 

by the resistant strain mustard gas mutagen. Biochem Biophys Res Commun 31:355-360. 

*Venkateswaran KS, Malhotra RC, Venkateswaran KS. 1994b. Degradation of bacteriophage λ

deoxyribonucleic acid in vitro by sulfur. Biochem Mol Biol Int 34(3):429-435. 

*Venkateswaran KS, Neeraja V, Sugendran K, et al. 1994a. Dose dependent effects on lymphoid organs 

following a single dermal application of sulphur mustard in mice. Hum Exp Toxicol 13:247-251. 

*Vieira I, Sonnier M, Cresteil T. 1996. Developmental expression of CYP2E1 in the human liver: 

Hypermethylation control of gene expression during the neonatal period. Eur J Biochem 238:476-483. 

VIEW Database. 1989. Agency for Toxic Substances and Disease Registry (ATSDR), Office of External 

Affairs, Exposure and Disease Registry Branch, Atlanta, GA. September 1989. 
SULFUR MUSTARD 207 

9. REFERENCES 

*Vijaayaraghavan R. 1997. Modifications of breathing pattern induced by inhaled sulphur mustard in 

mice. Arch Toxicol 71:157-164. 

*Vijayaraghavan R, Kumar P, Joshi U, et al. 2001. Prophylactic efficacy of amifostine and its analogues 

against sulphur mustard toxicity. Toxicology 163:83-91. 

*Vijayaraghavan R, Sugendran K, Pant SC, et al. 1991. Dermal intoxication of mice with bis(2­

chloroethyl)sulphide and the protective effect of flavonoids. Toxicology 69:35-42. 

*Vogt RF Jr, Dannenberg AM Jr, Schofield BH. 1984. Pathogenesis of skin lesions caused by sulfur 

mustard. Fundam Appl Toxicol 4:71-83. 

*Vojvodic V, Milosavljevic Z, Boskovic B, et al. 1985. The protective effect of different drugs in rats 

poisoned by sulfur and nitrogen mustards. Toxicol 5:S160-S168. 

*Vycudilik W. 1985. Detection of mustard gas bis(2-chloroethyl) sulfide in urine. Forensic Sci Int 

28:131-136. 

*Vycudilik W. 1987. Detection of bis(2-chloroethyl) sulfide (yperite) in urine by high resolution gas 

chromatography-mass spectrometry. Forensic Sci Int 35:67-71. 

Wada S, Nishimoto Y, Miyanish M, et al. 1962. Malignant respiratory tract neoplasms related to poison 

gas exposure. Hiroshima J Med Sci 11:81-91. 

*Wada S, Nishimoto Y, Niyanishi M, et al. 1968. Mustard gas as a cause of respiratory neoplasia in 

man. Lancet 1:1161-1163. 

*Walker IG, Thatcher CJ. 1968. Lethal effects of sulfur mustard on dividing mammalian cells. Radiat 

Res 34:110-127. 

Walker JE, Kaplan DL. 1992. Biological degradation of explosives and chemical agents. 

Biodegradation 3:369-385. 

*Wariishi H, Itoh N, Yoshida M, et al. 2002. Complete degradation of yperite, a chemical warfare agent, 

by basidiomycetes. Biotechnol Lett 24:501-505. 

*Warthin AS, Weller CV. 1919. The medical aspects of mustard gas poisoning. St. Louis: C.V. Mosby. 

Waters MD, Garrett NE, Covone-de Serres CM, et al. 1983. Genetic toxicology of some known or 

suspected human carcinogens. In: de Serres FJ, ed. Chemical mutagens, principles and methods for their 

detection. New York: Plenum Press, 261-341. 

*Watson AP, Griffin GD. 1992. Toxicity of vesicant agents scheduled for destruction by the chemical 

stockpile disposal program. Environ Health Perspect 98:259-280. 

Watson AP, Jones TD, Griffin GD. 1989. Sulfur mustard as a carcinogen application of relative potency 

analysis to the chemical warfare agents H, HD, and HT. Regul Toxicol Pharmacol 10:1-25. 

*Weiss A, Weiss B. 1975. [Carcinogenesis due to mustard gas exposure in man.] Deutsche Medizinsche 

Wonchenschrift 100:919-923. (German) 
SULFUR MUSTARD 208 

9. REFERENCES 

*West JR, Smith HW, Chasis H. 1948. Glomerular filtration rate, effective renal blood flow, and 

maximal tubular excretory capacity in infancy. J Pediatr 32:10-18. 

*Whitfield D. 1987. A literature review upon the toxicology, mechanism of action and treatment of 

sulphur and nitrogen mustard poisoning. Chemical Defence Establishment, Porton, Wilts, U.K., CDE 

Technical Note No. 840. 

Whitten B, ed. 1963. Kirk-Othmer encyclopedia of chemical technology. Gas warfare agents, nitrogen 

mustards. Vol. 7, 1st ed. New York, NY: The Interscience Encyclopedia, 127-130, 144-145. 

*Widdowson EM, Dickerson JWT. 1964. Chemical composition of the body. In: Comar CL, Bronner 

F, eds. Mineral metabolism: An advanced treatise. Volume II: The elements Part A. New York: 

Academic Press. 

Wilde PE, Upshall DG. 1994. Cysteine esters protect cultured rodent lung slices from sulphur mustard. 

Hum Exp Toxicol 13:743-748. 

*Willems JL. 1989. Clinical management of mustard gas casualties. Annales Medicinae Militaris 

Belgicae, 1989, Vol 3 Supp. Heymans Institute of Pharmacology, University of Ghent Medical School 

and Royal School of the Medical Services, Leopoldskazerne, B-900 Ghent, Belgium. 

Wils ERJ. 1987. Analysis of thiodiglycol in urine of victims of an alleged attack with mustard gas. Part 

II. Prins Maurits Laboratorium, Institute for Chemical and Technological Research, The Netherlands. 

PML 1987-31. 

Wils ERJ, Hulst AJ. 1992. The use of thermospray-liquid chromatography/mass spectrometry for the 

verification of chemical warfare agents. Fresenius J Anal Chem 342:749-758. 

*Wils ERJ, Hulst AG, De Jong AL, et al. 1985. Analysis of thiodiglycol in urine of victims of an alleged 

attack with mustard gas. J Anal Toxicol 9:254-277. 

*Wils ERJ, Hulst AG, de Jong AL. 1992. Determination of mustard gas and related vesicants in rubber 

and paint by gas chromatography-mass spectrometry. J Chromatogr 625:382-386. 

*Wils ERJ, Hulst AG, van Laar J. 1988. Analysis of thiodiglycol in urine of victims of an alleged attack 

with mustard gas part II. J Anal Toxicol 12:15-19. 

*Winternitz MC, Finney WP Jr. 1920. The pathology of mustard poisoning. In: Winternitz MC, ed. 

Pathology of war gas poisoning. New Haven, CT: Yale University Press, 101-111. 

Woessner JF, Dannenberg AM, Pula PJ, et al. 1990. Extracellular collagenase, proteoglycanase and 

products of their activity, released in organ culture by intact dermal inflammatory lesions produced by 

sulfur mustard. J Invest Dermatol 95:717-726. 

*Wormser U, Brodsky B, Green BS, et al. 1997. Protective effect of povidone-iodine ointment against 

skin lesions induced by sulphur and nitrogen mustards and by non-mustard vesicants. Arch Toxicol 

71:165-170. 

Wormser U, Brodsky B, Reich R. 2002. Topical treatment with povidone iodine reduces nitrogen 

mustard-induced skin collagenolytic activity. Arch Toxicol 76:119-121. 
 

SULFUR MUSTARD 209 

9. REFERENCES 

*Wulf HC, Aasted A, Darre E, et al. 1985. Sister chromatid exchanges in fishermen exposed to leaking 

mustard gas shells. Lancet 1:690-691. 

*Yamada A. 1963. On the late injuries following occupational inhalation of mustard gas, with special 

references to carcinoma of the respiratory tract. Acta Pathol Jpn 13(3):131-155. 

*Yamada A. 1974. Patho-anatomical studies on occupational poisoning. Tr Soc Path Jap 63:17-61. 

Yamada A, Hirose F, Miyanishi M. 1953. An autopsy of bronchial carcinoma found in a patient 

succumbed to occupational mustard gas poisoning. Gann 44:216-219. 

Yamada A, Hirose F, Nagai M, et al. 1957. Five cases of cancer of the larynx found in persons who 

suffered from occupational mustard gas poisoning. Gann 48:366-368. 

*Yamakido M, Ishioka S, Hiyama K, et al. 1996. Former poison gas workers and cancer: Incidence and 

inhibition of tumor formation by treatment with biological response modifier N-CWS. Environ Health 

Perspect 104(Suppl. 3):485-488. 

Yamakido M, Ishioka S, Hozawa S, et al. 1992. Effect of nocardia ruba cell-wall skeleton on cancer 

prevention in humans. Cancer Immunol Immunother 34:389-392. 

*Yamakido M, Nishimoto Y, Shigenobu T, et al. 1985. Study of genetic effects of sulfur mustard gas on 

former workers of Ohkunojim poison gas factory and their offspring. Hiroshima J Med Sci 34:311-322. 

Yamakido M, Yanagida J, Ishioka S, et al. 1986. Immune functions of former poison gas workers. I. 

Mitogenic response of lymphocytes and serum factors. Hiroshima J Med Sci 35(2):117-126. 

Yanagida J, Hozawa S, Ishioka S, et al. 1988. Somatic mutation in peripheral lymphocytes of former 

workers at the Okunojima poison gas factory. Jpn J Cancer Res 79:1276-1283. 

*Yang YC, Baker JA, Ward JR. 1992. Decontamination of chemical warfare agents. Chem Rev 

92:1729-1743. 

*Young L. 1947. Observations on the effects of mustard gas on the rat. Canadian Journal of Research; 

Section E: Medical Sciences, 25:141-151. 

*Yourick JJ, Clark CR, Mitcheltree LW. 1991. Niacinamide pretreatment reduces microvesicle 

formation in hairless guinea pigs cutaneously exposed to sulfur mustard. Fundam Appl Toxicol 17:533­

542. 

*Yourick JJ, Dawson JS, Benton CD, et al. 1993. Pathogeneses of 2,2'-dichlorodiethyl sulfide in hairless 

guinea pigs. In: Proceedings of the medical defense bioscience review (1993) held in Baltimore 

Maryland on 10-13, May 1993. Vol. 1. Springfield, VA: US Department of Commerce, 21-30. 

Yourick JJ, Dawson JS, Mitcheltree LW. 1992. Sulfur mustard-induced microvesication in hairless 

guinea pigs: Effect of short-term niacinamide administration. Toxicol Appl Pharmacol 117:104-109. 

Yourick JJ, Dawson JS, Mitcheltree LW. 1995. Reduction of erythema in hairless guinea pigs after 

cutaneous sulfur mustard vapor exposure by pretreatment with niacinamide, promethazine and 

indomethacin. J Appl Toxicol 15:133-138. 
SULFUR MUSTARD 210 

9. REFERENCES 

*Zackerinia M, Namdar M, Alavi S, et al. 1998. Development of hematologic malignancies and aplastic 

anemia following exposure to mustard gas. Irn J Med Sci 23(1&2):5. 

*Zhang B-Z, Wu Y. 1987. Toxicokinetics of sulfur mustard. Chinese J Pharm and Toxicol 1:188-194. 

Zhang P, Ng P, Caridha D, et al. 2002. Gene expressions in Jurkat cells poisoned by a sulphur mustard 

vesicant and the induction of apoptosis. Br J Pharmacol 137:245-252. 

*Zhang Z, Fine JD, Monteiro-Riviere NA. 1998. Uncein may be a potential target for sulfur mustard 

alkylation. Toxicol Meth 8:27-36. 

*Zhang Z, Riviere JE, Monteiro-Riviere A. 1995. Evaluation of protective effects of sodium thiosulfate, 

cysteine, niacinamide and indomethacin on sulfur mustard-treated isolated perfused porcine skin. Chem 

Biol Int 96:249-262. 

*Ziegler EE, Edwards BB, Jensen RL, et al. 1978. Absorption and retention of lead by infants. Pediatr 

Res 12:29-34. 
SULFUR MUSTARD 211 

10. GLOSSARY 

Absorption—The taking up of liquids by solids, or of gases by solids or liquids. 

Acute Exposure—Exposure to a chemical for a duration of 14 days or less, as specified in the 

Toxicological Profiles. 

Adsorption—The adhesion in an extremely thin layer of molecules (as of gases, solutes, or liquids) to the 

surfaces of solid bodies or liquids with which they are in contact. 

Adsorption Coefficient (Koc)—The ratio of the amount of a chemical adsorbed per unit weight of 

organic carbon in the soil or sediment to the concentration of the chemical in solution at equilibrium. 

Adsorption Ratio (Kd)—The amount of a chemical adsorbed by a sediment or soil (i.e., the solid phase) 

divided by the amount of chemical in the solution phase, which is in equilibrium with the solid phase, at a 

fixed solid/solution ratio. It is generally expressed in micrograms of chemical sorbed per gram of soil or 

sediment. 

Benchmark Dose (BMD)—Usually defined as the lower confidence limit on the dose that produces a 

specified magnitude of changes in a specified adverse response. For example, a BMD10 would be the 

dose at the 95% lower confidence limit on a 10% response, and the benchmark response (BMR) would be 

10%. The BMD is determined by modeling the dose response curve in the region of the dose response 

relationship where biologically observable data are feasible. 

Benchmark Dose Model—A statistical dose-response model applied to either experimental toxicological 

or epidemiological data to calculate a BMD. 

Bioconcentration Factor (BCF)—The quotient of the concentration of a chemical in aquatic organisms 

at a specific time or during a discrete time period of exposure divided by the concentration in the 

surrounding water at the same time or during the same period. 

Biomarkers—Broadly defined as indicators signaling events in biologic systems or samples. They have 

been classified as markers of exposure, markers of effect, and markers of susceptibility. 

Cancer Effect Level (CEL)—The lowest dose of chemical in a study, or group of studies, that produces 

significant increases in the incidence of cancer (or tumors) between the exposed population and its 

appropriate control. 

Carcinogen—A chemical capable of inducing cancer. 

Case-Control Study—A type of epidemiological study which examines the relationship between a 

particular outcome (disease or condition) and a variety of potential causative agents (such as toxic 

chemicals). In a case-controlled study, a group of people with a specified and well-defined outcome is 

identified and compared to a similar group of people without outcome. 

Case Report—Describes a single individual with a particular disease or exposure. These may suggest 

some potential topics for scientific research but are not actual research studies. 
SULFUR MUSTARD 212 

10. GLOSSARY 

Case Series—Describes the experience of a small number of individuals with the same disease or 

exposure. These may suggest potential topics for scientific research but are not actual research studies. 

Ceiling Value—A concentration of a substance that should not be exceeded, even instantaneously. 

Chronic Exposure—Exposure to a chemical for 365 days or more, as specified in the Toxicological 

Profiles. 

Cohort Study—A type of epidemiological study of a specific group or groups of people who have had a 

common insult (e.g., exposure to an agent suspected of causing disease or a common disease) and are 

followed forward from exposure to outcome. At least one exposed group is compared to one unexposed 

group. 

Cross-sectional Study—A type of epidemiological study of a group or groups which examines the 

relationship between exposure and outcome to a chemical or to chemicals at one point in time. 

Data Needs—Substance-specific informational needs that if met would reduce the uncertainties of human 

health assessment. 

Developmental Toxicity—The occurrence of adverse effects on the developing organism that may result 

from exposure to a chemical prior to conception (either parent), during prenatal development, or 

postnatally to the time of sexual maturation. Adverse developmental effects may be detected at any point 

in the life span of the organism. 

Dose-Response Relationship—The quantitative relationship between the amount of exposure to a 

toxicant and the incidence of the adverse effects. 

Embryotoxicity and Fetotoxicity—Any toxic effect on the conceptus as a result of prenatal exposure to 

a chemical; the distinguishing feature between the two terms is the stage of development during which the 

insult occurs. The terms, as used here, include malformations and variations, altered growth, and in utero 

death. 

Environmental Protection Agency (EPA) Health Advisory—An estimate of acceptable drinking water 

levels for a chemical substance based on health effects information. A health advisory is not a legally 

enforceable federal standard, but serves as technical guidance to assist federal, state, and local officials. 

Epidemiology—Refers to the investigation of factors that determine the frequency and distribution of 

disease or other health-related conditions within a defined human population during a specified period. 

Genotoxicity—A specific adverse effect on the genome of living cells that, upon the duplication of 

affected cells, can be expressed as a mutagenic, clastogenic or carcinogenic event because of specific 

alteration of the molecular structure of the genome. 

Half-life—A measure of rate for the time required to eliminate one half of a quantity of a chemical from 

the body or environmental media. 

Immediately Dangerous to Life or Health (IDLH)—The maximum environmental concentration of a 

contaminant from which one could escape within 30 minutes without any escape-impairing symptoms or 

irreversible health effects. 
SULFUR MUSTARD 213 

10. GLOSSARY 

Incidence—The ratio of individuals in a population who develop a specified condition to the total 

number of individuals in that population who could have developed that condition in a specified time 

period. 

Intermediate Exposure—Exposure to a chemical for a duration of 15–364 days, as specified in the 

Toxicological Profiles. 

