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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Occupational asthma is a disease characterized by variable obstruction of the airway and&#47;or bronchial hyperresponse owing to causes and conditions attributable to a particular work environment<span class="elsevierStyleSup">1</span>&#46; Depending on whether or not a latency period occurs between exposure to the agent and the onset of symptoms&#44; two types of occupational asthma have been described&#58; immunologic and nonimmunologic&#46; Nonimmunologic occupational asthma is the reaction observed in patients whose illness is caused by irritants&#46; This type of asthma&#44; in which there is no latency period&#44; can occur after a single exposure to a high concentration of a particular irritant<span class="elsevierStyleSup">2&#44;3</span>&#46; Immunologic occupational asthma is characterized by the fact that onset of symptoms occurs only after a latency period&#46; It may be mediated by an IgE-dependent immunologic mechanism or by other mechanisms not dependent on IgE&#44; some of which are as yet not well understood<span class="elsevierStyleSup">4</span>&#46;</p><p class="elsevierStylePara">It is believed that between 5 and 15&#37; of all asthma cases that develop in adulthood are work related<span class="elsevierStyleSup">5</span>&#44; and asthma is currently considered to be the most common work-related respiratory pathology in industrialized countries<span class="elsevierStyleSup">6</span> with more than 250 different agents involved in its genesis<span class="elsevierStyleSup">7&#44;8</span>&#46; The majority of these agents have been studied in depth&#44; but in certain cases there is still some doubt regarding the etiological agent involved and the possible mechanism of action&#46; Such is the case of food packer&#39;s asthma&#44; initially known as meat wrapper&#39;s asthma&#46; While polyvinyl chloride &#40;PVC&#41; has been implicated as the causal agent in this type of asthma<span class="elsevierStyleSup">9&#44;10</span>&#44; there remains some doubt as to whether the illness is caused directly by this agent or&#44; alternatively&#44; by the products of its thermal degradation&#46; Doubt also exists as to whether this type of asthma is immunologic&#44; affecting only sensitized individuals&#44; or whether it is a nonimmunologic type of asthma caused by the irritant effect of the products of combustion on the bronchial mucosa&#46;</p><p class="elsevierStylePara">The objective of this case report is to present the first recorded case of food packer&#39;s asthma in Spain and to discuss&#44; on the basis of the results of the challenge test performed&#44; the possible origin of this disease&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical findings</span></p><p class="elsevierStylePara">The patient was a 26-year-old woman&#44; a cigarette smoker of 5 packets&#47;year with no other toxic habits or relevant medical history&#44; who had been working for four years for a company involved in the manufacture and sale of a range of fish products&#46; Six months after transferring from her usual job in a cleaning room to a new post in the vacuum packing area&#44; the woman started to experience delayed symptoms&#44; such as cough&#44; bronchospasm and dyspnea&#44; at the end of the working day and during the night&#46; On two occasions she had to go to an emergency room&#46; The patient&#39;s symptoms improved with inhaled beta-adrenergic drugs&#44; and were clearly work related since they improved on weekends and during vacations and other times she was away from the workplace&#46;</p><p class="elsevierStylePara">A chest x-ray was normal&#46; Test results revealed an eosinophil percentage of 8&#46;5 &#37; and a total serum IgE level of 90 kU&#47;l&#46; Skin tests for common respiratory allergens were negative&#46; A study of lung function revealed an obstructive ventilatory pattern with a forced vital capacity &#40;FVC&#41; of 3&#46;78 l &#40;104&#37;&#41;&#44; a forced expiratory volume in one second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; of 2&#46;38 l &#40;75&#37;&#41; and FEV<span class="elsevierStyleInf">1</span>&#37; of 63&#37;&#44; with a positive bronchodilator test showing an improvement in FEV<span class="elsevierStyleInf">1</span> of 16&#37;&#46; A methacholine challenge gave a positive result&#44; with a PCO<span class="elsevierStyleInf">2</span> of 0&#46;3 mg&#47;ml&#46; A record of peak expiratory flow rate measured by the patient during two working weeks and one week away from the workplace revealed a variation on working days of more than 20&#37;&#59; and visual interpretation of the record was consistent with the diagnosis of occupational asthma&#46; In