Irritant vocal cord dysfunction and occupational bronchial asthma: differential diagnosis in a health care worker

Abstract

Objectives: Vocal cord dysfunction (VCD) is an uncommon respiratory disease characterized by the paradoxical adduction of vocal cords during inspiration, that may mimic bronchial asthma. The pathogenesis of VCD has not been clearly defined but it is possible to recognize non-psychologic and psychologic causes. The majority of patients are female but, interestingly, a high incidence of VCD has been documented in health care workers. A misdiagnosis with asthma leads to hospitalisation, unnecessary use of systemic steroids with related adverse effects, and sometimes tracheostomy and intubation. In a subset of VCD patients, the disease can be attributed to occupational or environmental exposure to inhaled irritants. Materials and Methods: We report the case of a 45-year-old woman, working as a nurse, who complained of wheezing, cough, dyspnoea related to inhalation of irritating agents (isopropylic alcohol, formaldehyde, peracetic acid). She underwent chest radiography, pulmonary function assessment both in the presence and in the absence of symptoms, bronchial provocation with methacholine and bronchodilation test with salbutamol to recognize asthma's features, allergy evaluation by skin prick tests and patch tests and video-laryngoscopy. Results: VCD diagnosis was made on the basis of video-laryngoscopy, that visualized the paradoxical motion of the vocal cords during symptoms, in the absence of other pathologic processes. Conclusions: This case fulfils the proposed criteria for the diagnosis of irritant VCD (IVCD). This is the first report of VCD onset following exposure to several irritants: formaldehyde, glutaraldehyde, isopropylic alcohol, peracetic acid-hydrogen performaldehyde, glutaraldehyde, isopropylic alcohol, peracetic acid-hydrogen perisopropylic alcohol, peracetic acid-hydrogen perisopropylic alcohol, peracetic acid-hydrogen peroxide mixture. These substances are used as cleaning and antiseptic agents in healthcare settings and some ones can also be found in many indoor environments. A correct diagnosis is important both to give the appropriate treatment and for medical legal implications.

Diagnosis of concomitant inducible laryngeal obstruction and asthma

“…Secondly, ILO has been reported to have a higher prevalence among healthcare workers and other occupations where exposure to a variety of irritant chemicals, dusts, mists and fumes may increase risk. 28,[30][31][32] Although some of our patients had identifiable occupational risk factors, the majority of patients did not. We therefore believe that clinicians should be alert to the possibility of ILO even in patients who do not fit the "typical" demographic and clinical profile.…”

Paradoxical vocal cord motion: Classification and treatment

“…The inhalation of histamine and methacholine in patients with and without asthma produces laryngeal narrowing 32. Hyperresponsiveness can be induced by chemical exposures, fumes, and strong scents, and irritant induced PVCM has been reported 33, 34. Laryngeal edema and PVCM is an important cofactor in patients with industrial or occupational asthma due to inhalation exposures.…”

Ethyl Glucuronide, Ethyl Sulfate and Acetone as Biomarkers for Alcohol Based Hand Sanitizers Chronic Exposure in Health Care Workers

“…ABHSs users are exposed to alcohols via both inhalation and dermal routes, as alcohols are volatile organic oxygenated species, water soluble, and highly mobile (INRS, 2007). Cumulative occupational exposures to wellknown irritants, such as ISOP can cause respiratory and dermal irritations (Tonini et al, 2009).…”