Immunologic Toxicity—The occurrence of adverse effects on the immune system that may result from 

exposure to environmental agents such as chemicals. 

Immunological Effects—Functional changes in the immune response. 

In Vitro—Isolated from the living organism and artificially maintained, as in a test tube. 

In Vivo—Occurring within the living organism. 

Lethal Concentration(LO) (LCLO)—The lowest concentration of a chemical in air which has been 

reported to have caused death in humans or animals. 

Lethal Concentration(50) (LC50)—A calculated concentration of a chemical in air to which exposure for 

a specific length of time is expected to cause death in 50% of a defined experimental animal population. 

Lethal Dose(LO) (LDLO)—The lowest dose of a chemical introduced by a route other than inhalation that 

has been reported to have caused death in humans or animals. 

Lethal Dose(50) (LD50)—The dose of a chemical which has been calculated to cause death in 50% of a 

defined experimental animal population. 

Lethal Time(50) (LT50)—A calculated period of time within which a specific concentration of a chemical 

is expected to cause death in 50% of a defined experimental animal population. 

Lowest-Observed-Adverse-Effect Level (LOAEL)—The lowest exposure level of chemical in a study, 

or group of studies, that produces statistically or biologically significant increases in frequency or severity 

of adverse effects between the exposed population and its appropriate control. 

Lymphoreticular Effects—Represent morphological effects involving lymphatic tissues such as the 

lymph nodes, spleen, and thymus. 

Malformations—Permanent structural changes that may adversely affect survival, development, or 

function. 

Minimal Risk Level (MRL)—An estimate of daily human exposure to a hazardous substance that is 

likely to be without an appreciable risk of adverse noncancer health effects over a specified route and 

duration of exposure. 

Modifying Factor (MF)—A value (greater than zero) that is applied to the derivation of a minimal risk 

level (MRL) to reflect additional concerns about the database that are not covered by the uncertainty 

factors. The default value for a MF is 1. 

Morbidity—State of being diseased; morbidity rate is the incidence or prevalence of disease in a specific 

population. 
SULFUR MUSTARD 214 

10. GLOSSARY 

Mortality—Death; mortality rate is a measure of the number of deaths in a population during a specified 

interval of time. 

Mutagen—A substance that causes mutations. A mutation is a change in the DNA sequence of a cell’s 

DNA. Mutations can lead to birth defects, miscarriages, or cancer. 

Necropsy—The gross examination of the organs and tissues of a dead body to determine the cause of 

death or pathological conditions. 

Neurotoxicity—The occurrence of adverse effects on the nervous system following exposure to a 

chemical. 

No-Observed-Adverse-Effect Level (NOAEL)—The dose of a chemical at which there were no 

statistically or biologically significant increases in frequency or severity of adverse effects seen between 

the exposed population and its appropriate control. Effects may be produced at this dose, but they are not 

considered to be adverse. 

Octanol-Water Partition Coefficient (Kow)—The equilibrium ratio of the concentrations of a chemical 

in n-octanol and water, in dilute solution. 

Odds Ratio (OR)—A means of measuring the association between an exposure (such as toxic substances 

and a disease or condition) which represents the best estimate of relative risk (risk as a ratio of the 

incidence among subjects exposed to a particular risk factor divided by the incidence among subjects who 

were not exposed to the risk factor). An odds ratio of greater than 1 is considered to indicate greater risk 

of disease in the exposed group compared to the unexposed. 

Organophosphate or Organophosphorus Compound—A phosphorus containing organic compound 

and especially a pesticide that acts by inhibiting cholinesterase. 

Permissible Exposure Limit (PEL)—An Occupational Safety and Health Administration (OSHA) 

allowable exposure level in workplace air averaged over an 8-hour shift of a 40-hour workweek. 

Pesticide—General classification of chemicals specifically developed and produced for use in the control 

of agricultural and public health pests. 

Pharmacokinetics—The science of quantitatively predicting the fate (disposition) of an exogenous 

substance in an organism. Utilizing computational techniques, it provides the means of studying the 

absorption, distribution, metabolism and excretion of chemicals by the body. 

Pharmacokinetic Model—A set of equations that can be used to describe the time course of a parent 

chemical or metabolite in an animal system. There are two types of pharmacokinetic models: data-based 

and physiologically-based. A data-based model divides the animal system into a series of compartments 

which, in general, do not represent real, identifiable anatomic regions of the body whereby the 

physiologically-based model compartments represent real anatomic regions of the body. 

Physiologically Based Pharmacodynamic (PBPD) Model—A type of physiologically-based doseresponse model which quantitatively describes the relationship between target tissue dose and toxic end 

points. These models advance the importance of physiologically based models in that they clearly 

describe the biological effect (response) produced by the system following exposure to an exogenous 

substance. 
SULFUR MUSTARD 215 

10. GLOSSARY 

Physiologically Based Pharmacokinetic (PBPK) Model—Comprised of a series of compartments 

representing organs or tissue groups with realistic weights and blood flows. These models require a 

variety of physiological information: tissue volumes, blood flow rates to tissues, cardiac output, alveolar 

ventilation rates and, possibly membrane permeabilities. The models also utilize biochemical information 

such as air/blood partition coefficients, and metabolic parameters. PBPK models are also called 

biologically based tissue dosimetry models. 

Prevalence—The number of cases of a disease or condition in a population at one point in time. 

Prospective Study—A type of cohort study in which the pertinent observations are made on events 

occurring after the start of the study. A group is followed over time. 

q1*—The upper-bound estimate of the low-dose slope of the dose-response curve as determined by the 

multistage procedure. The q1* can be used to calculate an estimate of carcinogenic potency, the 

incremental excess cancer risk per unit of exposure (usually μg/L for water, mg/kg/day for food, and 

μg/m3

 for air). 

Recommended Exposure Limit (REL)—A National Institute for Occupational Safety and Health 

(NIOSH) time-weighted average (TWA) concentrations for up to a 10-hour workday during a 40-hour 

workweek. 

Reference Concentration (RfC)—An estimate (with uncertainty spanning perhaps an order of 

magnitude) of a continuous inhalation exposure to the human population (including sensitive subgroups) 

that is likely to be without an appreciable risk of deleterious noncancer health effects during a lifetime. 

The inhalation reference concentration is for continuous inhalation exposures and is appropriately 

expressed in units of mg/m3 or ppm. 

Reference Dose (RfD)—An estimate (with uncertainty spanning perhaps an order of magnitude) of the 

daily exposure of the human population to a potential hazard that is likely to be without risk of deleterious 

effects during a lifetime. The RfD is operationally derived from the no-observed-adverse-effect level 

(NOAEL-from animal and human studies) by a consistent application of uncertainty factors that reflect 

various types of data used to estimate RfDs and an additional modifying factor, which is based on a 

professional judgment of the entire database on the chemical. The RfDs are not applicable to 

nonthreshold effects such as cancer. 

Reportable Quantity (RQ)—The quantity of a hazardous substance that is considered reportable under 

the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA). Reportable 

quantities are (1) 1 pound or greater or (2) for selected substances, an amount established by regulation 

either under CERCLA or under Section 311 of the Clean Water Act. Quantities are measured over a 24­

hour period. 

Reproductive Toxicity—The occurrence of adverse effects on the reproductive system that may result 

from exposure to a chemical. The toxicity may be directed to the reproductive organs and/or the related 

endocrine system. The manifestation of such toxicity may be noted as alterations in sexual behavior, 

fertility, pregnancy outcomes, or modifications in other functions that are dependent on the integrity of 

this system. 
 

 

SULFUR MUSTARD 216 

10. GLOSSARY 

Retrospective Study—A type of cohort study based on a group of persons known to have been exposed 

at some time in the past. Data are collected from routinely recorded events, up to the time the study is 

undertaken. Retrospective studies are limited to causal factors that can be ascertained from existing 

records and/or examining survivors of the cohort. 

Risk—The possibility or chance that some adverse effect will result from a given exposure to a chemical. 

Risk Factor—An aspect of personal behavior or lifestyle, an environmental exposure, or an inborn or 

inherited characteristic, that is associated with an increased occurrence of disease or other health-related 

event or condition. 

Risk Ratio—The ratio of the risk among persons with specific risk factors compared to the risk among 

persons without risk factors. A risk ratio greater than 1 indicates greater risk of disease in the exposed 

group compared to the unexposed. 

Short-Term Exposure Limit (STEL)—The American Conference of Governmental Industrial 

Hygienists (ACGIH) maximum concentration to which workers can be exposed for up to 15 minutes 

continually. No more than four excursions are allowed per day, and there must be at least 60 minutes 

between exposure periods. The daily Threshold Limit Value - Time Weighted Average (TLV-TWA) may 

not be exceeded. 

Standardized Mortality Ratio (SMR)—A ratio of the observed number of deaths and the expected 

number of deaths in a specific standard population. 

Target Organ Toxicity—This term covers a broad range of adverse effects on target organs or 

physiological systems (e.g., renal, cardiovascular) extending from those arising through a single limited 

exposure to those assumed over a lifetime of exposure to a chemical. 

Teratogen—A chemical that causes structural defects that affect the development of an organism. 

Threshold Limit Value (TLV)—An American Conference of Governmental Industrial Hygienists 

(ACGIH) concentration of a substance to which most workers can be exposed without adverse effect. 

The TLV may be expressed as a Time Weighted Average (TWA), as a Short-Term Exposure Limit 

(STEL), or as a ceiling limit (CL). 

Time-Weighted Average (TWA)—An allowable exposure concentration averaged over a normal 8-hour 

workday or 40-hour workweek. 

Toxic Dose(50) (TD50)—A calculated dose of a chemical, introduced by a route other than inhalation, 

which is expected to cause a specific toxic effect in 50% of a defined experimental animal population. 

Toxicokinetic—The study of the absorption, distribution and elimination of toxic compounds in the 

living organism. 
SULFUR MUSTARD 217 

10. GLOSSARY 

Uncertainty Factor (UF)—A factor used in operationally deriving the Minimal Risk Level (MRL) or 

Reference Dose (RfD) or Reference Concentration (RfC) from experimental data. UFs are intended to 

account for (1) the variation in sensitivity among the members of the human population, (2) the 

uncertainty in extrapolating animal data to the case of human, (3) the uncertainty in extrapolating from 

data obtained in a study that is of less than lifetime exposure, and (4) the uncertainty in using lowestobserved-adverse-effect level (LOAEL) data rather than no-observed-adverse-effect level (NOAEL) data. 

A default for each individual UF is 10; if complete certainty in data exists, a value of one can be used; 

however a reduced UF of three may be used on a case-by-case basis, three being the approximate 

logarithmic average of 10 and 1. 

Xenobiotic—Any chemical that is foreign to the biological system. 

SULFUR MUSTARD A-1 

APPENDIX A. ATSDR MINIMAL RISK LEVELS AND WORKSHEETS 

The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) [42 U.S.C. 

9601 et seq.], as amended by the Superfund Amendments and Reauthorization Act (SARA) [Pub. L. 99– 

499], requires that the Agency for Toxic Substances and Disease Registry (ATSDR) develop jointly with 

the U.S. Environmental Protection Agency (EPA), in order of priority, a list of hazardous substances most 

commonly found at facilities on the CERCLA National Priorities List (NPL); prepare toxicological 

profiles for each substance included on the priority list of hazardous substances; and assure the initiation 

of a research program to fill identified data needs associated with the substances. 

The toxicological profiles include an examination, summary, and interpretation of available toxicological 

information and epidemiologic evaluations of a hazardous substance. During the development of 

toxicological profiles, Minimal Risk Levels (MRLs) are derived when reliable and sufficient data exist to 

identify the target organ(s) of effect or the most sensitive health effect(s) for a specific duration for a 

given route of exposure. An MRL is an estimate of the daily human exposure to a hazardous substance 

that is likely to be without appreciable risk of adverse noncancer health effects over a specified duration 

of exposure. MRLs are based on noncancer health effects only and are not based on a consideration of 

cancer effects. These substance-specific estimates, which are intended to serve as screening levels, are 

used by ATSDR health assessors to identify contaminants and potential health effects that may be of 

concern at hazardous waste sites. It is important to note that MRLs are not intended to define clean-up or 

action levels. 

MRLs are derived for hazardous substances using the no-observed-adverse-effect level/uncertainty factor 

approach. They are below levels that might cause adverse health effects in the people most sensitive to 

such chemical-induced effects. MRLs are derived for acute (1–14 days), intermediate (15–364 days), and 

chronic (365 days and longer) durations and for the oral and inhalation routes of exposure. Currently, 

MRLs for the dermal route of exposure are not derived because ATSDR has not yet identified a method 

suitable for this route of exposure. MRLs are generally based on the most sensitive chemical-induced end 

point considered to be of relevance to humans. Serious health effects (such as irreparable damage to the 

liver or kidneys, or birth defects) are not used as a basis for establishing MRLs. Exposure to a level 

above the MRL does not mean that adverse health effects will occur. 

MRLs are intended only to serve as a screening tool to help public health professionals decide where to 

look more closely. They may also be viewed as a mechanism to identify those hazardous waste sites that 
SULFUR MUSTARD A-2 

APPENDIX A 

are not expected to cause adverse health effects. Most MRLs contain a degree of uncertainty because of 

the lack of precise toxicological information on the people who might be most sensitive (e.g., infants, 

elderly, nutritionally or immunologically compromised) to the effects of hazardous substances. ATSDR 

uses a conservative (i.e., protective) approach to address this uncertainty consistent with the public health 

principle of prevention. Although human data are preferred, MRLs often must be based on animal studies 

because relevant human studies are lacking. In the absence of evidence to the contrary, ATSDR assumes 

that humans are more sensitive to the effects of hazardous substance than animals and that certain persons 

may be particularly sensitive. Thus, the resulting MRL may be as much as a hundredfold below levels 

that have been shown to be nontoxic in laboratory animals. 

Proposed MRLs undergo a rigorous review process: Health Effects/MRL Workgroup reviews within the 

Division of Toxicology, expert panel peer reviews, and agency wide MRL Workgroup reviews, with 

participation from other federal agencies and comments from the public. They are subject to change, as 

new information becomes available concomitant with updating the toxicological profiles. Thus, MRLs in 

the most recent toxicological profiles supersede previously published levels. For additional information 

regarding MRLs, please contact the Division of Toxicology, Agency for Toxic Substances and Disease 

Registry, 1600 Clifton Road NE, Mailstop E-29, Atlanta, GA 30333. 
 

 

 

 

 

SULFUR MUSTARD A-3 

APPENDIX A 

MINIMAL RISK LEVEL (MRL) WORKSHEET 

Chemical name: Sulfur mustard [bis(2-chlorethyl) sulfide] 

CAS number(s): 505-60-2 

Date: August 29, 2003 

Profile status: Third Draft 

Route: [X] Inhalation [ Oral 

Duration: [X] Acute [ ] Intermediate [ ] Chronic 

Key to figure: 2 

Species: Human 

Minimal Risk Level: 0.0007 [ ] mg/kg/day [ ] ppm [X] mg/m3 

Reference: Guild WJF, Harrison KP, Fairley A, et al.. 1941. The effect of mustard gas vapor on the 

eyes. Chemical Board, Physiological Sub-Committee and Panel of Opthalmic Specialists. Porton Report 

2297. Chemical Defense Experimental Station, Porton, UK. 

Experimental design: Male soldiers wearing respirators (2–6 men/group) were exposed to sulfur mustard 

vapor concentrations, checked by continuous chemical sampling, ranging from 0.06 to 320 mg/m3

. 

Continuous exposure durations ranged from 15 seconds to 10 hours, yielding concentration time (Ct) 

products in the range of 42–144 mg-minute/m3. Two repeated-exposure tests were also conducted; a 

group of four men was exposed to 0.22 mg/m3

, 2.5 hours/day, for 2 days, and another group of four men 

was exposed to 0.06 mg/m3

, 8 hours/day, for 3 days (intermittent Cts of 66 and 86 mg-minute/m3, 

respectively). Chamber temperatures for each experiment were not provided, but chamber temperatures 

were stated to range from 55 to 80 oF during the testing. Soldiers were in good health and had no 

previous exposures to sulfur mustard. The subject’s eyes were examined for evidence of toxicity 

subsequent to exposure. 

Effects noted in study and corresponding doses: No deaths occurred. For continuous exposures, ocular 

effects and severity depended on the concentration and duration, or Ct. At the lowest continuous Ct of 

42 mg-minute/m3 (1.4 mg/m3 for 30 minutes), four of four soldiers showed a slight generalized 

conjunctival reaction. A slight or just discernable or slight conjunctival reaction was also reported at the 

lowest concentration of 0.1 mg/m3

 for 8 and 10 hours exposures (Cts of 48 and 60 mg-minute/m3, 

respectively). Just discernable angular congestion of the bulbar conjunctiva was reported for Cts ranging 

from 48 to 75 mg-minute/m3. Slight to moderate degree of conjunctival congestion was reported for the 

Ct range of 80-90 mg-minute/m3

. The first casualties (two of two men) [casualty meaning any 

interference with vision or any lesion of the eyes sufficiently severe to render a soldier, for a time, 

incapable of carrying out his normal duties] were reported at a Ct of 99 mg-minute/m3

 (16.5 mg/m3 for 

6 minutes). Both subjects showed generalized established conjunctivitis with photophobia. At a Ct of 

144 mg-minute/m3

, six of six subjects showed marked generalized conjunctival congestion, with 

photophobia in one of six subjects. While specific results were not reported for the 2-day repeated 

exposure (0.22 mg/m3

, 2.5 hours/day, for 2 days), the authors stated that there was no discernable 

difference in the degree of conjunctival reaction between subjects in this group and subjects exposed to 

the same concentration for 5 hours (Ct of 66 mg-minute/m3

). A scarcely discernable generalized 

conjunctival reaction (incidence unspecified) was reported in subjects undergoing the 3-day repeated 

exposure (0.06 mg/m3

, 8 hours/day, for 3 days; intermittent Cts of 86 mg-minute/m3). The severity of 

conjunctivitis for the 3-day intermittent exposure was described as far slighter than the moderate degree 

of conjunctivitis observed from continuous exposures with Cts ≥80 mg-minute/m3

. 
 

