Asthma associated with denatonium benzoate in a healthcare worker in Taiwan

Abstract

Rationale: Denatonium benzoate is a useful indicator to ensure that the respirator being used by an individual forms a tight enough seal to adequately protect against unwanted airborne exposure. Although the relative risk for adverse effects of fit testing using denatonium benzoate is low, the absolute number of workers with adverse reactions may nevertheless be sizeable. Patient concerns: A 34-year-old female nurse rapidly developed shortness of breath, cough, and agitation after denatonium benzoate fit testing. She had a history of allergy to shrimp, crab, mite, and disinfecting products (containing quaternary ammonium). Diagnoses: Due to typical symptoms of asthma after exposure to denatonium benzoate aerosol without any other apparent cause, serial pulmonary function tests indicating obstructive lung function and a higher concentration of immunoglobulin antibody E, she was diagnosed with allergic asthma. Interventions: This patient was treated with omalizumab (Xolair), corticosteroid, β 2 agonist, montelukast, and Symbicort turbuhaler. Outcomes: The patient showed quick responses after treatment with diphenhydramine (intramuscularly), fenoterol HBr (inhalation), and prednisolone (oral). Approximately 2 weeks later, she suffered from difficulty breathing and asthmatic symptoms again when she was exposed to polished wax and disinfectant. She was treated with omalizumab (Xolair), corticosteroid, β 2 agonist, montelukast, and Symbicort turbuhaler. The patient was in stable condition with improvement in symptoms during follow-up. Lessons: There may be potentially important health risks when healthcare workers are exposed to denatonium benzoate. Individuals who have a history of allergy to disinfecting products (containing quaternary ammonium) should avoid exposure of denatonium benzoate. More advanced research is needed in the future.

Comments on the Risks From Exposure to Denatonium Benzoate (Bitrex®): Denatured Alcohol Disinfection and Pandemic Times

“…9 (b) Denatonium benzoate can definitely induce sensitization, at least in a certain group of individuals 10,11 (as previously suggested by Youakim 8,9 ). Because asthma and diabetes are conditions that increase the risk of severe illness from COVID-19, 12,13 and since denatonium benzoate could complicate respiratory conditions, 8,9,11 the use of denatured alcohol could constitute a serious risk for a certain vulnerable group. As the susceptible individuals are not well identified and since the knowledge about all potential medical conditions that could be associated with risk for severe COVID-19 outcomes is still limited, 12,13 denatonium benzoate-related complications may go unnoticed for both the patients themselves and the health care professionals.…”

“…Unfortunately, there are only a few reports available in the scientific or medical literature documenting adverse reactions to denatonium benzoate 7-11 ; indeed, since adverse reactions to this denaturing agent could be difficult to recognize, 9 it is expected that most of the cases in the population have not been reported. However, when analyzing these few published case reports of adverse reactions to denatonium benzoate, 7-11 the following conclusions come to light: (a) Denatonium benzoate can provoke asthma exacerbation or other reactions when inhaled, 7-11 especially when a history of asthma or allergies exists 8-11 and perhaps, in part, when there is underlying diabetes and/or hypothyroidism. 9 (b) Denatonium benzoate can definitely induce sensitization, at least in a certain group of individuals 10,11 (as previously suggested by Youakim 8,9 ).…”

“…However, when analyzing these few published case reports of adverse reactions to denatonium benzoate, 7-11 the following conclusions come to light: (a) Denatonium benzoate can provoke asthma exacerbation or other reactions when inhaled, 7-11 especially when a history of asthma or allergies exists 8-11 and perhaps, in part, when there is underlying diabetes and/or hypothyroidism. 9 (b) Denatonium benzoate can definitely induce sensitization, at least in a certain group of individuals 10,11 (as previously suggested by Youakim 8,9 ). Because asthma and diabetes are conditions that increase the risk of severe illness from COVID-19, 12,13 and since denatonium benzoate could complicate respiratory conditions, 8,9,11 the use of denatured alcohol could constitute a serious risk for a certain vulnerable group.…”

Exposure frequency, intensity, and duration: What we know about work-related asthma risks for healthcare workers from cleaning and disinfection

“…Other data were extracted from sources that described the time from initial exposure to onset of other asthma-related outcomes, including unspecified asthma symptoms ( Massachusetts Department of Public Health 2001 ; Adisesh et al 2011 ), hospitalization ( Chen et al 2019 ), chest tightness ( Corrado et al 1986 ; Cristofari-Marquand et al 2007 ), rhinorrhea ( Cristofari-Marquand et al 2007 ), rhinitis ( Corrado et al 1986 ), conjunctivitis ( Cristofari-Marquand et al 2007 ), lower respiratory tract symptoms ( Vyas 2000 ), and nasal symptoms ( Corrado et al 1986 ), with times ranging from 0.04–14 years ( Corrado et al 1986 ; Adisesh et al 2011 ). This full data set is available in supplemental materials ( Table S2 ); pooled analyses were not performed owing to the variety of outcomes.…”

Audit of qualitative fit testing for FFP3 respirators

“…It also provided an important record where an allergic reaction was reported. 5,6 The audit enabled this process to be performed efficiently and safely, benefiting both dental professionals and patients.…”