the hospital&#44; a specific challenge test was carried out in which the patient&#39;s working conditions were simulated in a provocation chamber &#40;Fig&#46; 1&#41; <span class="elsevierStyleSup"> 13&#46;</span> No response was observed after the initial 1-hour exposure on the first day&#46; On the second day&#44; after a 3-hour exposure&#44; the patient experienced a delayed positive response &#40;Fig&#46; 2&#41;&#44; with a drop in FEV<span class="elsevierStyleInf">1</span> of 28&#37; approximately 12 hours after exposure&#44; and bronchospasm which required treatment with inhaled bronchodilators&#46; In order to rule out a possible irritant effect&#44; the same specific challenge test was carried out on two volunteer asthmatic patients whose bronchial hyperresponse to methacholine was similar to that observed in the patient&#46; The result was negative in both cases&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046509tab01.gif"></img></p><p class="elsevierStylePara">Fig&#46; 1&#46; Provocation chamber and shrink wrapping machine used in the specific challenge test&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046509tab02.gif"></img></p><p class="elsevierStylePara">Fig&#46; 2&#46; Results of the specific challenge test&#46; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in one second&#46;</p><p class="elsevierStylePara"> When the patient was transferred away from the packing area and relocated in her original job&#44; the symptoms disappeared and have not reappeared to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> PVC&#44; a thermoplastic material&#44; is a product of a chemical combination of carbon&#44; hydrogen and chlorine&#46; The raw materials are derived from oil and common salt&#46; Spain has approximately 1750 PVC converter companies&#44; which provide employment for some 38 000 people directly and over 150 000 indirectly&#46; It is estimated that the PVC industry provides employment for more than 542 000 people in Europe<span class="elsevierStyleSup">14</span>&#46;</p><p class="elsevierStylePara"> Most industrial processes using PVC involve heating the product in order to take advantage of its physical properties&#46; This heating process can give rise to the release of PVC in gaseous form and of irritative products such as hydrochloric acid and carbon monoxide&#46; Exposure to these agents can cause acute intoxication in the central nervous system and irritative lesions in airway and other mucosal tissues&#46; These effects are directly related to the length of exposure and the quantity of toxic agent released<span class="elsevierStyleSup">12</span>&#46;</p><p class="elsevierStylePara">In 1973&#44; Sokol et al<span class="elsevierStyleSup">15</span> described the first recorded cases of occupational asthma attributed to PVC inhalation in 3 patients whose job was vacuum packing meat products&#46; Subsequent studies carried out in the few recorded cases of this type of asthma have cast doubt on the etiological role of PVC&#46; Andrasch et al<span class="elsevierStyleSup">10</span>&#44; after carrying out various challenge tests&#44; attributed the etiology of the process to an additional source of sensitizing agents released as a result of the thermal activation of substances used in labeling the packaged food&#46; These results are&#44; however&#44; difficult to evaluate since the challenge tests carried out did not simulate the usual workplace exposure&#44; and may well represent an overexposure that could have resulted in a bronchoconstrictor response caused by direct irritation&#46; Other causal agents that have been associated with this type of asthma are polyethylene<span class="elsevierStyleSup">16</span>&#44; anhydride acids and&#47;or soy oil derivatives<span class="elsevierStyleSup">11</span>&#44; also released during the heating process&#46; Finally&#44; some authors believe this to be a nonimmunologic&#44; irritative asthma caused by inhalation of the combustion products of PVC<span class="elsevierStyleSup">12</span>&#46;</p><p class="elsevierStylePara"> This case is interesting for two reasons&#58; firstly because it is the first recorded occurrence of this type of asthma in Spain&#59; and secondly because of the results observed in the challenge test&#46; The fact that the patient&#39;s response was delayed in both clinical and functional terms&#44; and that this response was not observed in the control asthma patients suggests that this is in effect an immunologic rather than an irritative type of asthma&#46; The clinical characteristics of the case -- delayed onset of symptoms after exposure&#44; the absence of elevated IgE&#44; and the delayed response to the challenge test -- lead us to conclude that the immunological mechanism