 

 

 

SULFUR MUSTARD A-4 

APPENDIX A 

Dose and end point used for MRL derivation: The 3-day repeated exposure experiment is considered to 

best represent a potential acute exposure, and the time-weighted average concentration of 0.02 mg/m3 

(0.06 mg/m3 x 8 hours/24 hours) is considered a minimal LOAEL for ocular effects. 

[ ] NOAEL [X] LOAEL 

Uncertainty factors (UF) and Modifying Factor (MF) used in MRL derivation: 

[X] 3 for use of a minimal LOAEL 

[X] 10 for human variability 

Was a conversion factor used from ppm in food or water to a mg/body weight dose? NA 

Was a conversion used from intermittent to continuous exposure? Yes 

LOAEL[ADJ]=0.06 mg/m3

 · (8 hours/24 hours) =0.02 mg/m3 

If an inhalation study in animals, list conversion factors used in determining human equivalent dose: NA 

Other additional studies or pertinent information that lend support to this MRL: Ocular effects were 

reported in other chamber tests reported by Reed (1919) and Anderson (1942); however, these studies did 

not include repeated exposures. Conjunctivitis with photophobia and blepharospasm were reported as the 

initial signs of exposure in two subjects who underwent chamber tests wearing no respirators and clad 

only in khaki uniform pants without shirts (Reed 1918). The two subjects were exposed to 1.2 mg/m3

 of 

sulfur mustard vapor for 20 and 45 minutes (Cts of 24 and 54 mg-minute/m3

), respectively. The variation 

in sensitivity to sulfur mustard was demonstrated by a latency of 3 hours for the subject exposed to the Ct 

of 24 mg-minute/m3

, as compared to 6 hours for the subject exposed to the higher Ct. In subsequent 

chamber tests conducted by Reed (1918), no signs were reported in six subjects exposed to the lowest Ct 

of 1.0 mg-minute/m3

 (0.1 mg/m3 for 10 minutes), whereas one of two subjects showed slight, but distinct, 

conjunctival injection at the next higher Ct of 1.5 mg-minute/m3

 (0.1 mg/m3 for 15 minutes). In 

continuous flow tests with human subjects, with only the face and one eye exposed, conjunctivitis was 

observed at Cts as low as 7 mg-minute/m3

 (0.7 mg/m3 for 10 minutes); Cts as low as 1.5 mg-minute/m3 

(0.1 mg/m3 for 15 minutes) were tested (Reed 1918). However, it should be noted that methods for 

measuring low vapor concentrations of sulfur mustard were not yet validated at the time of these studies. 

In chamber tests conducted by Anderson (1942), using male soldier wearing respirators, a trace of angular 

conjunctivitis and “band of fine injection” across the exposed part bulbar conjunctiva were reported at the 

lowest Ct of 12.5 mg-minute/m3

 (6.25 mg/m3 for 2 minutes). A “fine injection band” over the exposed 

sclera was reported at the lowest concentration of 1.7 mg/m3 (33 min; Ct=56.1 mg-minute/m3

) (Anderson 

1942). In addition to chamber testing, numerous reports exist of ocular lesions that occurred in soldiers 

exposed to sulfur mustard during World War I (Hughes 1942; Philips 1940). In a more recent study of 

Iranian fighters with a history of sulfur mustard poisoning, delayed ocular lesions from undetermined, 

presumably acute, exposures included chronic conjunctivitis in 75/85 (32%), keratoconjunctivitis in 7/85 

(3%) and blindness in 2/85 (1%) (Balali-Mood 1986). A range of ocular effects, including conjunctivitis, 

chronic keratitis, and corneal ulcerations, have been reported in dogs and rabbits following acute exposure 

to sulfur mustard depending on the concentration and duration of exposures (Balali-Mood 1986; Gates 

and Moore 1946; Laughlin 1944a; Maumenee and Scholts 1948; Reed 1918; Warthin and Weller 1919). 

Agency Contact (Chemical Manager): Zemoria A. Rosemond 
 

 

 

 

 

SULFUR MUSTARD A-5 

APPENDIX A 

MINIMAL RISK LEVEL (MRL) WORKSHEET 

Chemical name: Sulfur mustard [bis(2-chlorethyl) sulfide] 

CAS number(s): 505-60-2 

Date: August 29, 2003 

Profile status: Third Draft 

Route: [X] Inhalation [ ] Oral 

Duration: [ ] Acute [X ] Intermediate [ ] Chronic 

Key to figure: 11 

Species: Dog 

Minimal Risk Level: 0.00002 [ ] mg/kg/day [ ] ppm [X] mg/m3 

Reference: McNamara BP, Owens EJ, Christensen MK, et al. 1975. Toxicological basis for controlling 

levels of mustard in the environment. Edgewood Arsenal Special Publication. Aberdeen Proving 

Ground, Maryland: Department of the Army. EB-SP-74030. 

Experimental design: Male and female beagle dogs (6 initially and 4 added), rats (140), A/J mice (140), 

rabbits (12 initially and 6 added), and guinea pigs (30 initially and 12 added) were exposed to sulfur 

mustard vapor at a concentration of 0.001 mg/m3

 for 24 hours/day, 5 days/week (time-weighted average 

concentration of 0.0007 mg/m3

), for varying durations up to 1 year. The same number of animals of each 

species were exposed to 0.1 mg/m3

 for 6.5 hours followed by exposure to 0.0025 mg/m3 for the remaining 

17.5 hours of the day, 5 days/week, for durations up to a year. The latter exposure is equivalent to a timeweighted average concentration of 0.0206 mg/m3

 [{0.1 mg/m3 x (6.5 hours/24 hours) + 0.0025 mg/m3 x 

(17.5 hours/24 hours)} x (5 days/7 days) = 0.0206 mg/m3

]. Unexposed controls consisted of 10 dogs 

(6 initially and 4 added), 100 rats, 140 A/J mice (120 initially and 20 added), 22 rabbits (7 initially and 

15 added), and 32 guinea pigs (20 initially and 12 added). The treatment protocol was unusual in that 

new animals were added to replace exposed animals that were sacrificed periodically. At about 7 months 

after the study was initiated, 100 ICR Swiss albino mice were added to the test chambers, and 50 A/J 

mice were added about 3 months later. At these same times, the same numbers of each strain were added 

to the study as additional controls. The animals were observed periodically for clinical signs of toxicity. 

Body weights were recorded. Red and white blood cell counts, hematocrit, and hemoglobin were 

measured in dogs and rabbits, but not other species. Clinical chemistry analyses including blood urea 

nitrogen (BUN), lactic dehydrogenase (LDH), alkaline phosphatase (ALP), and serum alanine 

aminotransferase (ALT) were conducted in dogs. Gross and microscopic examinations were performed. 

Effects noted in study and corresponding doses: No dogs died during the study. Mortality was unrelated 

to concentration in rabbits and guinea pigs, and comparable to controls in exposed ICR Swiss mice. 

While no control rats died, death occurred in 3/140 and 16/140 at the low- and high-concentrations, 

respectively. In the first group of A/J mice, mortality incidence was concentration-related; 4/140, 14/140, 

and 24/140 in the control, low- and high-concentration groups, respectively. However, in the second 

group of A/J mice, 3/50 animals in the low-concentration group died, while there were no deaths in the 

control and high-concentration groups. Because of the lack of correlation between deaths and exposure in 

the ICR Swiss mice and the second group of A/J mice the authors concluded that deaths were more likely 

due to conditions of animal storage than treatment. Of 79 rats exposed to the lower concentration and 

necropsied, 5 developed chronic keratitis. This lesion was not observed in control or high-dose rats. No 

clinical signs of toxicity were observed in any of the other species exposed to the low concentration. At 

the high concentration, the only overt signs of toxicity were ocular effects, observed only in dogs. Ocular 

effects first appearing after 16 weeks of exposure, including corneal opacity, pannus, chronic keratitis, 

vascularization, pigmentation, and granulation were reported in 3 of 10 high-concentration dogs exposed 
 

 

 

 

SULFUR MUSTARD A-6 

APPENDIX A 

for 7.5 or 12 months. The time-weighted average concentration of 0.0206 mg/m3 is considered a LOAEL 

for ocular effects in beagle dogs. 

Dose and end point used for MRL derivation: The lowest concentration tested in dogs, 0.001 mg/m3

, is a 

NOAEL for ocular effects (conjunctivitis and chronic keratitis). 

[ X] NOAEL [ ] LOAEL 

Uncertainty factors (UF) and Modifying Factor (MF) used in MRL derivation: 

[X] 10 for human variability 

[X] 3 for animal-to-human extrapolation 

Was a conversion factor used from ppm in food or water to a mg/body weight dose? NA 

Was a conversion used from intermittent to continuous exposure? Yes 

NOAEL[ADJ]=0.001 mg/m3

 · (24 hours/24 hours) · (5 days/7 days)=0.0007 mg/m3 

If an inhalation study in animals, list conversion factors used in determining human equivalent dose: 

Gates and Moore (1946) reported that the human eye is about four times more sensitive to sulfur mustard 

than the rabbit eye based on the observation of corneal ulceration produced in rabbits and dogs at Cts of 

4 and 2 times the value, respectively, at which this effect occurred in humans. This is consistent with the 

observation by McNamara et al. (1975) of ocular effects in dogs, but not in rabbits, at the high 

concentration. Thus, an uncertainty factor of 3 for extrapolation of data from dogs to humans is 

considered appropriate for derivation of the MRL. 

Other additional studies or pertinent information that lend support to this MRL: The intermediateduration inhalation MRL was based on the same critical endpoint as the acute-duration inhalation MRL. 

In addition to the supporting information for ocular lesions as provided for the acute-duration MRL, there 

are numerous reports of eye burns in workers accidentally exposed to large quantities of sulfur mustard 

vapor, as well as to slow leaks that were not detected by smell (Hughes 1945a; Pechura and Rall 1993; 

Uhde 1946). 

Agency Contact (Chemical Manager): Zemoria A. Rosemond 
 

 

 

 

 

SULFUR MUSTARD A-7 

APPENDIX A 

MINIMAL RISK LEVEL (MRL) WORKSHEET 

Chemical name: Sulfur mustard [bis(2-chlorethyl) sulfide] 

CAS number(s): 505-60-2 

Date: August 29, 2003 

Profile status: Third Draft 

Route: [ ] Inhalation [X] Oral 

Duration: [X] Acute [ ] Intermediate [ ] Chronic 

Key to figure: 5, 6 

Species: Rat 

Minimal Risk Level: 0.5 [X] μg/kg/day [ ] ppm [ ] mg/m3 

Reference: DOA. 1987. Teratology studies on lewisite and sulfur mustard agents: Effects of sulfur 

mustard in rats and rabbits. Fort Detrick, MD: U.S. Army Medical Research and Development 

Command, U.S. Department of Army. ADA187495. 

Experimental design: Sulfur mustard (95.9–96.1% purity) dissolved in sesame oil was administered by 

intragastric intubation to mated Sprague-Dawley female rats (10–11 weeks old) on gestation days 6 

through 15 (10 days). The administered doses were 0, 0.5, 1.0, or 2.0 mg/kg/day and there were 25– 

27 animals/dose group, of which 20–26/dose group were pregnant. All animals were observed for clinical 

signs of toxicity prior to and following administration of sulfur mustard. Treated rats were weighed on 

gestation days 0, 6–15 (exposure days), and on day 20. Necropsy was performed on all rats found dead or 

in moribund condition. Scheduled necropsy was performed on gestation day 20. Blood samples were 

collected from maternal animals for hematocrit measurement prior to sacrifice. The animals were 

examined for gross lesions of major organ systems. The numbers of corpora lutea, implantation sites, 

resorptions, and live and dead fetuses were determined. Uterine weights were recorded. Live fetuses 

were removed, weighed, sexed, and examined for gross, soft tissue, and skeletal anomalies. 

Effects noted in study and corresponding doses: There were no treatment-related deaths. In rats, a 

significant dose-related decrease in maternal body weight was observed by gestation day 12 at 

0.5 mg/kg/day (4.1–6.6%) and by gestation day 9 in the 1.0 (4.7–9.1%) and 2.0 (6.5–16.0%) mg/kg/day 

groups. Extragestation weight gain was significantly reduced at ≥0.5 mg/kg/day with dose-related 

reductions of 25, 38, and 57% at 0.5, 1.0, and 2.0 mg/kg/day, compared to controls. A significantly 

decreased (16%) gravid uteri weight was measured at the highest dose. Maternal hematocrit values were 

statistically significantly reduced by 5.4% at 1.0 and 2.0 mg/kg/day. Gastric mucosa inflammation was 

observed in 2/30 (6.7%) rats at 2.0 mg/kg/day, but not in any of the lower dose or control groups. A 

significantly increased incidence of inflamed mesenteric lymph nodes was found at ≥0.5 mg/kg/day; the 

incidences were 0/27 controls, and 11/25 (44%), 16/25 (64%), and 15/27 (56%) rats at 0.5, 1.0, and 

2.0 mg/kg/day, respectively. 

Fetal body weight was significantly decreased (6–7%) from controls in litters exposed to doses of 

≥1.0 mg/kg/day; no clear dose-relation was evident. The sex ratio (percent males) was significantly lower 

than control at the highest dose (46.2 vs. 51.0%). Placental weight was also significantly reduced (8.4%) 

at the highest dose. Supernumerary ribs were found in 9/299 (3%) fetuses of one litter in the highest dose 

group, while this anomaly was not found in any of the fetuses in the lower dose or control groups. The 

incidence of reduced ossification of the vertebrae and/or sternebrae in all treated groups was significantly 

higher than controls when individual pup data were compared, but not with litter comparisons, 

42/272 (15%) in controls, 51/229 (22%) at 0.5 mg/kg/day, 76/315 (24%) at 1.0 mg/kg/day, and 

72/299 (24%) at 2.0 mg/kg/day. All fetal effects in rats occurred at doses that also produced maternal 

toxicity. 
 

 

 

 

SULFUR MUSTARD A-8 

APPENDIX A 

Dose and end point used for MRL derivation: The lowest dose tested in rats, 0.5 mg/kg/day is a LOAEL 

for inflamed mesenteric lymph nodes in the dams and reduced ossification in the fetuses. 

[ ] NOAEL [X] LOAEL 

Uncertainty factors (UF) and Modifying Factor (MF) used in MRL derivation: 

[X] 10 for LOAEL-to-NOAEL extrapolation 

[X] 10 for human variability 

[X] 10 for animal-to-human extrapolation 

Was a conversion factor used from ppm in food or water to a mg/body weight dose? NA 

Was a conversion used from intermittent to continuous exposure? NA 

If an inhalation study in animals, list conversion factors used in determining human equivalent dose: NA 

Other additional studies or pertinent information that lend support to this MRL: In support of the critical 

effect, there is some evidence in humans to indicate that sulfur mustard affects the lymph system. 

Discoloration of the lymph nodes in the axillary, inguinal, and mesenteric glands were noted in autopsies 

of victims of the World War II Bari Harbor incident, during which sulfur mustard was released in to the 

air and water (Alexander 1947). The spleen also demonstrated evidences of gross pathology in 33 of 

53 (62%) autopsies (Alexander 1947). In the majority of cases, the spleen was described as shrunken in 

size with pale color. Microscopically, only 2 of 32 spleens examined showed degeneration or necrosis; 

pyknosis and karyorrhexis of lymphocytes in some corpuscles were observed in one and slight necrosis of 

the malpighian follicle, was observed in the other. Additional studies in animals also revealed sulfur 

mustard-induced damage to the lymph system. Cameron et al. (1946), after observing damage to the 

cervical lymph nodes and lymphoid tissue throughout the body in rabbits and monkeys that had 

undergone tracheal cannulation and had been exposed to chamber concentrations of sulfur mustard 

ranging from 30 to 350 mg/m3

 (5–54 ppm), administered sulfur mustard to animal skin topically or by 

subcutaneous injection and observed identical changes to the lymph tissue, suggesting that lymphoid 

tissue damage may be due to systemic absorption. Sulfur mustard produced a significant dose-related 

decrease in the weight of peripheral lymph nodes (12–44%) when topically applied at single doses of 

3.88, 7.75, or 15.5 mg/kg to the shaved backs of Balb/c mice (Venkateswaran et al. 1994a). A significant 

decrease in the weight of mesenteric lymph nodes (18%) was noted at the highest dose. Incidence and 

severity of histological changes in the thymus and spleen were also dose-related. Spleen histopathology 

included hypocellularity, atrophy of the lymphoid follicles, degeneration of germinal centers, and red pulp 

infiltrated with macrophages. The cortex and medulla regions of the thymus showed atrophy and 

hypocellularity. A significant dose-related decrease in the cellularity of the spleen (24–45%) was 

measured. A dose-related decrease in the cellularity of the thymus was also found, and was significant at 

the mid- and high doses (36–42%). A significant dose-related reduction in spleen cell number was 

measured in female mice 7 days after intraperitoneal injection with sulfur mustard (23% at 5 mg/kg and 

49% at 10 mg/kg) (Coutelier et al. 1991). 

