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Occupational and Granulomatous


Wednesday, October 27, 2004

2:00 PM - 3:30 PM

Metal Fume Fever Presenting as Aseptic Meningitis with Pericarditis, Pleuritis, and Pneumonitis

Hesham A. Hassaballa, MD*, Omar B. Lateef, DO, Julian Bell, MD, Eileen H. Kim, MD and Larry C. Casey, MD, PhD

Rush University Medical Center, Chicago, IL

INTRODUCTION: Metal fume fever (MFF) is an acute influenza-like illness typically occurring after exposure to zinc, iron, or copper oxide fumes. We present a case of MFF presenting as aseptic meningitis with pericarditis, pleuritis, and pneumonitis.

CASE PRESENTATION: Our patient is a 25-year-old male who presented with a recent onset of headache, neck pain, myalgias, fever, and chills. He presented to an outside hospital and had a lumbar puncture, after which he was diagnosed with aseptic meningitis, placed on antibiotics, and admitted to the hospital. His symptoms worsened, and he was transferred to our institution. Upon evaluation, the patient was afebrile, tachycardic (pulse > 150 bpm), and tachypneic (respiratory rate between 30-40 breaths/min) with oxygen saturation of 92% on 100% FIO2. Physical examination revealed nuchal rigidity and coarse breath sounds with crackles bilaterally. Laboratory studies showed a WBC count of 10.2 thou/uL, ESR of 56 mm/hr, and LDH of 561 U/L. Autoimmune profile was negative. Arterial blood gas on 100% FIO2 showed a pH of 7.47, pCO2 of 28 mm Hg, and pO2 of 55 mm Hg. CT of the chest revealed bilateral pleural effusions, bilateral consolidations, and large pericardial effusion (Figure 1 ). Echocardiography showed normal left ventricular function and pericardial effusion. The patient was switched to broad-spectrum antibiotics and placed on bronchodilators, diuretics, and received one dose of oral prednisone. Further history from the patient revealed that his symptoms began immediately after cutting galvanized steel conduit containing copper wires. He was not wearing a protective respirator, and he inhaled a substantial amount of fumes and complained of a metallic taste in his mouth. Five other co-workers had similar but less severe complaints. Antibiotics were discontinued, and the patient was started on indomethacin 50 mg three times daily. His symptoms improved promptly, and his pulmonary consolidations quickly resolved (Figure 2 ). Blood, urine, and CSF cultures were all negative. He was discharged in good condition, and his pericardial effusion resolved completely one week later.



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DISCUSSIONS: It is estimated that more than 1,000 cases of MFF are reported each year in the United States [1]. MFF is a self-limited illness characterized by fever, chills, cough, dyspnea, headache, myalgias, and malaise, most commonly occurring within 4–12 hours of exposure to zinc, copper, or iron oxide fumes. Patients also frequently complain of a sweet or metallic taste in the mouth, irritated or dry throat, and chest pain. The temporal association between the patient’s symptoms and inhaling of metal fumes, along with the negative cultures and prompt resolution of his illness strongly support the diagnosis of MFF. To our knowledge, this is the first case of metal fume fever associated with aseptic meningitis, pericarditis, pleuritis, and pneumonitis. Symptoms usually improve within 24–48 hours with supportive treatment, bed rest, analgesics, and antipyretics. While the pathophysiology remains unclear [2], recent research has suggested a major role for cytokines in the development of MFF [1,34]. We postulate that the metal fumes induced a cytokine-mediated systemic inflammatory response in our patient.

CONCLUSION: We report the first case of metal fume fever in association with aseptic meningitis, pericarditis, pleuritis, and pneumonitis. As metal fume fever mimics many infectious diseases, a detailed occupational history is essential to establish the diagnosis and avoid inappropriate therapy.

DISCLOSURE: H.A. Hassaballa, None.

REFERENCES

  1. Blanc P, Wong H, Bernstein MS, Boushey HA. An experimental human model of metal fume fever. Ann Intern Med1991; 114 :930 –936.
  2. Offermann PV, Finley CJ. Metal fume fever. Ann Emerg Med1992; 21 :872 –875.
  3. Blanc PD, Boushey HA, Wong H, Wintermyeyer SF, Bernstein MS. Cytokines in metal fume fever. Am Rev Respir Dis1993; 147 :134 –138.
  4. Kuschner WG, D’Alessandro A, Wong H, Blanc PD. Early pulmonary cytokine responses to zinc oxide fume inhalation. Environ Res1997; 75 :7 –11.





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