involved was not IgE dependent&#46;</p><p class="elsevierStylePara">In this case&#44; in which the work involved shrink wrapping fish in sheets of plastic&#44; it was not possible to establish the specific causal agent&#44; although any of the substances described above could have played a role&#46; The recent demonstration that PVC in resinous form can cause occupational asthma even without being heated<span class="elsevierStyleSup">17</span> once again opens up the possibility that PVC could be the causal agent in this type of asthma&#46; In view of the widespread use of PVC in our country&#44; we believe that it is important to investigate its possible role in cases of asthma in order to facilitate the early diagnosis of patients who may possibly be affected&#44; since early avoidance of the causal agent represents the best treatment in patients suffering from occupational asthma<span class="elsevierStyleSup">18</span>&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence to&#58; Dr&#46; X&#46; Mu&#241;oz&#46;<br></br> Servicio de Neumolog&#237;a&#46; Hospital General Vall d&#8217;Hebron&#46;<br></br> Paseo Vall d&#8217;Hebron&#44; 119&#46; 08035 Barcelona&#46; Spain&#46;<br></br> Email&#58; <a href="mailto&#58;xmgall&#64;hg&#46;vhebron&#46;es" class="elsevierStyleCrossRefs"> xmgall&#64;hg&#46;vhebron&#46;es</a>&#46;</p><p class="elsevierStylePara">Manuscript received 2 December 2002&#46;<br></br> Accepted for publication 30 December 2002&#46;</p>"
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Occupational asthma in food packers
Asma ocupacional en envasadores de alimentos
X. Muñoza, M J. Cruza, M. Albanellb, F. Morella
a ervicio de Neumología. Hospital Universitari Vall d'Hebron. Barcelona. Spain.
b Territorio de Cataluña. ASEPEYO. Barcelona. Spain.
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Occupational asthma is a disease characterized by variable obstruction of the airway and&#47;or bronchial hyperresponse owing to causes and conditions attributable to a particular work environment<span class="elsevierStyleSup">1</span>&#46; Depending on whether or not a latency period occurs between exposure to the agent and the onset of symptoms&#44; two types of occupational asthma have been described&#58; immunologic and nonimmunologic&#46; Nonimmunologic occupational asthma is the reaction observed in patients whose illness is caused by irritants&#46; This type of asthma&#44; in which there is no latency period&#44; can occur after a single exposure to a high concentration of a particular irritant<span class="elsevierStyleSup">2&#44;3</span>&#46; Immunologic occupational asthma is characterized by the fact that onset of symptoms occurs only after a latency period&#46; It may be mediated by an IgE-dependent immunologic mechanism or by other mechanisms not dependent on IgE&#44; some of which are as yet not well understood<span class="elsevierStyleSup">4</span>&#46;</p><p class="elsevierStylePara">It is believed that between 5 and 15&#37; of all asthma cases that develop in adulthood are work related<span class="elsevierStyleSup">5</span>&#44; and asthma is currently considered to be the most common work-related respiratory pathology in industrialized countries<span class="elsevierStyleSup">6</span> with more than 250 different agents involved in its genesis<span class="elsevierStyleSup">7&#44;8</span>&#46; The majority of these agents have been studied in depth&#44; but in certain cases there is still some doubt regarding the etiological agent involved and the possible mechanism of action&#46; Such is the case of food packer&#39;s asthma&#44; initially known as meat wrapper&#39;s asthma&#46; While polyvinyl chloride &#40;PVC&#41; has been implicated as the causal agent in this type of asthma<span class="elsevierStyleSup">9&#44;10</span>&#44; there remains some doubt as to whether the illness is caused directly by this agent or&#44; alternatively&#44; by the products of its thermal degradation&#46; Doubt also exists as to whether this type of asthma is immunologic&#44; affecting only sensitized individuals&#44; or whether it is a nonimmunologic type of asthma caused by the irritant effect of the products of combustion on the bronchial mucosa&#46;</p><p class="elsevierStylePara">The objective of this case report is to present the first recorded case of food packer&#39;s asthma in Spain and to discuss&#44; on the basis of the results of the challenge test performed&#44; the possible origin of this disease&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical findings</span></p><p class="elsevierStylePara">The patient was a 26-year-old woman&#44; a cigarette smoker of 5 packets&#47;year with no other toxic habits or relevant medical history&#44; who had been working for four years for