The principal study (DOA 1987) identified the lowest LOAEL of 0.5 mg/kg/day for inflamed mesenteric 

lymph nodes in rats following acute administration of sulfur mustard. In range-finding experiments, 

conducted prior to the principal teratology study, in which rats were dosed with 0, 0.2, 0.4, 0.8, 1.6, 2.0, 

or 2.5 mg/kg/day (3–9 animals/dose group of which 2–7/dose group were pregnant) on gestation days 6– 

15, significant incidences of inflamed mesenteric lymph nodes occurred at ≥0.4 mg/kg/day (DOA 1987). 

Also in support of the critical dose, another lymphoretic effect, enlarged Peyer’s patches, was observed in 
SULFUR MUSTARD A-9 

APPENDIX A 

rabbits at 0.5 g/kg/day in a range-finding study and at 0.4 g/kg/day in a teratology study (incidence data 

were not reported) (DOA 1987). 

Agency Contact (Chemical Manager): Zemoria A. Rosemond 
 

 

 

 

 

SULFUR MUSTARD A-10 

APPENDIX A 

MINIMAL RISK LEVEL (MRL) WORKSHEET 

Chemical name: Sulfur mustard [bis(2-chlorethyl) sulfide] 

CAS number(s): 505-60-2 

Date: August 29, 2003 

Profile status: Third Draft 

Route: [ ] Inhalation [X] Oral 

Duration: [ ] Acute [X] Intermediate [ ] Chronic 

Key to figure: 9 

Species: Rat 

Minimal Risk Level: 0.07 [X] μg/kg/day [ ] ppm [ ] mg/m3 

Reference: Sasser LB, Cushing JA, Dacre JC. 1996a. Two-generation reproduction study of sulfur 

mustard in rats. Repro Toxicol 10(4):311-319. 

Experimental design: Sulfur mustard (97.3% purity) dissolved in sesame oil was administered 

intragastrically by intubation to groups of 8-week-old Sprague-Dawley rats (27 females and 

20 males/group/generation) at doses of 0, 0.03, 0.1, or 0.4 mg/kg/day. Male and female rats were dosed 

5 days/week for 15 weeks that included 13 weeks before and 2 weeks during the mating period. Females 

were dosed daily (7 days/week) throughout the 21-day gestation period and 4–5 days/week during the 

21-day lactation period. Males were dosed 5 days/week during the 21-day gestation period and sacrificed 

at the birth of their pups. Dams were sacrificed when their pups were weaned. Male and female F1 pups 

were treated with sulfur mustard until they were mated and the females became pregnant and gave birth. 

F1 males were sacrificed at the birth of their pups. The dosing of F1 dams continued until pup weaning, 

at which time, the study was terminated. Animals were weighed weekly. A complete gross necropsy was 

performed on all rats found dead or in moribund condition. Weights of the testis, prostate, epididymis, 

ovary, and uterus were recorded. Histopathological evaluations were performed on reproductive organs 

of the high dose group and control group of the F0 and F1 adults and on the forestomach of animals in all 

dose groups. 

Effects noted in study and corresponding doses: There were no treatment-related deaths. The body 

weights of the F0 sulfur mustard-exposed rats were not significantly different from controls; however, the 

growth rate of the high-dose males tended to decline after about 7 weeks of exposure. Body weight gain 

was significantly lower (p<0.05) than control values in F1 rats of both sexes born to high-dose parents 

beginning 1 or 2 weeks after dosing was started (approximately 20% for males and 15–24% for females). 

No significant dose-response in body weight occurred at the lower doses. Breeding and reproductive 

performance in F0 and F1 animals was not affected by treatment. The only statistically significant birth 

parameter difference was an altered sex ratio (an increase in the fraction of males) of the high-dose F0 

offspring. Although not significantly different, litter weights and number of pups per litter tended to 

decrease in both F1 and F2 animals at the highest exposure level. Except for a slight reduction in absolute 

ovary weight in high-dose F0 females, absolute and/or relative male and female reproductive organ 

weights were unaffected by treatment. Microscopic examination of the reproductive organs revealed no 

evidence of treatment-related effects. Dose-related incidence and severity of lesions of the squamous 

epithelium of the forestomach characterized by cellular disorganization of the basilar layer, an apparent 

increase in mitotic activity of the basilar epithelial cells and thickening of the epithelial layer, occurred in 

both sexes of each treatment group. The incidence of squamous acanthosis (combined F0 and F1 males 

and females; minimal to marked severity) was 0/94 controls, 69/94 (73%; 27 males/42 females) in the 

low-dose groups, 90/94 (96%; 39 males/51 females) in the mid-dose groups, and 94/94 in the high-dose 

groups. Benign neoplasms of the forestomach (squamous papilloma) occurred in 0/94 controls, 0/94 in 

the low-dose groups, 8/94 (9%) in the mid-dose groups, and 10/94 (11%) in the high-dose groups. 
 

 

 

SULFUR MUSTARD A-11 

APPENDIX A 

Dose and end point used for MRL derivation: The lowest dose tested, 0.03 mg/kg/day, is a LOAEL for 

gastric lesions (mild epithelial acanthosis of the forestomach). Although humans do not have 

forestomachs, the primary mechanism of toxicity of sulfur mustard is epithelial tissue damage from direct 

contact and, therefore, epithelial acanthosis is considered a suitable critical noncancer end point for 

deriving an oral MRL. Tissue damage would be expected to occur at the point of contact, even if it were 

another part of the gastrointestinal tract. 

[ ] NOAEL [X] LOAEL 

Uncertainty factors (UF) and Modifying Factor (MF) used in MRL derivation: 

[X] 10 for LOAEL-to-NOAEL extrapolation 

[X] 10 for human variability 

[X] 3 for animal-to-human extrapolation* 

*Because sulfur mustard is a highly corrosive agent, epithelial lesions at the point of entry into the 

stomach are likely to occur across species. For this reason, the typical default value of 10 for the 

uncertainty factor for extrapolation of data from animals to humans is considered to be too high and a 

lower value of 3 is applied. 

Was a conversion factor used from ppm in food or water to a mg/body weight dose? NA 

Was a conversion used from intermittent to continuous exposure? A time-weighted average (TWA) daily 

dose was calculated as follows. Females were dosed during the lactation period while males were not. 

Female rats were treated 5 days/week for 15 weeks (75 days), total dose=2.25 mg/kg 

(75 days x 0.03 mg/kg/day); daily for 3 gestation weeks (21 days), total dose=0.63 mg/kg; and 

4 days/week for 3 lactation weeks (12 days), total dose=0.36 mg/kg. The cumulative dose for females 

over the 21-week period is 3.24 mg/kg (2.25+0.63+0.36 mg/kg). Dividing the cumulative dose of 3.24 by 

147 days (21 weeks) yields a TWA dose of 0.02 mg/kg/day. For males, the same TWA daily dose 

results; however, different time weighting applies [0.03 mg/kg/day x (5 days/7 days)=0.02 mg/kg/day]. 

If an inhalation study in animals, list conversion factors used in determining human equivalent dose: NA 

Other additional studies or pertinent information that lend support to this MRL: Injury to the gastric 

mucosa (mild epithelial acanthosis of the forestomach) is a portal-of-entry direct contact toxic effect that 

is consistent with the vesicant properties of sulfur mustard following oral exposure. In support of the 

critical effect, gastrointestinal effects have been reported in humans following combat exposure to sulfur 

mustard, in sulfur mustard testing volunteers, and in sulfur mustard factory workers. In all of these cases, 

exposure was likely by multiple routes including inhalation, oral, and dermal. In 19 of 53 (36%) victims 

of the World War II Bari Harbor incident autopsied, stomach irritation and inflammation were 

documented. The lesions varied from simple hyperemia to focal loss of epithelium, necrosis, and 

ulceration (Alexander 1947). In a review of the clinical manifestations of sulfur mustard exposure in the 

Iran-Iraq war victims, Pierard et al. (1990) reported that endoscopy frequently revealed acute gastritis. 

Incidences of gastrointestinal effects of nausea (64%), vomiting (43%), and bleeding (14%) were reported 

in a group of 14 children and teenagers following exposure to sulfur mustard from air bombs during the 

Iran-Iraq war (Momeni and Aminjavaheri 1994). Gastrointestinal neoplasms were reported in Japanese 

sulfur mustard factory workers who were involved with the production of chemical agents during World 

War II (Yamakido et al. 1985). Sulfur mustard testing volunteers who were wearing respirators and who 

were exposed to unspecified levels of sulfur mustard vapors and liquids had skin burns, but also 

complained of nausea, vomiting, anorexia, abdominal pain, diarrhea, headache, and lassitude (Sinclair 
 

SULFUR MUSTARD A-12 

APPENDIX A 

1948). These signs could have been primary effects of the sulfur mustard on the rapidly dividing cells of 

the gastrointestinal epithelium, secondary effects from the skin burns, or psychological effects not related 

to the sulfur mustard exposure at all. 

In addition to the principal study, Sasser et al. (1996a), similar gastric effects, edema, hemorrhage or 

sloughing of the mucosa, and ulceration) have been identified in rabbits following 14-day exposures at 

≥0.4 mg/kg/day (DOA 1987), in rats following 10-day exposures at ≥2.0 mg/kg/day (DOA 1987), and in 

rats following 13-week exposures at ≥0.1 mg/kg/day (Sasser et al. 1996b). Regarding the relevance of the 

toxic effects to humans lacking a forestomach, tissue damage at the point of contact would be expected by 

a vesicant and direct alkylating agent such as sulfur mustard, regardless of the location in the 

gastrointestinal tract. 

Agency Contact (Chemical Manager): Zemoria A. Rosemond 
 

SULFUR MUSTARD B-1 

APPENDIX B. USER'S GUIDE 

Chapter 1 

Public Health Statement 

This chapter of the profile is a health effects summary written in non-technical language. Its intended 

audience is the general public especially people living in the vicinity of a hazardous waste site or 

chemical release. If the Public Health Statement were removed from the rest of the document, it would 

still communicate to the lay public essential information about the chemical. 

The major headings in the Public Health Statement are useful to find specific topics of concern. The 

topics are written in a question and answer format. The answer to each question includes a sentence that 

will direct the reader to chapters in the profile that will provide more information on the given topic. 

Chapter 2 

Relevance to Public Health 

This chapter provides a health effects summary based on evaluations of existing toxicologic, 

epidemiologic, and toxicokinetic information. This summary is designed to present interpretive, weightof-evidence discussions for human health end points by addressing the following questions. 

1.	 What effects are known to occur in humans? 

2. What effects observed in animals are likely to be of concern to humans? 

3. What exposure conditions are likely to be of concern to humans, especially around hazardous 

waste sites? 

The chapter covers end points in the same order they appear within the Discussion of Health Effects by 

Route of Exposure section, by route (inhalation, oral, dermal) and within route by effect. Human data are 

presented first, then animal data. Both are organized by duration (acute, intermediate, chronic). In vitro 

data and data from parenteral routes (intramuscular, intravenous, subcutaneous, etc.) are also considered 

in this chapter. If data are located in the scientific literature, a table of genotoxicity information is 

included. 

The carcinogenic potential of the profiled substance is qualitatively evaluated, when appropriate, using 

existing toxicokinetic, genotoxic, and carcinogenic data. ATSDR does not currently assess cancer 

potency or perform cancer risk assessments. Minimal risk levels (MRLs) for noncancer end points (if 

derived) and the end points from which they were derived are indicated and discussed. 

Limitations to existing scientific literature that prevent a satisfactory evaluation of the relevance to public 

health are identified in the Chapter 3 Data Needs section. 

Interpretation of Minimal Risk Levels 

Where sufficient toxicologic information is available, we have derived minimal risk levels (MRLs) for 

inhalation and oral routes of entry at each duration of exposure (acute, intermediate, and chronic). These 

MRLs are not meant to support regulatory action; but to acquaint health professionals with exposure 

levels at which adverse health effects are not expected to occur in humans. 
 

SULFUR MUSTARD B-2 

APPENDIX B 

They should help physicians and public health officials determine the safety of a community living near a 

chemical emission, given the concentration of a contaminant in air or the estimated daily dose in water. 

MRLs are based largely on toxicological studies in animals and on reports of human occupational 

exposure. 

MRL users should be familiar with the toxicologic information on which the number is based. Chapter 2, 

"Relevance to Public Health," contains basic information known about the substance. Other sections such 

as Chapter 3 Section 3.9, "Interactions with Other Substances,” and Section 3.10, "Populations that are 

Unusually Susceptible" provide important supplemental information. 

MRL users should also understand the MRL derivation methodology. MRLs are derived using a 

modified version of the risk assessment methodology the Environmental Protection Agency (EPA) 

provides (Barnes and Dourson 1988) to determine reference doses for lifetime exposure (RfDs). 

To derive an MRL, ATSDR generally selects the most sensitive end point which, in its best judgement, 

represents the most sensitive human health effect for a given exposure route and duration. ATSDR 

cannot make this judgement or derive an MRL unless information (quantitative or qualitative) is available 

for all potential systemic, neurological, and developmental effects. If this information and reliable 

quantitative data on the chosen end point are available, ATSDR derives an MRL using the most sensitive 

species (when information from multiple species is available) with the highest NOAEL that does not 

exceed any adverse effect levels. When a NOAEL is not available, a lowest-observed-adverse-effect 

level (LOAEL) can be used to derive an MRL, and an uncertainty factor (UF) of 10 must be employed. 

Additional uncertainty factors of 10 must be used both for human variability to protect sensitive 

subpopulations (people who are most susceptible to the health effects caused by the substance) and for 

interspecies variability (extrapolation from animals to humans). In deriving an MRL, these individual 

uncertainty factors are multiplied together. The product is then divided into the inhalation concentration 

or oral dosage selected from the study. Uncertainty factors used in developing a substance-specific MRL 

are provided in the footnotes of the LSE Tables. 

Chapter 3 

Health Effects 

Tables and Figures for Levels of Significant Exposure (LSE) 

Tables (3-1, 3-2, and 3-3) and figures (3-1 and 3-2) are used to summarize health effects and illustrate 

graphically levels of exposure associated with those effects. These levels cover health effects observed at 

increasing dose concentrations and durations, differences in response by species, minimal risk levels 

(MRLs) to humans for noncancer end points, and EPA's estimated range associated with an upper- bound 

individual lifetime cancer risk of 1 in 10,000 to 1 in 10,000,000. Use the LSE tables and figures for a 

quick review of the health effects and to locate data for a specific exposure scenario. The LSE tables and 

figures should always be used in conjunction with the text. All entries in these tables and figures 

represent studies that provide reliable, quantitative estimates of No-Observed-Adverse-Effect Levels 

(NOAELs), Lowest-Observed-Adverse-Effect Levels (LOAELs), or Cancer Effect Levels (CELs). 

The legends presented below demonstrate the application of these tables and figures. Representative 

examples of LSE Table 3-1 and Figure 3-1 are shown. The numbers in the left column of the legends 

correspond to the numbers in the example table and figure. 
SULFUR MUSTARD B-3 

APPENDIX B 

LEGEND 

See LSE Table 3-1 

(1) Route of Exposure One of the first considerations when reviewing the toxicity of a substance 

using these tables and figures should be the relevant and appropriate route of exposure. When 

sufficient data exists, three LSE tables and two LSE figures are presented in the document. The 

three LSE tables present data on the three principal routes of exposure, i.e., inhalation, oral, and 

dermal (LSE Table 3-1, 3-2, and 3-3, respectively). LSE figures are limited to the inhalation 

(LSE Figure 3-1) and oral (LSE Figure 3-2) routes. Not all substances will have data on each 

route of exposure and will not therefore have all five of the tables and figures. 

(2) Exposure Period Three exposure periods - acute (less than 15 days), intermediate (15–364 days), 

and chronic (365 days or more) are presented within each relevant route of exposure. In this 

example, an inhalation study of intermediate exposure duration is reported. For quick reference 

to health effects occurring from a known length of exposure, locate the applicable exposure 

period within the LSE table and figure. 

(3) Health Effect The major categories of health effects included in LSE tables and figures are death, 

systemic, immunological, neurological, developmental, reproductive, and cancer. NOAELs and 

LOAELs can be reported in the tables and figures for all effects but cancer. Systemic effects are 

further defined in the "System" column of the LSE table (see key number 18). 

(4) Key to Figure Each key number in the LSE table links study information to one or more data 

points using the same key number in the corresponding LSE figure. In this example, the study 

represented by key number 18 has been used to derive a NOAEL and a Less Serious LOAEL 

(also see the 2 "18r" data points in Figure 3-1). 

