Late Cutaneous Manifestations 14 to 20 Years After Wartime Exposure to Sulfur Mustard Gas: A Long-term Investigation

Iranian soldiers were attacked with chemical bombs, rockets and artillery shells 387 times during the 8-years war by Iraq (1980–1988). More than 1,000 tons of sulfur mustard gas was used in the battlefields by the Iraqis against Iranian people. A high rate of morbidities occurred as the result of these attacks. This study aimed to evaluate the delayed toxic effects of sulfur mustard gas on Iranian victims. During a systematic search, a total of 193 (109 more relevant to the main aim) articles on sulfur mustard gas were reviewed using known international and national databases. No special evaluation was conducted on the quality of the articles and their publication in accredited journals was considered sufficient. High rate of morbidities as the result of chemical attacks by sulfur mustard among Iranian people occurred. Iranian researchers found a numerous late complications among the victims which we be listed as wide range of respiratory, ocular, dermatological, psychological, hematological, immunological, gastrointestinal and endocrine complications, all influenced the quality of life of exposed victims. The mortality rate due to this agent was 3%. Although, mortality rate induced by sulfur mustard among Iranian people was low, variety and chronicity of toxic effects and complications of this chemical agent were dramatic.

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“…Table 3 shows distribution of pulmonary, ophthalmic and dermatologic complications in several studies in Iran [10,15,30-34]. …”

Section: Resultsmentioning

confidence: 99%

A review on delayed toxic effects of sulfur mustard in Iranian veterans

et al. 2012

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“…Excessive dry skin (xerosis), hyperpigmentation, burning sensation, pruritis, hypopigmentation, and cherry angioma are the most common non-specific skin lesions reported in the literature [4] , [6] , [17] . The previously reported differences in the incidence and prevalence of these lesions are affected by factors such as age, socioeconomic status, geography, occupation, and genetics [8] . The differences were also attributed to variations in patient sampling and assessment methods as well as the dose, duration, and extension of exposure [10] .…”

Section: Discussionmentioning

confidence: 97%

“…Complete alopecia was reported in one patient. It seems, however, that there is not enough evidence yet to make definitive claims about the increased prevalence of these conditions [5] , [17] , [8] . Interestingly, dry skin and associated itching appears to intensify gradually over time in SM-exposed patients, while other skin complications decrease [4] .…”

Section: Discussionmentioning

confidence: 99%

Skin manifestations in sulfur mustard exposed victims with ophthalmologic complications: Association between early and late phase

Hejazi

Soroush

Moradi³

et al. 2016

Toxicology Reports

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ContextSulfur mustard (SM) was used during the Iraq-Iran war (1980–1988). Exposed veterans continue to suffer from its ocular, skin, and respiratory complications.ObjectiveWe aimed to evaluate associations between early (at the time of acute exposure) and decades later skin manifestations in individuals with severe ophthalmologic complications secondary to sulfur mustard exposure.Materials and methodsOne hundred forty-nine veterans with severe ocular injuries were evaluated for acute and chronic skin complications. Logistic regression models were used to examine the associations between early and late skin manifestations.ResultsLate skin complaints were observed in nearly all survivors who had early skin lesions (131 out of 137; 95.62%). Seven out of 12 patients (58.33%) who did not have early skin lesions ultimately developed late skin complications. There was a significant relationship between the presence of lesions at the time of exposure and developing late skin complaints (two-sided Fisher's exact test, OR = 15.59, p < 0.001). There was an association between having at least one early skin lesion and occurrence of late skin complications. Survivors with blisters at the time of chemical exposure were more likely to complain of itching (95% CI: 3.63–25.97, p < 0.001), burning (OR = 11.16; 95% CI: 2.97–41.89, p < 0.001), pigmentation changes (OR = 10.17; 95% CI: 2.54–40.75, p = 0.001), dryness (OR = 6.71, 95% CI: 1.22–37.01, p = 0.03) or cherry angioma (OR = 2.59; 95% CI:1.21–5.55, p = 0.01) during the late phase. Using multivariate logistic models, early blisters remained significantly associated with latent skin complaints. Of note, the genitalia and great flexure areas were the most involved anatomical sites for both early and late skin lesions in SM exposed survivors.ConclusionAccording to this study, the presence of blisters at the time of exposure to SM is the most important predictor of developing dermatologic complications decades later in patients with severe ophthalmologic complications from sulfur mustard exposure.