a company involved in the manufacture and sale of a range of fish products&#46; Six months after transferring from her usual job in a cleaning room to a new post in the vacuum packing area&#44; the woman started to experience delayed symptoms&#44; such as cough&#44; bronchospasm and dyspnea&#44; at the end of the working day and during the night&#46; On two occasions she had to go to an emergency room&#46; The patient&#39;s symptoms improved with inhaled beta-adrenergic drugs&#44; and were clearly work related since they improved on weekends and during vacations and other times she was away from the workplace&#46;</p><p class="elsevierStylePara">A chest x-ray was normal&#46; Test results revealed an eosinophil percentage of 8&#46;5 &#37; and a total serum IgE level of 90 kU&#47;l&#46; Skin tests for common respiratory allergens were negative&#46; A study of lung function revealed an obstructive ventilatory pattern with a forced vital capacity &#40;FVC&#41; of 3&#46;78 l &#40;104&#37;&#41;&#44; a forced expiratory volume in one second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; of 2&#46;38 l &#40;75&#37;&#41; and FEV<span class="elsevierStyleInf">1</span>&#37; of 63&#37;&#44; with a positive bronchodilator test showing an improvement in FEV<span class="elsevierStyleInf">1</span> of 16&#37;&#46; A methacholine challenge gave a positive result&#44; with a PCO<span class="elsevierStyleInf">2</span> of 0&#46;3 mg&#47;ml&#46; A record of peak expiratory flow rate measured by the patient during two working weeks and one week away from the workplace revealed a variation on working days of more than 20&#37;&#59; and visual interpretation of the record was consistent with the diagnosis of occupational asthma&#46; In the hospital&#44; a specific challenge test was carried out in which the patient&#39;s working conditions were simulated in a provocation chamber &#40;Fig&#46; 1&#41; <span class="elsevierStyleSup"> 13&#46;</span> No response was observed after the initial 1-hour exposure on the first day&#46; On the second day&#44; after a 3-hour exposure&#44; the patient experienced a delayed positive response &#40;Fig&#46; 2&#41;&#44; with a drop in FEV<span class="elsevierStyleInf">1</span> of 28&#37; approximately 12 hours after exposure&#44; and bronchospasm which required treatment with inhaled bronchodilators&#46; In order to rule out a possible irritant effect&#44; the same specific challenge test was carried out on two volunteer asthmatic patients whose bronchial hyperresponse to methacholine was similar to that observed in the patient&#46; The result was negative in both cases&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046509tab01.gif"></img></p><p class="elsevierStylePara">Fig&#46; 1&#46; Provocation chamber and shrink wrapping machine used in the specific challenge test&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046509tab02.gif"></img></p><p class="elsevierStylePara">Fig&#46; 2&#46; Results of the specific challenge test&#46; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in one second&#46;</p><p class="elsevierStylePara"> When the patient was transferred away from the packing area and relocated in her original job&#44; the symptoms disappeared and have not reappeared to date&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> PVC&#44; a thermoplastic material&#44; is a product of a chemical combination of carbon&#44; hydrogen and chlorine&#46; The raw materials are derived from oil and common salt&#46; Spain has approximately 1750 PVC converter companies&#44; which provide employment for some 38 000 people directly and over 150 000 indirectly&#46; It is estimated that the PVC industry provides employment for more than 542 000 people in Europe<span class="elsevierStyleSup">14</span>&#46;</p><p class="elsevierStylePara"> Most industrial processes using PVC involve heating the product in order to take advantage of its physical properties&#46; This heating process can give rise to the release of PVC in gaseous form and of irritative products such as hydrochloric acid and carbon monoxide&#46; Exposure to these agents can cause acute intoxication in the central nervous system and irritative lesions in airway and other mucosal tissues&#46; These effects are directly related to the length of exposure and the quantity of toxic agent released<span class="elsevierStyleSup">12</span>&#46;</p><p class="elsevierStylePara">In 1973&#44; Sokol et al<span class="elsevierStyleSup">15</span> described the first recorded cases of occupational asthma attributed to PVC inhalation in 3 patients whose job was vacuum packing meat products&#46; Subsequent studies carried out in the few recorded cases of this type of asthma have cast doubt on the etiological role of PVC&#46; Andrasch et