(5) Species The test species, whether animal or human, are identified in this column. Chapter 2, 

"Relevance to Public Health," covers the relevance of animal data to human toxicity and 

Section 3.4, "Toxicokinetics," contains any available information on comparative toxicokinetics. 

Although NOAELs and LOAELs are species specific, the levels are extrapolated to equivalent 

human doses to derive an MRL. 

(6) Exposure Frequency/Duration The duration of the study and the weekly and daily exposure 

regimen are provided in this column. This permits comparison of NOAELs and LOAELs from 

different studies. In this case (key number 18), rats were exposed to 1,1,2,2-tetrachloroethane via 

inhalation for 6 hours per day, 5 days per week, for 3 weeks. For a more complete review of the 

dosing regimen refer to the appropriate sections of the text or the original reference paper, i.e., 

Nitschke et al. 1981. 

(7) System This column further defines the systemic effects. These systems include: respiratory, 

cardiovascular, gastrointestinal, hematological, musculoskeletal, hepatic, renal, and 

dermal/ocular. "Other" refers to any systemic effect (e.g., a decrease in body weight) not covered 

in these systems. In the example of key number 18, 1 systemic effect (respiratory) was 

investigated. 

(8) NOAEL A No-Observed-Adverse-Effect Level (NOAEL) is the highest exposure level at which 

no harmful effects were seen in the organ system studied. Key number 18 reports a NOAEL of 

3 ppm for the respiratory system which was used to derive an intermediate exposure, inhalation 

MRL of 0.005 ppm (see footnote "b"). 
SULFUR MUSTARD B-4 

APPENDIX B 

(9) LOAEL A Lowest-Observed-Adverse-Effect Level (LOAEL) is the lowest dose used in the study 

that caused a harmful health effect. LOAELs have been classified into "Less Serious" and 

"Serious" effects. These distinctions help readers identify the levels of exposure at which adverse 

health effects first appear and the gradation of effects with increasing dose. A brief description of 

the specific end point used to quantify the adverse effect accompanies the LOAEL. The 

respiratory effect reported in key number 18 (hyperplasia) is a Less serious LOAEL of 10 ppm. 

MRLs are not derived from Serious LOAELs. 

(10) Reference The complete reference citation is given in Chapter 9 of the profile. 

(11) CEL A Cancer Effect Level (CEL) is the lowest exposure level associated with the onset of 

carcinogenesis in experimental or epidemiologic studies. CELs are always considered serious 

effects. The LSE tables and figures do not contain NOAELs for cancer, but the text may report 

doses not causing measurable cancer increases. 

(12) Footnotes Explanations of abbreviations or reference notes for data in the LSE tables are found in 

the footnotes. Footnote "b" indicates the NOAEL of 3 ppm in key number 18 was used to derive 

an MRL of 0.005 ppm. 

LEGEND 

See Figure 3-1 

LSE figures graphically illustrate the data presented in the corresponding LSE tables. Figures 

help the reader quickly compare health effects according to exposure concentrations for particular 

exposure periods. 

(13) Exposure Period The same exposure periods appear as in the LSE table. In this example, health 

effects observed within the intermediate and chronic exposure periods are illustrated. 

(14) Health Effect These are the categories of health effects for which reliable quantitative data exists. 

The same health effects appear in the LSE table. 

(15)	 Levels of Exposure concentrations or doses for each health effect in the LSE tables are 

graphically displayed in the LSE figures. Exposure concentration or dose is measured on the log 

scale "y" axis. Inhalation exposure is reported in mg/m3

 or ppm and oral exposure is reported in 

mg/kg/day. 

(16) NOAEL In this example, the open circle designated 18r identifies a NOAEL critical end point in 

the rat upon which an intermediate inhalation exposure MRL is based. The key number 18 

corresponds to the entry in the LSE table. The dashed descending arrow indicates the 

extrapolation from the exposure level of 3 ppm (see entry 18 in the Table) to the MRL of 

0.005 ppm (see footnote "b" in the LSE table). 

(17) CEL Key number 38r is 1 of 3 studies for which Cancer Effect Levels were derived. The 

diamond symbol refers to a Cancer Effect Level for the test species-mouse. The number 38 

corresponds to the entry in the LSE table. 

(18)	 Estimated Upper-Bound Human Cancer Risk Levels This is the range associated with the upperbound for lifetime cancer risk of 1 in 10,000 to 1 in 10,000,000. These risk levels are derived 

from the EPA's Human Health Assessment Group's upper-bound estimates of the slope of the 

cancer dose response curve at low dose levels (q1*). 
SULFUR MUSTARD B-5 

APPENDIX B 

(19) Key to LSE Figure The Key explains the abbreviations and symbols used in the figure. 
SAMPLE 

1 → TABLE 3-1. Levels of Significant Exposure to [Chemical x] - Inhalation 

Exposure LOAEL (effect) 

Key to frequency/ NOAEL 

figurea Species duration System (ppm) Less serious (ppm) Serious (ppm) 

2 → INTERMEDIATE EXPOSURE 

5 6 7 8 9 

3 → Systemic ↓ ↓ ↓ ↓ ↓ 

3b 18 Rat 13 wk Resp 10 (hyperplasia) 

4 → 5 d/wk 

6 hr/d 

CHRONIC EXPOSURE 

Cancer 11 

↓

38 Rat 18 mo 20 (CEL, multiple organs) 

5 d/wk 7 hr/d 

39 Rat 89-104 wk 10 (CEL, lung tumors, nasal 

5 d/wk tumors) 

6 hr/d 

40 Mouse 79-103 wk 10 (CEL, lung tumors, 

5 d/wk hemangiosarcomas) 

6 hr/d 

a 12 → The number corresponds to entries in Figure 3-1. b Used to derive an intermediate inhalation Minimal Risk Level (MRL) of 5 x 10-3 ppm; dose adjusted for intermittent ex

by an uncertainty factor of 100 (10 for extrapolation from animal to humans, 10 for human variability).


SULFUR MUSTARD C-1 

APPENDIX C. ACRONYMS, ABBREVIATIONS, AND SYMBOLS 

ACOEM American College of Occupational and Environmental Medicine 

ACGIH American Conference of Governmental Industrial Hygienists 

ADI acceptable daily intake 

ADME absorption, distribution, metabolism, and excretion 

AED atomic emission detection 

AOEC Association of Occupational and Environmental Clinics 

AFID alkali flame ionization detector 

AFOSH Air Force Office of Safety and Health 

ALT alanine aminotransferase 

AML acute myeloid leukemia 

AOAC Association of Official Analytical Chemists 

AP alkaline phosphatase 

APHA American Public Health Association 

AST aspartate aminotranferase 

atm atmosphere 

ATSDR Agency for Toxic Substances and Disease Registry 

AWQC Ambient Water Quality Criteria 

BAT best available technology 

BCF bioconcentration factor 

BEI Biological Exposure Index 

BSC Board of Scientific Counselors 

C centigrade 

CAA Clean Air Act 

CAG Cancer Assessment Group of the U.S. Environmental Protection Agency 

CAS Chemical Abstract Services 

CDC Centers for Disease Control and Prevention 

CEL cancer effect level 

CELDS Computer-Environmental Legislative Data System 

CERCLA Comprehensive Environmental Response, Compensation, and Liability Act 

CFR Code of Federal Regulations 

Ci curie 

CI confidence interval 

CL ceiling limit value 

CLP Contract Laboratory Program 

cm centimeter 

CML chronic myeloid leukemia 

CPSC Consumer Products Safety Commission 

Ct concentration time product 

CWA Clean Water Act 

DHEW Department of Health, Education, and Welfare 

DHHS Department of Health and Human Services 

DNA deoxyribonucleic acid 

DOD Department of Defense 

DOE Department of Energy 

DOL Department of Labor 

DOT Department of Transportation 

DOT/UN/ Department of Transportation/United Nations/ 

NA/IMCO North America/International Maritime Dangerous Goods Code 

DWEL drinking water exposure level 
 

SULFUR MUSTARD C-2 

APPENDIX C 

ECD electron capture detection 

ECG/EKG electrocardiogram 

EEG electroencephalogram 

EEGL Emergency Exposure Guidance Level 

EPA Environmental Protection Agency 

F Fahrenheit 

F1 first-filial generation 

FAO Food and Agricultural Organization of the United Nations 

FDA Food and Drug Administration 

FEMA Federal Emergency Management Agency 

FIFRA Federal Insecticide, Fungicide, and Rodenticide Act 

FPD flame photometric detection 

fpm feet per minute 

FR Federal Register 

FSH follicle stimulating hormone 

g gram 

GC gas chromatography 

gd gestational day 

GLC gas liquid chromatography 

GPC gel permeation chromatography 

HPLC high-performance liquid chromatography 

HRGC high resolution gas chromatography 

HSDB Hazardous Substance Data Bank 

IARC International Agency for Research on Cancer 

IDLH immediately dangerous to life and health 

ILO International Labor Organization 

IRIS Integrated Risk Information System 

Kd adsorption ratio 

kg kilogram 

Koc organic carbon partition coefficient 

Kow octanol-water partition coefficient 

L liter 

LC liquid chromatography 

LCLo lethal concentration, low 

LC50 lethal concentration, 50% kill 

LCt50 lethal Ct, 50% kill 

LDLo lethal dose, low 

LD50 lethal dose, 50% kill 

LDH lactic dehydrogenase 

LH luteinizing hormone 

LT50 lethal time, 50% kill 

LOAEL lowest-observed-adverse-effect level 

LSE Levels of Significant Exposure 

m meter 

MA trans,trans-muconic acid 

MAL maximum allowable level 

mCi millicurie 

MCL maximum contaminant level 

MCLG maximum contaminant level goal 

MFO mixed function oxidase 

mg milligram 

mL milliliter 
 

SULFUR MUSTARD C-3 

APPENDIX C 

mm millimeter 

mmHg millimeters of mercury 

mmol millimole 

mppcf millions of particles per cubic foot 

MRL Minimal Risk Level 

MS mass spectrometry 

NAAQS National Ambient Air Quality Standard 

NAS National Academy of Science 

NATICH National Air Toxics Information Clearinghouse 

NATO North Atlantic Treaty Organization 

NCE normochromatic erythrocytes 

NCEH National Center for Environmental Health 

NCI National Cancer Institute 

ND not detected 

NFPA National Fire Protection Association 

ng nanogram 

NIEHS National Institute of Environmental Health Sciences 

NIOSH National Institute for Occupational Safety and Health 

NIOSHTIC NIOSH's Computerized Information Retrieval System 

NLM National Library of Medicine 

nm nanometer 

NHANES National Health and Nutrition Examination Survey 

nmol nanomole 

NOAEL no-observed-adverse-effect level 

NOES National Occupational Exposure Survey 

NOHS National Occupational Hazard Survey 

NPD nitrogen phosphorus detection 

NPDES National Pollutant Discharge Elimination System 

NPL National Priorities List 

NR not reported 

NRC National Research Council 

NS not specified 

NSPS New Source Performance Standards 

NTIS National Technical Information Service 

NTP National Toxicology Program 

ODW Office of Drinking Water, EPA 

OERR Office of Emergency and Remedial Response, EPA 

OHM/TADS Oil and Hazardous Materials/Technical Assistance Data System 

OPP Office of Pesticide Programs, EPA 

OPPTS Office of Prevention, Pesticides and Toxic Substances, EPA 

OPPT Office of Pollution Prevention and Toxics, EPA 

OR odds ratio 

OSHA Occupational Safety and Health Administration 

OSW Office of Solid Waste, EPA 

OW Office of Water 

OWRS Office of Water Regulations and Standards, EPA 

PAH polycyclic aromatic hydrocarbon 

PBPD physiologically based pharmacodynamic 

PBPK physiologically based pharmacokinetic 

PCE polychromatic erythrocytes 

PEL permissible exposure limit 

PID photo ionization detector 
SULFUR MUSTARD C-4 

APPENDIX C 

pg picogram 

pmol picomole 

PHS Public Health Service 

PMR proportionate mortality ratio 

ppb parts per billion 

ppm parts per million 

ppt parts per trillion 

PSNS pretreatment standards for new sources 

RBC red blood cell 

REL recommended exposure level/limit 

RfC reference concentration 

RfD reference dose 

RNA ribonucleic acid 

RTECS Registry of Toxic Effects of Chemical Substances 

RQ reportable quantity 

SARA Superfund Amendments and Reauthorization Act 

SCE sister chromatid exchange 

SGOT serum glutamic oxaloacetic transaminase 

SGPT serum glutamic pyruvic transaminase 

SIC standard industrial classification 

SIM selected ion monitoring 

SMCL secondary maximum contaminant level 

SMR standardized mortality ratio 

SNARL suggested no adverse response level 

SPEGL Short-Term Public Emergency Guidance Level 

STEL short term exposure limit 

STORET Storage and Retrieval 

TD50 toxic dose, 50% specific toxic effect 

TLV threshold limit value 

TOC total organic carbon 

TPQ threshold planning quantity 

TRI Toxics Release Inventory 

TSCA Toxic Substances Control Act 

TWA time-weighted average 

UF uncertainty factor 

U.S. United States 

USDA United States Department of Agriculture 

USGS United States Geological Survey 

VOC volatile organic compound 

WBC white blood cell 

WHO World Health Organization 
SULFUR MUSTARD C-5 

APPENDIX C 

> $

= 

< #

% αβγδ

μm

μg q1

* 

– 

+ 

(+) 

(–) 

greater than 

greater than or equal to 

equal to 

less than 

less than or equal to 

percent 

alpha 

beta 

 gamma 

delta 

 micrometer 

microgram 

cancer slope factor 

negative 

positive 

weakly positive result 

weakly negative result 

SULFUR MUSTARD D-1 

APPENDIX D. ACUTE EXPOSURE GUIDELINE LEVELS (AEGLS) FOR 

SULFUR MUSTARD 

The National Advisory Committee for the Acute Exposure Guideline Levels for Hazardous Substances 

has developed acute exposure guideline levels (AEGLs) for sulfur mustard (NAC/AEGL 2001). The 

AEGLs are threshold exposure limit values for the general public applicable to emergency exposure periods

 ranging from 10 minutes to 8 hours. For each chemical, three levels of AEGLs, distinguished by varying 

degrees of severity of toxic effects, are developed: at exposure levels above the AEGL-1, the general

 population could experience notable discomfort, irritation, or asymptomatic, nonsensory effects; above 

AEGL-2, the general population could experience irreversible or other serious, long lasting health effects 

or impaired ability to escape; and above AEGL-3, the general population could experience life-threatening 

health effects or death. At each AEGL level, values are developed for five exposure periods: 10 minutes, 

30 minutes, 1 hour, 4 hours, and 8 hours. 

The derivation of the AEGLs for sulfur mustard presented below was excerpted from NRC (2003). 

5. DATA ANALYSIS FOR AEGL-l 

5.1. Summary of Human Data Relevant to AEGL-l 

Walker et al. (1928) reported that four of seven men exposed to sulfur mustard at 

0.001 mg/L (1 mg/m3

) for 5-45 min exhibited conjunctivitis, and two exhibited 

skin burns. It was also reported that, of 17 men exposed at 0.0005 mg/L (0.5 

mg/m3) for 10-45 min (5-22.5 mg.min/m3), six exhibited conjunctivitis, and one 

had a skin burn. Three of 13 men exposed for 10-30 min at 0.0001 mg/L (0.1 

mg/m3; Ct of 1-3 mg.min/m3) showed slight but distinct conjunctivitis. Although 

not of a severity consistent with an AEGL-2 level, those effects are of greater 

severity than would be acceptable for AEGL-l development. Guild et al. (1941) 

also conducted experiments using humans and reported that (1) exposure to Ct 

values <70 mg.

min/m3 would result in mild conjunctival responses that would not 

be indicative of a casualty (temporary loss of vision); (2) Ct values of 70-100 

mg.

min/m3 would produce some casualties and; (3) Ct values >l00 mg.min/m3 

would be expected to produce disabling ocular effects of several days' duration. 

Because the subjects wore respiratory protection, effects on the respiratory tract 

could not be determined. 

In experiments with human volunteers exposed to varying concentration-time 

regimens, Anderson (1942) found that an exposure concentration-time product of 

12 mg.

min/m3 was without effects and 30 mg.min/m3 represented the upper range 

for mild effects (conjunctival injection and minor discomfort with no functional 

decrement). Ct products slightly higher than that (e.g., 34-38.1 mg.

min/m3) were, 
SULFUR MUSTARD D-2 

APPENDIX D 

however, also without appreciable effects, thereby indicating that the response to 

30 mg.

min/m3 is consistent with AEGL-l effects. 

Odor thresholds of 1 mg.

min/m3 (Bloom 1944), 0.15 mg/m3 (Ruth 1986) and 0.6 

mg/m3

 (Dudley and Wells 1938; Bowden 1943; Fuhr and Krakow 1945) have 

been reported. 

Analysis of the exposure-effect values from the human studies indicated that the 

12-mg.

min/m3 value represented a defensible estimate of the threshold for effects 

consistent with the AEGL-l definition. The 12-mg.

min/m3 exposure was without 

a symptomatic effect and, therefore, provides the basis for protective AEGL-l 

values consistent with the AEGL- 1 definition. 