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“…Although the acute systemic and cutaneous effects of SM are well known, few investigations have focused on reporting the long-term carcinogenic effects. 6,7 Case Report A 58-year-old farmer developed a generalized, erythrodermic, pruritic eruption of two months duration. His past medical history revealed no prior dermatitis.…”

Section: Introductionmentioning

confidence: 99%

“…In all of these patients except 2 cases of basal cell carcinoma, the skin neoplasm developed on the scar of previous SMinduced lesions. 6 We report herein a unique case of de novo erythrodermic CTCL subsequent to SM, a known genotoxin, exposure accompanied by compromised T-cell function leading to the development of Kaposi sarcoma and an opportunistic generalized dermatophytosis. …”

mentioning

confidence: 99%

Sézary syndrome, Kaposi sarcoma and generalized dermatophytosis 15 years after sulfur mustard gas exposure

Emadi¹,

Babamahmoodi²,

Poursaleh³

et al. 2012

J Dermatol Case Rep

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Background:The relationship between compromised immune system and the development of malignancy, generalized dermatitis, and infection after sulfur mustard gas exposure has been established. Main observation:We introduce a 58-year-old man with an abrupt, de novo and erythrodermic eruption in 2002 that was previously exposed to sulfur mustard during the Iran -Iraq war in 1987. Six weeks after the onset of diffuse eruption, he developed papules on the glans penis and generalized dermatophytosis. A biopsy of his eruption was consistent with cutaneous T-cell lymphoma/Sézary syndrome. A complete blood count demonstrated leukocytosis, eosinophilia and atypical lymphocytosis. Subsequently, Sézary syndrome was confirmed and T-cell count with increased CD4/CD8 in flow cytometry. The biopsy of his penile papules was consistent with Kaposi's sarcoma. Conclusion:These findings suggest a causative relationship between sulfur mustard gas exposure, cutaneous T cell lymphoma and immune compromised state with opportunistic infections. (J Dermatol Case Rep. 2012; 6(3): 86-89) Sézary syndrome, Kaposi sarcoma and generalized dermatophytosis 15 years after sulfur mustard gas exposure IntroductionCutaneous T-cell lymphoma (CTCL) comprises a group of clinicopathologic entities that are neoplastic proliferation of T lymphocytes that home to the skin. Eventually the T-cells may lose their dependence on an epidermal environment for growth, and spread to the dermis, lymph nodes, blood, and viscera. 1,2The cutaneous lesions evolve from patches to plaque and tumors (mycosis fungoides), and Sézary syndrome, where the neoplastic cells circulate in the peripheral blood. The patients present with generalized exfoliation erythroderma, intense pruritus, peripheral lymphadenophaty, and abnormal hyperchromatic mononuclear cells in the skin and peripheral blood. Decreased T-cell function may lead to subsequent immune compromised status and is followed by infection. 4 Kaposi sarcoma (KS) is a vascular tumor of intermediate malignancy, histologically characterized by proliferation of lymphatic and/or vascular endothelial cells caused by the Kaposi's sarcoma-associated herpesvirus (KSHV), human herpesvirus 8. KS is a systemic disease, which can present with cutaneous lesions with or without internal involvement. Four subtypes have been described: Classic KS, affecting middle aged men of Mediterranean descent, African endemic KS, KS in iatrogenically immunosuppressed patients, and AIDS-related KS. 5Sulfur mustard gas is a potent alkylating agent that has a long history of use as a chemical warfare agent, including recent use by Iraq against Iranian soldiers and civilians. The organs most commonly affected by sulfur mustard gas (SM) are skin, eyes, and airways. Skin lesions are seen in more than 90% of the patients exposed to SM. Although the acute DOI: http://dx.doi.org/10.3315/jdcr.2012.1109 86 systemic and cutaneous effects of SM are well known, few investigations have focused on reporting the long-term carcinogenic effects. 6,7Case Repor...

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Late Cutaneous Manifestations 14 to 20 Years After Wartime Exposure to Sulfur Mustard Gas: A Long-term Investigation

Cited by 36 publications

References 2 publications

A review on delayed toxic effects of sulfur mustard in Iranian veterans

A review on delayed toxic effects of sulfur mustard in Iranian veterans

Skin manifestations in sulfur mustard exposed victims with ophthalmologic complications: Association between early and late phase

Sézary syndrome, Kaposi sarcoma and generalized dermatophytosis 15 years after sulfur mustard gas exposure

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