A 61‐year‐old white man with significant history of hypertension was brought to the emergency department with sudden onset shortness of breath, epigastric pain, diaphoresis, and light‐headedness for 30 minutes. Examination was positive for hypertension (201/121 mm Hg), tachycardia, and tachypnea. Blood work revealed anion‐gap metabolic acidosis, respiratory acidosis with hypoxemia, and lactic acidosis. The patient was placed on 15 L/min supplemental oxygen through a nonre‐breather mask and later changed to bilevel positive airway pressure, following which there was dramatic clinical improvement. A repeat blood gas analysis revealed resolution of metabolic and respiratory acidosis. Chest x‐ray demonstrated bibasilar opacities. Pulmonary embolism, aortic dissection, and acute coronary syndrome were ruled out. Pulmonology and cardiology were consulted for further evaluation. A comprehensive history revealed occupational exposure to nitrogen gases. As he was a farmer by occupation, the patient had been in and out of a grain elevator filled with fresh corn the day before, 4 hours before the onset of symptoms. He was diagnosed with silo filler's disease (SFD) based on typical clinical presentation and rapid resolution of symptoms with supplemental oxygen. He was started on a tapering dose of steroids. After a stable hospital course, he was discharged on day 3. A pulmonary function test at 3 months did not demonstrate any evidence of obstructive or restrictive lung disease. He was advised to follow up with the pulmonologist every 6 months.
Silo filler's disease, a preventable occupational hazard, results from exposure to oxides of nitrogen. It is prevalent during the harvest months of September and October. An estimated incidence of 5 cases per 100,000 silo‐associated farm workers per year was reported in New York. SFD is likely significantly underreported. A silo filled with freshly cut corn generates oxides of nitrogen within hours, and maximum concentration is reached within 1–2 days. Nitrogen dioxide hydrolyzes to nitrous and nitric acid, causing profound chemical pneumonitis and pulmonary edema. Most exposures are mild and self‐limiting; however, some events may cause sudden death from acute respiratory distress syndrome, laryngeal spasm, bronchiolar spasm, or asphyxia. Oxygen supplementation is the treatment of choice. Failure to use corticosteroids in some patients with SFD can result in the development of bronchiolitis obliterans, a permanent restrictive lung disease.
Acute chemical emergencies can occur as a result of industrial disaster, occupational exposure, recreational mishap or acts of terrorism. However, real‐time identification of specific chemical by means of environmental or clinical laboratory testing is difficult. SFD is a clinical diagnosis simulating acute cardiovascular events, and the appropriate diagnosis mandates comprehensive occupational medical history.
V. Ramalingam ‐ none; R. Sinnakirouchenan ‐ none; K. Patel ‐ none
To cite this abstract:Ramalingam V, Sinnakirouchenan R, Patel K. Reap the Harvest on Time!. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 379. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/reap-the-harvest-on-time/. Accessed January 26, 2020.