5.2. Summary of Animal Data Relevant to AEGL-l 

The effects described in the animal studies tend to be of a greater severity than 

those associated with AEGL-l (i.e., signs of severe ocular irritation, body weight 

loss, respiratory depression, evidence, evidence of respiratory tract 

histopathology, etc.). There were no definitive exposure-response data in animals 

that were considered appropriate for the development of AEGL-l values. 

5.3. Derivation of AEGL-l 

The most tenable AEGL-l values were developed using data reported by 

Anderson (1942) in which three to four human volunteers were exposed to agent 

HD at varying concentration-time regimens. In an analysis of those data, 

Anderson found that an exposure concentration-time product of 30 mg.

min/m3 

represented the upper range for mild effects (conjunctival injection and minor 

discomfort with no functional decrement) and that 12 mg.min/m3 represented a 

threshold for such effects. The 12 mg.

min/m3 represents a defensible estimate of 

the threshold for AEGL-1 effects. The 12-mg.

min/m3 exposure resulted in only 

minor conjunctival injection and no sensation of irritation. Ocular effects appear 

to be the most sensitive indicator of sulfur mustard exposure and toxicity, thereby 

justifying ocular irritation as an appropriate end point for development of AEGL 

values. All of the data considered were from human subjects, and, therefore, the 

uncertainty factor (UF) application to the 12-mg.

min/m3 value was limited to 3 for 

protection of sensitive individuals. The adjustment is considered appropriate for 

acute exposures to chemicals whose mechanism of action primarily involves 

surface contact irritation of ocular and/or respiratory tract rather than systemic 

activity that involves absorption and distribution of the parent chemical or a 

biotransformation product to a target tissue. In addition, Anderson (1942) noted 

that there was little variability in the ocular responses among the individuals 

participating in the study. That the AEGL-1 values are based on a sensitive end 

point is also reflected in that they are below reported odor thresholds (0.6 mg/m3 

and 1 mg.

min/m3). 
SULFUR MUSTARD D-3 

APPENDIX D 

Because exposure-response data were unavailable for all of the AEGL- specific 

exposure durations, temporal extrapolation was used in the development of 

AEGL-1 values for the AEGL-specific time periods. The concentration-exposure 

time relationship for many irritant and systemically acting vapors and gases can 

be described by Cn x t = k, where the exponent n ranges from 0.8 to 3.5 (ten Berge 

et al. 1986). Analyses of available data regarding AEGL-1 type effects reported 

by Reed (1918), Reed et al. (1918), Guild et al. (1941), and Anderson (1942) 

indicate that for the exposure periods up to several hours, the concentrationexposure time relationship is a near-linear function (i.e., Haber's law where n = 1 

for Cn x t = k) as shown by n values of 1.11 and 0.96 for various data sets 

consistent with AEGL-l effects (Appendix B). Therefore, an empirically derived, 

chemical-specific estimate of n = 1 was used, rather than a default value, based on 

the ten Berge (1986) analyses. The derivation of the exponent (n) utilized human 

response data where 75-100% of the responders showed a mild response that 

would be consistent with the definition of AEGL-l effects. In addition, the data 

provided by Anderson (1942) were indicative of a linear concentration-time 

relationship. The AEGL-l values developed using the 12-mg.min/m3 exposure 

value reported by Anderson (1942) are shown in Table 2-9. The AEGL-l values 

are below the odor threshold for sulfur mustard (0.6 mg/m3 and 1 mg.min/m3). 

6. DATA ANALYSIS FOR AEGL-2 

6.1. Summary of Human Data Relevant to AEGL-2 

Quantitative data regarding the human experience and AEGL-2 level effects are 

limited to responses ranging from signs of mild ocular irritation to ocular irritation 

that impairs normal visual function. Reed (1918) reported that 20-45 min 

exposure of himself and a volunteer at 1.2 mg/m3

 resulted in severe ocular 

irritation and dermal lesions. In a report of a subsequent experiment, Reed et al. 

(1918) noted that exposure of human volunteers at 0.1- 4.3 mg/m3 for 5 -45 min 

produced ocular irritation and skin burns (0.5 mg/m3

 for 30 min) and very severe 

conjunctivitis, photophobia, skin bums, and nasopharyngeal exfoliation (1.0 

mg/m3

 for 45 min). The analytical techniques used in these experiments were 

suspect; actual exposures were likely 30-40% higher. The report by Guild et al. 

(1941) of human exposure experiments did not provide findings of effects 

consistent with the AEGL-2 definition. Anderson (1942) reported on a series of 

human exposures resulting in varying degrees of ocular responses ranging from 

nonsymptomatic ocular injection to ocular irritation that required medical 

treatments and was considered severe enough to impair normal function. 

6.2. Summary of Animal Data Relevant to AEGL-2 

With the exception of a study reported by Warthin and Weller (1919) regarding 

the effects in rabbits following acute exposure, there is little exposure-response 

data for animals consistent with AEGL-2-severity effects. Weller and Warthin 

reported severe ocular effects and dermal burns in rabbits exposed for 12 h to 
SULFUR MUSTARD D-4 

APPENDIX D 

sulfur mustard at 130 mg/m3. That study, however, was compromised by the use 

of single animals and lacks detail. Kumar and Vijayaraghavan (1998) reported 

alterations in purine catabolism exposed for 1 h to sulfur mustard at 21.2- 84.6 

mg/m3

 but those exposures also represented 0.5, 1.0, and 2.0 LC50 responses. 

Statistically significant reductions in body weights were also observed for the 

mice at 14 d following a 1-h exposure to concentrations at 16.9- 42.3 mg/m3

; 

however at least some of the exposures were also associated with lethality. Dogs, 

rats, mice, and guinea pigs exposed continuously to sulfur mustard at 0.001 

mg/m3

 or discontinuously (6.5 h/d, 5 d/wk) at 0.1 mg/m3 for up to 52 wk did not 

exhibit effects consistent with the AEGL-2 definition (McNamara et al. 1975). 

Table 2-9 AEGL-l Values for Sulfur Mustard (ppm [mg/m3

]) a 

10-min 30-min 1-h 4-h 8-h 

0.06 

(0.40) 

0.02 

(0.13) 

0.01 

(0.067) 

0.003 

(0.017) 

0.001 

(0.008) a

The AEGL-1 values are at or below the odor threshold for sulfur mustard. 

6.3. Derivation of AEGL-2 

The AEGL-2 values for sulfur mustard were developed using data from Anderson 

(1942). The study utilized three or four human volunteers’ exposed to varying 

concentrations of sulfur mustard (1. 7-15.6mg/m3

) for time periods varying from 

2 to 33 min. Anderson considered a Ct value of 60 mg.

min/m3 as the lowest 

concentration-time product for which ocular effects could be characterized as 

military casualties and that personnel exposed might be ineffective for up to (but 

no more than) 7 d. Effects included irritation, soreness, and widespread 

conjunctivitis, frequently accompanied by chemosis and photophobia. The 60­

mg.min/m3 exposure was used as the basis for developing the AEGL-2 values 

because it is representative of an acute exposure causing an effect severe enough 

to impair normal visual function and, although not irreversible, would certainly 

result in potential for additional injury. The ocular irritation and damage were 

also considered appropriate as a threshold estimate for AEGL-2 effects, because 

the eyes are generally considered the most sensitive indicator of sulfur mustard 

exposure, and irritation would likely occur in the absence of vesication effects and 

severe pulmonary effects. The fact that the AEGL-2 is based on human data 

precludes the use of an interspecies UF. A factor of 3 was applied for intraspecies 

variability (protection of sensitive populations). The factor was limited to 3 under 

the assumption that the primary mechanism of action of sulfur mustard involves a 

direct effect on the ocular surface and that the response will not vary greatly 

among individuals (as noted by Anderson [1942]). A modifying factor of 3 was 

applied to accommodate potential onset of long-term ocular or respiratory effects. 

It was justified by the absence of long-term follow-up in the subjects of the 

Anderson (1942) study to confirm or deny development of permanent ocular or 

respiratory tract damage. Because the factors of 3 each represent a logarithmic 

mean (3.16) of 10, their product is 3.16 x 3.16 = 10. Further reduction by the 
SULFUR MUSTARD D-5 

APPENDIX D 

application of additional modifying factors was not warranted because of the use 

of a sensitive indicator representing an AEGL-2 effect of marginal severity. As is 

the case for AEGL-1 values, time scaling was conducted using an n of 1 for all 

time points (Appendix B). The resulting AEGL-2 values are shown in Table 2­

10, and their derivation is presented in Appendix A. Similar to the AEGL-l 

values, all of the AEGL-2 values are at or below the reported odor thresholds (0.6 

mg/m3

 and 1 mg.min/m3). 

TABLE 2-10 AEGL-2 Values for Sulfur Mustard (ppm [mg/m3])a 

10-min 30-min 1-h 4-h 8-h 

0.09 

(0.60) 

0.03 

(0.20) 

0.02 

(0.10) 

0.004 

(0.025) 

0.002 

(0.013) a

The AEGL-2 values are at or below odor threshold for sulfur mustard. 

7. DATA ANALYSIS FOR AEGL-3 

7.1. Summary of Human Data Relevant to AEGL-3 

Human lethality data are limited to an inhalation LCt50 estimate of 1,500 

mg.

min/m3 and percutaneous LCt50 estimate of 10,000 mg.min/m3 estimated from 

animal data (DA 1974). The NRC (1997) concluded that an estimated LCt50 for 

humans of 900 mg.min/m3 developed by the U. S. Army based on an average of 

animal LCt50 data was scientifically valid but was developed in reference to 

healthy male military personnel and does not apply to civilians. 

7.2. Summary of Animal Data Relevant to AEGL-3 

Various lethality values have been reported for laboratory species exposed to 

sulfur mustard. Vijayaraghavan (1997) reported a 1-h LC50 of 42.5 mg/m3 for 

mice (head-only exposure). In a follow-up study reported by Kumar and 

Vijayaraghavan (1998), 1-h exposure of mice at 21.2 mg/m3 did not result in 

lethality. Lethality estimates were based on deaths occurring up to 14 d after 

exposure. Langenberg et al. (1998) reported a 5-min LCt50 of 800 mg.

min/m3 for 

rabbits (deaths determined up to 96 h after exposure). These studies utilized upto-date exposure and analytical systems and provided lethality estimates based on 

adequate numbers of animals evaluated at post exposure time frames appropriate 

for the known latency in sulfur-mustard-induced lethality. 

7.3. Derivation of AEGL-3 

As noted in Section 3.1.4, the lethality data from earlier reports were not 

verifiable but are not inconsistent with those from later studies. The 1-h LC50 

values for rats and mice derived from the 840 and 860 mg.

min/m3 60-min LCt5o 

values reported by Fuhr and Krakow (1945) are similar to the lower confidence 

limit of the mouse 1-h LC50 reported by Vijayaraghavan (1997) (i.e., 14.0, 14.3, 
SULFUR MUSTARD D-6 

APPENDIX D 

and 13.5 mg/m3, respectively; the corresponding Ct values are 840,858, and 810 

mg.

min/m3). The values are also similar to a 1-h LC50 of 13.3 mg/m3 for guinea 

pigs extrapolated (assuming C1 x t = k) from the 5-min LCt50 of 800 mg.min/m3 

reported by Langenberg et al. (1998). However, the values from the earlier 

studies are not verifiable. In the inhalation toxicity study by Vijayaraghavan 

(1997), mice were exposed head only) for 60 min to sulfur mustard at 

concentrations of 0.0, 8.5, 16.9, 21.3, 26.8, 42.3 or 84.7 mg/m3. The study 

investigator derived a 60-min LC50 of 42.5 mg/m3 based on lethality at 14 d post 

exposure (95% confidence interval: 13.5-133.4 mg/m3

). In a follow-up study 

(Kumar and Vijayaraghavan 1998), there was no mortality in mice exposed at 0.5 

LC50 mg/m3

). Therefore, the 1-h exposure at 21.2 mg/m3 was selected as an 

estimate of the lethality threshold in mice. 

When compared with the human exposure-effect data, the 21.2-mg/m3 

concentration (Ct of 1,272 mg.

min/m3 for a 60-min exposure) is not an exposure 

that has been associated with lethality in humans (see Section 2.1). An 

intraspecies UF of 3 was applied for protection of sensitive individuals. This 

adjustment was considered appropriate for acute exposures to chemicals whose 

mechanism of action primarily involves surface contact irritation of ocular and/or 

respiratory tract tissue rather than systemic activity that involves absorption and 

distribution of the parent chemical or a biotransformation product to a target 

tissue. An interspecies UP was limited to 3 because available data do not suggest 

that humans are notably more sensitive than animals regarding lethality from 

inhalation exposure to sulfur mustard. The mechanism of pulmonary injury 

leading to lethality appears to be a function of the direct contact of an alkylating 

agent with epithelial tissue. This mechanism is likely to be more similar than 

different across mammalian species. Furthermore, the AEGL-3 values resulting 

from the aforementioned complement of UFs (total UF adjustment was 10; see 

Section 6.3) are equivalent to exposures known to cause only mild ocular effects 

in humans. The modifying factor of 3 utilized in the development of AEGL-2 

values to account for uncertainties regarding the latency and persistence of the 

irritant effects of low-level exposure to sulfur mustard was not applied for AEGL3 because lethality of the mice was assessed at 14 d post exposure in the key 

studies by Vijayaraghavan (1997) and Kumar and Vijayaraghavan (1998). 

For derivation of the AEGL-3 values, there was uncertainty regarding the validity 

of applying linear extrapolation based on ocular effects to concentration-time 

extrapolations for lethality. As reported by ten Berge et al. (1986), the 

concentration-time relationship for many irritant and systemically acting vapors 

and gases can be described by Cn

 x t = k, where the exponent n ranges from 0.8 to 

3.5. Therefore, in the absence of chemical-specific lethality data, time scaling 

was performed using exponential extrapolation (n = 3) for shorter time periods 

and linear extrapolation (n = 1) for longer time periods, thereby providing a 

somewhat more conservative (i.e., protective) estimate of the AEGL-3 values than 

would be obtained using an n value based on ocular irritation. The AEGL-3 

values were derived by scaling from the 1-h LC50 of 21.2 mg/m3

 reported by 
SULFUR MUSTARD D-7 

APPENDIX D 

Kumar and Vijayaraghavan (1998) using Cn x t = k where n = l or 3 (Appendix 

A). The concentration-time constant, k, was 1,272 mg.

min/m3 where n = 1 and 

571,687.68 mg.min/m3 where n = 3. The AEGL-3 values are shown In Table 2­

11, and their derivation is presented in Appendix A. The 4-h and 8-h AEGL-3 

values are at or below reported odor thresholds. 

TABLE 2-11 AEGL-3 Values for Sulfur Mustard (ppm [mg/m3]) 

10 min 30 min 1 h 4 h 8 h 

0.59 

(3.9) 

0.41 

(2.7) 

0.32 

(2.1) 

0.08 

(0.53) 

0.04 

(0.27) 

Note: The 4 –h and 8 – h AEGL-3 values are below the odor threshold for sulfur 

mustard. 

When comparing the Ct values generated by the draft AEGL-3 numbers the 

human exposure data, any further reduction appears indefensible. The Ct values 

resulting from theAEGL-3 numbers (i.e., 39-130 mg.min/m3) are similar to 

cumulative exposures shown to cause only ocular irritation in humans (Guild et 

al. 1941; Anderson 1942) and are similar to the ECt50 of 100 mg.min/m3 for 

severe ocular effects (for soldiers) determined by Reutter and Wade (1994) and 

the NRC (1997). Furthermore, the AEGL-3 values are nearly similar to those 

developed using the human lethality estimate of 900 mg.min/m3 (Reutter and 

Wade 1994) that was derived from multiple-species animal data and reviewed by 

the NRC (1997). Assuming a 3-fold reduction for estimation of a lethality 

threshold ([900 mg.min/m3]/3 = 300 mg.min/m3) and another 3-fold reduction for 

consideration of sensitive populations ([300 mg.

min/m3]/3 = 100 mg.min/m3), the 

resulting AEGL-3 values from the Reutter and Wade (1994) and NRC (1997) 

reports would be 4.8, 3.3, 1.7, 0.42, and 0.21 mg/m3 for 10 min, 30 min, and 1, 4, 

8 h, respectively. These highly derivative estimates are comparable to, and 

supportive of, AEGL-3 estimates derived from the experimental data of Kumar 

and Vijayaraghavan (1998) (see Table 2-11). 

8. SUMMARY OF AEGLs 

8.1. AEGL Values and Toxicity End Points 

Human data are available from several independent sources that define exposureresponse for AEGL-l and AEGL-2 effects. Although a definitive demarcation of 

the exposure-response for sensitive populations was not provided by those data, 

the human data eliminated the uncertainties inherent in the use of data from 

animal studies. Both the AEGL-l and AEGL-2 values were based on effect end 

points consistent with the respective AEGL definitions (i.e., threshold for barely 

discernible ocular irritation [AEGL-l] and threshold for ocular irritation indicative 

of functional impairment [AEGL-2]). Areas of uncertainty were associated with 

the sensitive responders and the relationship between ocular effects and the onset 

of respiratory effects. Human data from which to develop AEGL-3 values were 
SULFUR MUSTARD D-8 

APPENDIX D 

unavailable. The AEGL-3 was based on an estimated lethality threshold from 

studies in mice (Vijayaraghavan 1997; Kumar and Vijayaraghavan 1998). When 

compared with human exposure-response data and lethality estimates, the mouse 

lethality data were considered a defensible approach to AEGL-3 derivation. 