al<span class="elsevierStyleSup">10</span>&#44; after carrying out various challenge tests&#44; attributed the etiology of the process to an additional source of sensitizing agents released as a result of the thermal activation of substances used in labeling the packaged food&#46; These results are&#44; however&#44; difficult to evaluate since the challenge tests carried out did not simulate the usual workplace exposure&#44; and may well represent an overexposure that could have resulted in a bronchoconstrictor response caused by direct irritation&#46; Other causal agents that have been associated with this type of asthma are polyethylene<span class="elsevierStyleSup">16</span>&#44; anhydride acids and&#47;or soy oil derivatives<span class="elsevierStyleSup">11</span>&#44; also released during the heating process&#46; Finally&#44; some authors believe this to be a nonimmunologic&#44; irritative asthma caused by inhalation of the combustion products of PVC<span class="elsevierStyleSup">12</span>&#46;</p><p class="elsevierStylePara"> This case is interesting for two reasons&#58; firstly because it is the first recorded occurrence of this type of asthma in Spain&#59; and secondly because of the results observed in the challenge test&#46; The fact that the patient&#39;s response was delayed in both clinical and functional terms&#44; and that this response was not observed in the control asthma patients suggests that this is in effect an immunologic rather than an irritative type of asthma&#46; The clinical characteristics of the case -- delayed onset of symptoms after exposure&#44; the absence of elevated IgE&#44; and the delayed response to the challenge test -- lead us to conclude that the immunological mechanism involved was not IgE dependent&#46;</p><p class="elsevierStylePara">In this case&#44; in which the work involved shrink wrapping fish in sheets of plastic&#44; it was not possible to establish the specific causal agent&#44; although any of the substances described above could have played a role&#46; The recent demonstration that PVC in resinous form can cause occupational asthma even without being heated<span class="elsevierStyleSup">17</span> once again opens up the possibility that PVC could be the causal agent in this type of asthma&#46; In view of the widespread use of PVC in our country&#44; we believe that it is important to investigate its possible role in cases of asthma in order to facilitate the early diagnosis of patients who may possibly be affected&#44; since early avoidance of the causal agent represents the best treatment in patients suffering from occupational asthma<span class="elsevierStyleSup">18</span>&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence to&#58; Dr&#46; X&#46; Mu&#241;oz&#46;<br></br> Servicio de Neumolog&#237;a&#46; Hospital General Vall d&#8217;Hebron&#46;<br></br> Paseo Vall d&#8217;Hebron&#44; 119&#46; 08035 Barcelona&#46; Spain&#46;<br></br> Email&#58; <a href="mailto&#58;xmgall&#64;hg&#46;vhebron&#46;es" class="elsevierStyleCrossRefs"> xmgall&#64;hg&#46;vhebron&#46;es</a>&#46;</p><p class="elsevierStylePara">Manuscript received 2 December 2002&#46;<br></br> Accepted for publication 30 December 2002&#46;</p>"
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        "resumen" => "This report describes the case of a 26-year-old woman working in a fish-processing factory who developed bronchial asthma when transferred to the packing department&#46; Various tests&#44; including a specific bronchial challenge test&#44; confirmed a diagnosis of occupational asthma&#46; While polyvinyl chloride &#40;PVC&#41; appeared to be the causal agent in this case&#44; the possible role of other etiological agents is also discussed&#46; Although occupational asthma in food packers is rare&#44; we nonetheless consider it important to recognize this type of asthma given the widespread use of PVC&#46;"
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        "resumen" => "Se describe el caso de una paciente de 26 a&#241;os de edad que trabajando en una empresa manufacturadora de pescado desarroll&#243; asma bronquial cuando fue trasladada a una zona dedicada al envase del producto&#46; Las diversas pruebas efectuadas&#44; incluida una prueba de provocaci&#243;n bronquial espec&#237;fica&#44; confirmaron el diagn&#243;stico de asma ocupacional&#46; Si bien el cloruro de polivinilo ha sido el agente involucrado en este tipo de asma&#44; se discuten otros posibles agentes etiol&#243;gicos&#46; Aunque poco frecuente&#44; consideramos relevante reconocer este tipo de asma&#44; dado el amplio uso que tiene este material en nuestro medio&#46;"
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ISSN: 15792129
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