AEGL-3 values based on a human lethality estimate of 900 mg.min/m3 (Reutter 

and Wade 1994; NRC 1997) were very similar to those developed using the 

animal data of Vijayaraghavan (1997) and Kumar and Vijayaraghavan (1998). 

An estimate of theoretical excess cancer risk based upon a geometric mean of 

inhalation slope factors developed using various data sets and procedures revealed 

that exposure concentrations representing a theoretical 10-4 lifetime risk were 

similar to the AEGL-3 exposure concentration values. The exposures for 

theoretical excess lifetime cancer risk at 10-5 and 10-6 levels would be 

correspondingly reduced. The use of excess cancer risk estimates in setting 

AEGL values is precluded by the uncertainties involved in assessing excess 

cancer risk following a single acute exposure of 8-h or less duration, by the 

relatively small population exposed in an emergency release situation, and by the 

potential risks associated with evacuations. 

The AEGL values for sulfur mustard are summarized in Table 2-12. 

Extrapolation to exposure durations of less than 10 min is not recommended in 

the absence of careful evaluation of existing data and comparison of any 

derivative values with those data. 

8.2. Comparison with Other Standards and Guidelines 

Comparison of the draft AEGL values with other existing standards and 

guidelines is shown in Table 2-13. No other standards or guidelines from other 

agencies or programs (e.g., NIOSH, ERPG, ACGIH, MAK, MAC, and OSHA) 

were available. 

8.3. Data Adequacy and Research Needs 

The AEGL-1 values are based on human data and are considered estimates for 

exposures that would cause no significant health effects or sensations of irritation 

beyond minimal conjunctivitis. 
 

SULFUR MUSTARD D-9 

APPENDIX D 

TABLE 2-12 Summary of AEGL Values for Sulfur Mustarda 

AEGL Level 10 min 30 min 1 h 4 h 8 h 

AEGL-1a 

(Nondisabling) 

0.06 ppm 

(0.40 

mg/m3) 

0.02 ppm 

(0.13 

mg/m3) 

0.01 ppm 

(0.067 

mg/m3) 

0.003 ppm 

(0.017 

mg/m3) 

0.001 ppm 

(0.008 

mg/m3) 

AEGL-2a 

(Disabling) 

0.09 ppm 

(0.60 

mg/m3

) 

0.03 ppm 

(0.20 

mg/m3) 

0.02 ppm 

(0.10 

mg/m3) 

0.004 ppm 

(0.025 

mg/m3) 

0.002 ppm 

(0.013 

mg/m3) 

AEGL-3a

 0.59 ppm 

(3.9 mg/m3) 

0.41 ppm 

(2.7 mg/m3) 

0.32 ppm 

(2.1 

mg/m3

) 

0.08 ppm 

(0.53 

mg/m3) 

0.04 ppm 

(0.27 mg/m3

) 

A AEGL-1 and AEGL-2 values, and the 4- and 8-h AEGL-3 values are at or below the 

odor threshold for sulfur mustard. 

The ocular irritation on which the AEGL-l and AEGL-2 values are based is the 

most sensitive response to sulfur mustard vapor. The AEGL-2 values provide Ct 

exposures that are well below those known to induce severe ocular effects in 

normal humans (i.e., 70-90 mg.

min/m3). AEGL-3 values provide Ct values (39­

130 mg.min/m3) that are at levels known to cause moderate to severe ocular 

irritation and possible respiratory tract irritation in human subjects Anderson 

1942; Guild et al. 1941) but no life-threatening effects or death. Although the 

overall database for acute inhalation exposure to sulfur mustard is not extensive, 

the AEGL values are supported by the available data. 

The absence of multiple-species lethality data for acute exposures limits a 

thorough understanding of variability. Data providing definitive demarcation of 

the threshold for serious and/or irreversible effects would provide a more 

complete picture of responses resulting from acute inhalation exposure to sulfur 

mustard. That is especially relevant to assessing the potential for serious 

respiratory tract damage or permanent ocular pathology following acute exposure. 

Although sulfur mustard is a genotoxic chemical capable of inducing tumors in 

animals and humans, the carcinogenic potential of acute inhalation exposures has 

not been defined. 
 

 

 

 

 

 

 

 

SULFUR MUSTARD D-10 

APPENDIX D 

TABLE 2-13 Comparison of AEGL Values for Sulfur Mustard 

with Other Extant Standards and Guidelines 

Guideline 10 min 30 min 1 h 4 h 8 h Other 

AEGL-1 0.40 

mg/m3 

(0.06 

ppm) 

0.13 

mg/m3 

(0.02 

ppm) 

0.067 

mg/m3 

0.01 

ppm) 

0.017 

mg/m3 

(0.003 

ppm) 

0.008 mg/m3 

0.001 ppm) 

AEGL-2 0.60 

mg/m3 

(0.09 

ppm) 

0.20 

mg/m3 

(0.03 

ppm) 

0.10 

mg/m3 

(0.02 

ppm) 

0.025 

mg/m3 

(0.004 

ppm) 

0.013 mg/m3 

(0.002 ppm) 

AEGL-3 3.9 

mg/m3 

(0.59 

ppm) 

2.7 

mg/m3 

(0.41 

ppm) 

2.1 

mg/m3 

(0.32 

ppm) 

0.53 

mg/m3 

(0.08 

ppm) 

0.27 mg/m3 

(0.04 ppm) 

Department of 

the 

Army/Civilian 

Occupational 

WPLa 

0.003mg/m3 

(0.0005 

ppm) 

Department of 

the 

Army/Civilian 

GPLb 

0.0001 

mg/m3 

(1.5 x 10-5 

ppm) 

CDC-CSEPP 

(Thacker, 

1994)c 

2.0 

mg.

min/m3 

(0.3 ppm) a

Worker Population Exposure Limit (DA 1991, 1997; DHHS 1988), 8-h TWA, 5 d/wk 

b

General Population Limit (no observable effects), 24-h TWA, 7 d/wk 

c

Recommended acute effects levels for determining emergency evacuation distances in 

the Chemical Stockpile Emergency Preparedness Program (CSEPP); no set exposure 

time. 

9. REFERENCES 

Anderson, J.S. 1942. The effect of mustard gas vapour on eyes under Indian hot 

weather conditions. CDRE Report No. 241. Chemical Defense Research 

Establishment (India). 

Bloom et a1. 1944. Informal monthly progress report on toxicity of chemical 

warfare agents. OSRD Informal Report 9-4-1-12. January 10, 1944. (As cited in 

DNA 1993.) 

Bowden, E. 1943. Median detectable concentrations by odor of plant run mustard, 

plant run Lewisite and pilot plant ethyl nitrogen mustard. ADB 969801, TDMR 

615 (April 1943). 
SULFUR MUSTARD D-11 

APPENDIX D 

Crump, K.S., and R.B. Howe. 1984. The multistage model with a time-dependent 

dose pattern: Applications to carcinogenic risk assessment. Risk Analysis 4:163­

176. 

DA (U.S. Department of the Army). 1974. Chemical agent data sheets. Vol. 1. 

Tech. Report 

E-SR-74001, Edgewood Arsenal Special Report, U.S. Department of the Army, 

Defense Technical Information Center, Alexandria, V A. 

DA (U.S. Department of the Army). 1991. Occupational Health Guidelines for the 

Evaluation and Control of Occupational Exposure to Mustard Agents H, HD, and 

HT. Dept. of the Army, Pamphlet 40-173, Washington., DC. 

DA (U.S. Department of the Army). 1997. The Army Chemical Agent Safety 

Program Army Regulation AR 385-61. Headquarters, Department of the Army, 

Washington, DC. 

DHHS (U.S. Department of Health and Human Services). 1988. Final 

recommendations for protecting the health and safety against potential adverse 

effects of long-term exposure to low doses of agents: GA, GB, VX, mustard agent 

(H HD, HT), and lewisite (L). U.S. Department of Health and Human Services 

Centers for Disease Control. Fed. Reg. 53(50): 8504-8507. 

Dudley, H.C., and W. J. H. B. Wells. 1938. The detection of HS by odor. ADB 

959500, EATR 249 (March 1936). (As cited in personal communication from
 

S.Reutter, U.S. Army Edgewood Research Development and Engineering Center, 

APG, MD, October 1995.) 

Fuhr, I., and E.H. Krakow. 1945. Median lethal concentrations of H for mice and 

rats. For various exposure times. MDR 21, March 21. (As cited in McNarnara t al. 

1975.) 

Guild, W.J., K.P. Harrison, A. Fairly, and A.E. Childs. 1941. The effect of 

mustard gas vapour on the eyes. Porton Report No.2297 , Serial No. 12,8 

November 1941. 

Kumar, O., and R. Vijayaraghavan. 1998. Effect of sulphur mustard inhalation 

exposure on some urinary variables in mice. J. Appl. Toxicol. 18:257-259. 

Langenberg, J.P., G.P. van der Schans, H.E.T. Spruit, et al. 1998. Toxicokinetics 

of sulfur mustard and its DNA-adducts in the hairless guinea pig. Drug. Chem. 

Toxicol. 21(Supp1. 1):131-147. 

McNamara, B.P., E.J. Owens, M.K. Christensen, F.J. Vocci, D.F. Ford, and H. 

Rozimarek. 1975. Toxicological basis for controlling levels of mustard in the 
SULFUR MUSTARD D-12 

APPENDIX D 

environment. EASP EBSP 74030. Biomedical Laboratory, Department of the 

Army, Headquarters, Edgewood Arsenal, Aberdeen Proving Ground, MD. 

NRC (National Research Council). 1985. Emergency and continuous exposure 

guidance levels for selected airborne contaminants, Vol. 5. Washington, DC: 

National Academy Press. 

NRC (National Research Council). 1986. Criteria and methods for preparing 

emergency exposure guidance level (EEGL), short-term public emergency 

guidance level (SPEGL), and continuous exposure guidance level (CEGL) 

documents. Washington, DC: National Academy Press. Appendix F, pp. 25-27. 

NRC (National Research Council). 1997. Review of acute human-toxicity 

estimates for selected chemical-warfare agents. Washington, DC: National 

Academy Press. 

Reed, C.I. 1918. The minimum concentration of mustard gas effective for man. 

Preliminary Report. Report 318. War Department, Med. Div., C.W.S. Pharmacol. 

Res. Sec. Amer. Univ. Exp. Station, War Dept. October 26,1918. 

Reed, C.I., E.F. Hopkins, and C.F. Weyand. 1918. The minimum concentration of 

mustard gas effective for man. Final Report. Report 329. War Department, Med. 

Div., C.W.S., Pharmacol. Res. Sec. Amer. Univ. Exp. Station, War Dept. 

December 2, 1918. 

Reutter, S.A., and J.V. Wade. 1994. "Table 1; Summary of Existing and 

Recommended Estimates (U)," unclassified summary table. In: Review of 

existing toxicity data and human estimates for selected chemical agents and 

recommended human toxicity estimates appropriate for defending the soldier. 

ERDEC-SP-O 18. U.S. Department of the Army, Edgewood Research 

Development and Engineering Center, Aberdeen Proving Ground, MD (secret 

report). 

Ruth, J.H. 1986. Odor Thresholds and Irritation Levels of Several Chemical 

Substances: A review. Am. Ind. Hyg. Assoc. J. 47:A142-A151. 

ten Berge, W.F.,A. Zwart, and L.M. Appelman. 1986. Concentration-time 

mortality response relationship of irritant and systemically acting vapours and 

gases. J. Hazard Materials 13:301-309. 

U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM). 

2000. Evaluation of Airborne Exposure Limits for Sulfur Mustard: Occupational 

and General Population Exposure Criteria. Aberdeen Proving Ground, Maryland. 

Technical Report 47-EM-3767-00. 
 

SULFUR MUSTARD D-13 

APPENDIX D 

Vijayaraghavan, R. 1997. Modifications of breathing pattern induced by inhaled 

sulphur mustard in mice. Arch. Toxicol. 71:157-164. 

Walker, H.W., B.F. Smith, and A. Blake. 1928. Summary and Discussion of 

Available Mustard Gas Data from Field Tests Conducted Prior to 1928. Report. 

No.462, Chemical Warfare Service, Edgewood, Arsenal, Edgewood, MD. 

Warthin, A.S., and C.V. Weller. 1919. The lesions of the respiratory and 

gastrointestinal tracts produced by mustard gas ( dichloroethyl sulphide). J. Lab. 

Clin. Med. 4:229-264. 

Watson, A.P., and G.D. Griffin. 1992. Toxicity of vesicant agents scheduled for 

destruction by the chemical stockpile disposal program. Environ. Health 

Perspect. 98:259-280. 

APPENDIX A 

Derivations of AEGL Values 

Derivation of AEGL-l 

Key Study: Anderson (1942) 

Toxicity 

End point: Exposure concentration-time product of 12 mg.

min/m3 represented 

the threshold for ocular effects (conjunctival injection and minor 

discomfort with no functional decrement) for human volunteers 

exposed to agent HD at varying exposure regimens. The eye is 

generally considered to be the most sensitive organ/tissue relative 

to agent HD exposure. 

Scaling: The concentration-time relationship for many irritant and 

systemically acting vapors and gases can be described by Cn x t == 

k, where the exponent n ranges from 0.8 to 3.5 (ten Berge et al. 

1986). Analysis of available data indicated n to be near unity 

(Appendix B), hence, C1 

x t = k. 

Uncertainty 

factors: Total adjustment of 3. A factor of 3 was applied for intraspecies 

variability (protection of sensitive populations). This factor was 

limited to 3 under the assumption that the primary mechanism of 

action of agent HD involves a direct effect on the ocular surface 

and that the response will not vary greatly among individuals. In 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

SULFUR MUSTARD D-14 

APPENDIX D 

addition, subjects in the Anderson (1942) study exhibited little 

variability in ocular response. 

Because the AEGL-l is based on human data, the interspecies UF is 1. 

10-min AEGL-l: C1 x 10 min = 12 mg.min/m3

 C = 1.2 mg/m3 

10-min AEGL-1 = (1.2 mg/m3)/3 = 0.40 mg/m3

 (0.06 ppm) 

30-min AEGL-l: C1 x 30 min= 12mg.min/m3

 C = 0.4 mg/m3 

30-min AEGL-1 = (0.4 mg/m3)/3 = 0.13 mg/m3

 (0.02 ppm) 

l-h AEGL-l: C1 x 60 min = 12 mg.min/m3

 C= 0.2 mg/m3 

1-h AEGL-1 = (0.2 mg/m3)/3 = 0.067 mg/m3

 (0.01 ppm) 

4-h AEGL-l: C1 x 240 min = 12 mg.min/m3

 C= 0.05 mg/m3 

4-h AEGL-1 = (0.05 mg/m3)/3 = 0.017 mg/m3

 (0.003 ppm) 

8-h AEGL-l: C1 x 480 min = 12 mg.min/m3 

 C = 0.025 mg/m3 

8-h AEGL-1 = (0.025 mg/m3)/3 = 0.008 mg/m3 

(0.001ppm) 

Derivation of AEGL-2 

Key study: Anderson (1942) 

Toxicity 

end point: A concentration-time product of 60 mg.

min/m3 was 

considered the lowest exposure causing ocular effects (we1lmarked, generalized conjunctivitis, edema, photophobia, and 

irritation) resulting in effective performance decrement and 

characterized as a military casualty requiring treatment for up to 1 

wk. 

Scaling: The concentration-time relationship for many irritant and 

systemically acting vapors and gases may be described by Cn

 x t = 

k , where the exponent n ranges from 0.8 to 3.5 (ten Berge et al. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

SULFUR MUSTARD D-15 

APPENDIX D 

1986). Analysis of available data indicated n to be near unity 

(Appendix B), hence, C1 

x t = k. 

Uncertainty 

Factors: Total adjustment of 10. A factor of 3 was applied for intraspecies 

variability (protection of sensitive populations). This factor was 

limited to 3 under the assumption that the primary mechanism of 

action of agent HD involves a direct effect on the ocular surface 

and that this response will not vary greatly among individuals. 

Because the AEGL-l is based on human data, the interspecies UF 

is 1. A modifying factor of 3 was applied to accommodate 

potential onset of long-term ocular or respiratory effects. 

Because the factors of 3 each represent a logarithmic mean (3.16) 

of 10, their product is 3.16 x 3.16 = 10. 

10-min AEGL-2: C1 x 10 min = 60 mg.min/m3

 C = 6mg 

10-min AEGL-2 = (6 mg/m3)/10 = 0.60 mg/m3 

(0.09 ppm) 

30-min AEGL-2: C1 x 30 min = 60 mg.min/m3

 C= 2.00 mg 

 30-min AEGL-2 = (2.00 mg/m3)/10 = 0.20 mg/m3

 (0.03 ppm) 

1.-h AEGL-2: C1 x 60 min = 60 mg.min/m3

 C= 1.00 mg/m3 

1-h AEGL-2 = (1.00 mg/m3)/10 = 0.10 

(0.02 ppm) 

4 –h AEGL-2: C1 x 240 min = 60 mg.min/m3 

 C = 0.25 mg/m3 

4-h AEGL-2 = (0.25 mg/m3)/10 = 0.025 mg/m3 

(0.004 ppm) 

8-h AEGL-2: C1

 x 480 min = 60 mg.min/m3

 C= 0.125 mg/m3 

8-h AEGL-2 = (0.125 mg/m3)/10 = 0.013 mg/m3

 (0.002 ppm) 

Derivation of AEGL-3 

Key study: Kumar and Vijayaraghavan (1998) 
 

 

 

 

 

 

 

 

SULFUR MUSTARD D-16 

APPENDIX D 

Toxicity 

end point: Estimated lethality threshold of 21.2 mg/m3 for 1 h based on no 

deaths in mice exposed to that concentration, which is 0.5 of the 1­

h LC50 in mice reported by Vijayaraghavan (1997). 

Scaling: The concentration-time relationship for many irritant and 

systemically acting vapors and gases may be described by Cn x t = 

k, where the exponent n ranges from 0.8 to 3.5 (ten Berge et al. 

1986). Analysis of available data pertaining to ocular effects 

indicated n to be near unity (Appendix B). However, there was 

uncertainty regarding the validity of applying linear extrapolation 

based on ocular effects to concentration-time extrapolations for 

lethality. Therefore, in the absence of chemical-specific lethality 

data, time scaling was performed using exponential extrapolation 

(n = 3) for shorter time periods (<1 h) and linear extrapolation (n = 

1) for longer time periods (> 1 h), thereby providing a somewhat 

more conservative (i.e., protective) estimate of the AEGL-3 values 

than would be obtained using an n value based on ocular irritation. 

The concentration-time constant, k, was 1272 mg.min/m3 where n 

= 1 and 571,687.68 mg.

min/m3 where n = 3. 

Uncertainty 

factors: Total UF was 10. A UF for interspecies was limited to 3 

because human data are available showing that exposures to the 

AEGL-3 values are more likely to produce only severe ocular 

irritation and possible minor or moderate irritation of the upper 

respiratory tract. Intraspecies variability was limited to 3 because 

lethality appears to be a function of extreme pulmonary damage 

resulting from direct contact of the agent with epithelial surfaces. 

No modifying factor was applied because the basis of lethality 

estimate was from studies utilizing a 14-d observation period to 

assess the lethal response from a 1-h exposure. 

Because the factors of 3 each represent a logarithmic mean (3.16) 

of 10, their product is 3.16 x 3.16 = 10. 

10-min AEGL-3: C3

 x 10 min = 571,687.68 mg.min/m3

 C3

 = 57,168.76 mg.min/m3

 C = 38.52 mg/m3

 10-min AEGL-3 = (38.52 mg/m3)/10 = 3.9 mg/m3

 (0.59 ppm) 

30-min AEGL-3: C3

 x 30 min = 571,687.68 mg.min/m3

 C3

 = 19,056.26 mg.min/m3

 C= 26.7 mg/m3 
 

 

 

 

 

 

 

 

 

 

SULFUR MUSTARD D-17 

APPENDIX D 

 30-min AEGL-3 = (26.7 mg/m3)/10 = 2.7 mg/m3

 (0.41 ppm) 

1 –h AEGL-3: C1

 x 60 min = 1,272 mg.min/m3

 C= 21.2 mg/m3 

1-h AEGL-3 = (21.2 mg/m3)/10 = 2.1 mg/m3 

(0.32 ppm) 

4 –h AEGL-3: C1

 x 240 min = 1,272 mg.min/m3

 C = 5.3 mg/m3 

4-h AEGL-3 = (5.3 mg/m3)/10= 0.53 mg/m3

 (0.08 ppm) 

8-h AEGL-3: C1

 x 480 min = 1,272 mg.min/m3

 C = 2.65 mg/m3 

8-h AEGL-3 = (2.65 mg/m3)/10 = 0.27 mg/m3

 (0.04 ppm) 

APPENDIX B 

Determination of Temporal Scaling Factor (n) for AEGL Derivations 

Derivation of n for Cn x t = k; data points indicative of a 100% response for mild 

ocular irritation following exposure to sulfur mustard agent HD) at various 

concentrations and times (Reed 1918; Reed et al., 1918; Guild et a1. 1941; 

Anderson 1942) 

Time Concentration Log Time Log Concentration 

1 72 0.0000 1.8573 

30 1.4 1.4771 0.1461 

30 0.06 1.4771 -1.2218 

45 1.4 1.6532 0.6198 

210 0.24 2.3222 -0.6198 

480 0.1 2.6812 -1.0000 

600 0.1 2.7782 -1.0000 

1,440 0.06 3.1584 -1.2218 

Regression output: 

Intercept 1.3852 

Slope -0.9002 

R squared 0.7434 

Correlation -0.8622 

Degrees of Freedom 6 

Observations 8 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 

■

 1.5 

1

 0.5 

0

 -0.5 

-1 

 -1.5

 0 0.5 1

Best Fit Concentration x Time Curve 

■ ■

■

■ ■

■ ■

Log Time 

 1.5 2 2.5 3 3.5 

Log Concentration 

SULFUR MUSTARD D-18 

APPENDIX D 

n = 1.11 

k = 34.58 

Derivation of n for Cn x t = k; data points indicative of a 75-100% response for 

mild ocular irritation following exposure to sulfur mustard (agent HD) at various 

concentrations and times (Reed 1918; Reed et al. 1918; Guild et al. 1941; 

Anderson 1942) 

Time Concentration Log Time Log Concentration 

1 72 0.0000 1.8573 

30 1.4 1.4771 0.1461 

30 0.06 1.477 -1.2218 

45 1.4 1.6532 0.1461 

210 0.24 2.3222 -0.6198 

480 0.1 2.6812 -1.0000 

600 0.1 2.7782 -1.0000 

1,440 0.06 3.1584 -1.2218 

33 1.7 1.5185 0.2304 

3 12.7 0.4771 1.1038 

3 30 0.4771 1.4771 

2.5 30 0.3979 1.4771 

2 30 0.3010 1.4771 

0.25 320 -0.6021 2.5051 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SULFUR MUSTARD D-19 

APPENDIX D 

Regression Output: 

Intercept 1.7240 

Slope -1.0356 

R squared 0.8891 

Correlation -0.9429 

Degrees of freedom 12 

Observations 14 

n = 0.96 

k = 46.05 

Best Fit Concentration x Time Curve 

3 

■

 2 

■

■

 1 ■

■

 0 ■ ■

■

■

 -1 

■ ■

 -2

 -1 0 1 2 3 4 

Log Concentration 

Log Time 

APPENDIX C 

Carcinogenicity Assessment for Acute Exposure to Sulfur Mustard (Agent 

HD) 

The cancer assessment for acute inhalation exposure to sulfur mustard was 

conducted following the NRC methodology for EEGLs, SPEGLs, and CEGLs 

(NRC 1986). The virtually safe dose (VSD) was determined from an inhalation 

slope factor of 14 (mg/kg/d)-l for the general population (USACHPPM 2000). 

The slope factor was a geometric mean of slope factors developed using various 

data sets and procedures and was considered the most tenable quantitative 

assessment for potential cancer risk from inhalation exposure to sulfur mustard. 

The corresponding Inhalation Unit Risk was 0.0041 (μg/m3)

 -1 or 4.1 (mg/m3

)

-1 

(USACHPPM2000). The VSD was calculated as follows: 
 

 

 

 

SULFUR MUSTARD D-20 

APPENDIX D 

VSD = Risk Level/Unit Risk 

VSD = 1 x 10-4 risk = 2.5 x 10-5 mg/m3 

(4.1 mg/m3)

-1 

Assuming the carcinogenic effect to be a linear function of cumulative dose (d), a 

single-day exposure is equivalent to d x 25,600 d (average lifetime). 

24-h exposure = VSD x 25,600 

= (2.5 x 10-5 mg/m3

) x 25,600 

 = 0.64 mg/m3 

Adjustment to allow for uncertainties in assessing potential cancer risks under 

short term exposures under the multistage model (Crump and Howe 1984). 

24- hr exposure 0.64 mg/m3

= 

6 = 0.1 mg/m36 

If the exposure is limited to a fraction (f) of a 24-h period, the fractional exposure 

becomes l/f x 24 h (NRC 1985). For a 1 x 10-4, 1 x 10-5, and 1 x 10-6 risk, the 

fractional exposures are shown below. 

Exposure 

Duration 

10-4 10-5 10-6 

24-h 0.1 mg/m3 

(0.02 ppm) 

0.01 mg/m3 

(0.002 ppm) 

0.001 mg/m3 

(0.002 ppm) 

8-h 0.3 mg/m3 

(0.05 ppm) 

0.03 mg/m3 

(0.005 ppm) 

0.003 mg/m3 

(0.0005 ppm) 

4-h 0.6 mg/m3 

(0.09 ppm) 

0.06 mg/m3 

(0.009 ppm) 

0.006 mg/m3 

(0.0009 ppm) 

1-h 2.4 mg/m3 

(0.36 ppm) 

0.24 mg/m3 

(0.036 ppm) 

0.024 mg/m3 

(0.0036 ppm) 

30-min 4.8 mg/m3 

(0.72 ppm) 

0.48 mg/m3 

(0.072 ppm) 

0.048 mg/m3 

(0.0072 ppm) 

10-min 14.1 mg/m3 

(2.16 ppm) 

1.41 mg/m3 

(0.22 ppm) 

0.141 mg/m3 

(0.022 ppm) 

Because the derivation of the cancer slope factor requires conversion of animal 

doses to human equivalent doses, no reduction of exposure levels is applied to 

account for interspecies variability. With the exception of the 10-min, 30-min, 

and 1-h values for 10-4 risk and the 10- min 10-5 risk, these exposures are at or 

below the odor threshold for sulfur mustard. A cancer risk assessment based on a 

geometric mean of inhalation slope factors developed using various data sets and 

procedures indicated an excess cancer risk of 1 in 10,000 (10-4) may be associated 

with exposures similar to the AEGL-3 values. The use of excess cancer risk 
SULFUR MUSTARD D-21 

APPENDIX D 

estimates in setting AEGL values is precluded by the uncertainties involved in 

assessing excess cancer risk following a single acute exposure of 8-h or less 

duration, by the relatively small population exposed in an emergency release 

situation, and by the potential risks associated with evacuations. 

APPENDIX D 

DERIVATION SUMMARY FOR ACUTE EXPOSURE GUIDELINES 

LEVELS 

Sulfur Mustard (CAS NO.505-60-2) 

AEGL-1 

10 min 30 min 1 h 4 h 8 h 

0.40 mg/m3 

(0.06 ppm) 

0.13 mg/m3 

(0.02 ppm) 

0.067 mg/m3 

(0.01 ppm) 

0.017 mg/m3 

(0.003 ppm) 

0.008 mg/m3 

(0.001 ppm) 

Key Reference: Anderson, J.S. 1942. The effect of mustard gas vapour on eyes 

under Indian hot weather conditions. CDRE Report No. 241. Chemical Defense 

Research Establishment (India) 

Test species/strain/gender/number: 3-4 human volunteers 

Exposure route/concentrations/durations: Vapor exposure to varying 

concentrations (1.7 – 15.6 mg/m3) for varying durations (2-33 min) 

Effects: Mild ocular effects (mild injection to notable conjunctivitis) 

End point/concentration/rationale: Concentration-time threshold of 12 

mg.min/m3 for ocular effects (conjunctival injection with minor discomfort and 

no functional decrement. 

Uncertainty factors/rationale: 

Interspecies: 1 (human subjects) 

 Intraspecies: A factor of 3 was applies for intraspecies variability (protection 

of sensitive populations). This factor was limited to 3 under the assumption that 

the primary mechanism of action of agent HD involves a direct effect on the 

ocular surface and that the response will not vary greatly among individuals. 

Furthermore, little variability was observed in the tested subjects regarding 

ocular responses. 

Modifying factor: None applied 

Animal to human dosimetric adjustment: Not applicable 

Time scaling: Cn

 x t = k, where n = 1 based on analysis of available human 

exposure data for ocular effects. 

Data adequacy: The key study was conducted using human volunteers thus 

avoiding uncertainties associated with animal studies. Ocular irritation is 

considered the most sensitive end point for assessing the effects of acute 

exposure to sulfur mustard and the available data were sufficient for developing 

AEGL-1 values. 
SULFUR MUSTARD D-22 

APPENDIX D 

AEGL-2 

10 min 30 min 1 h 4 h 8 h 

0.60 mg/m3 

(0.09 ppm) 

0.20 mg/m3 

(0.03 ppm) 

0.10 mg/m3 

(0.02 ppm) 

0.025 mg/m3 

(0.004 ppm) 

0.013 mg/m3 

(0.002 ppm) 

Key Reference: Anderson, J.S. 1942. The effect of mustard gas vapour on eyes 

under Indian hot weather conditions. CDRE Report No. 241. Chemical 

Defense Research Establishment (India) 

Test species/strain/gender/number: 3-4 human volunteers 

Exposure route/concentrations/durations: Vapor exposure to varying 

concentrations (1.7 – 15.6 mg/m3) for varying durations (2-33 min) 

Effects: Ocular effects ranging from mild injection to notable conjunctivitis, 

photophobia, lacrimation, blepharospasm 

End point/concentration/rationale: Exposure-concentration time product of 60 

mg.min/m3 representing exposure at which ocular irritation (Well marked, 

generalized conjunctivitis, edema, photophobia, and irritation) will occur 

resulting in performance decrement and necessitating medical treatment. 

Uncertainty factors/rationale: 

Interspecies: 1 (human subjects) 

Intraspecies: A factor of 3 was applies for intraspecies variability (protection 

of sensitive populations). This factor was limited to 3 under the assumption 

that the primary mechanism of action of agent HD involves a direct effect on 

the ocular surface and that the response will not vary greatly among individuals. 

Furthermore, little variability was observed in the tested subjects regarding 

ocular responses. 

Modifying factor: A modifying factor of 3 was applied to accommodate 

uncertainties regarding the onset of potential long-term ocular effects of 

respiratory effects. 

Animal to human dosimetric adjustment: Not applicable 

Time scaling: Cn x t = k, where n = 1 based on analysis of available human 

exposure data for ocular effects. 

Data adequacy: The key study was conducted using human volunteers thus 

avoiding uncertainties associated with animal studies. The AEGL-2 values are 

based on ocular effects that may be considered severe enough to impair vision. 

The data were considered sufficient for developing AEGL-2 values. 
 

SULFUR MUSTARD D-23 

APPENDIX D 

AEGL-3 

10 min 30 min 1 h 4 h 8 h 

3.9 mg/m3 

(0.59 ppm) 

2.7 mg/m3 

(0.41 ppm) 

2.1 mg/m3 

(0.32 ppm) 

0.053 mg/m3 

(0.08 ppm) 

0.27 mg/m3 

(0.04 ppm) 

Key Reference: Kumar, O., and R. Vijayaraghavan. 1998. Effect of sulfur 

mustard inhalation exposure on some urinary variables in mice. J. Appl. 

Toxicol. 18:257-259. 

Test species/strain/gender/number: Swiss mice/femal/4 per exposure group. 

Exposure route/concentrations/durations: Head-only inhalation exposure for 1 

h to sulfur mustard (>99% purity) at 21.2, 42.3, or 84.6 mg/m3 (equivalent to 

0.5, 1.0, and 2.0LC50). Subjects were sacrificed at 6, 24, or 48 h or 7 d after 

exposure. Three groups of 10 mice were exposed at each concentration and 

observed for up to 14 d. 

Effects: Lethality assessed up to 14 d post exposure 

End point/concentration/rationale: No mortality in mice at 14 d following 10h 

exposure at 21.2 mg/m3. The exposure was considered an estimate of the 

lethality threshold in mice. 

Uncertainty factors/rationale: 

 Total uncertainty factor: 10 

 Interspecies: A factor of 3 was applied to account for possible interspecies 

variability in the lethal response to sulfur mustard. Application of any 

additional uncertainty factors or modifying factors was not warranted because 

the AEGL-3 values are equivalent to exposures in humans that are known to 

produce only ocular and respiratory tract irritation. 

Intraspecies: Intraspecies variability was limited to 3 because lethality appears 

to be a function of extreme pulmonary damage resulting from direct contact of 

the agent with epithelial surfaces. 

Modifying factor: No modifying factor was applied because the basis of 

lethality estimate was from a study utilizing a 14-d observation period to assess 

the lethal response from a 1-h exposure. 

Animal to human dosimetric adjustment: Insufficient data 

Time scaling: Cn

 x t = k, where n = 1 or 3. The concentration-time relationship 

for many irritant and systemically acting vapors and gases can be described by 

Cn

 x t = k, where the exponent n ranges from 0.8 to 3.5 (ten Berge et al. 1986). 

In the absence of chemical-specific lethality data, time scaling was performed 

using exponential extrapolation (n = 3) for shorter time periods and linear 

extrapolation (n = 1) for longer time periods, thereby providing a somewhat 

more conservative (i.e., protective) estimate of the AEGL-3 values than would 

be obtained using an n value of 1 based on ocular irritation. 

Data adequacy: Uncertainties exist regarding a definitive lethality threshold for 

single acute exposures to sulfur mustard. However, the key study appeared to 

be well-designed and properly conducted and is considered sufficient for 

developing AEGL-3 values.