Via The Lancet, a new health issue in Hong Kong: Allergic contact dermatitis and tracheobronchitis associated with repeated exposure to tear gas. Excerpt:
A 27-year-old man came to our emergency department with shortness of breath, a cough, and a globus sensation, which had all started earlier in the day. He also complained of an itchy rash on his neck, chest, and arms, which had developed 2 weeks earlier. During the previous 6 weeks, he had been repeatedly exposed to tear gas while working as a photojournalist at different protests around Hong Kong; the last exposure was 11 days before he came to see us. He said he had worn a full-face respirator during recent episodes.
The patient had attended our department on three previous occasions because of the rash. He had been given oral prednisolone, antihistamines, and topical steroids but his symptoms had not improved. He had a history of allergic rhinitis; he had no history of asthma or bronchitis.
On examination we found the patient to have a blanchable, maculopapular rash over his neck, upper trunk, and arms—consistent with an allergic contact dermatitis. His respiratory rate was 18 breaths per min and his oxygen saturation was 100% on room air; there was no evidence of angio-edema involving the upper airway. His lung fields were clear on auscultation.
Blood investigations showed no abnormalities: the patient's absolute eosinophil count and serum IgE concentration were normal.
A chest x-ray and thoracic CT showed no abnormalities. Bronchoscopy showed mild pharyngitis but severe tracheobronchitis. No pathogens were detected with PCR or culture of the bronchoalveolar lavage fluid. We decided not to do a bronchial biopsy of the severely inflamed bronchi because we were concerned about the risk of bleeding caused by the procedure. Lung function tests showed normal spirometry but a significant bronchodilator response: an increase of 19%, 640 mL in forced expiratory volume in 1 s, and a slightly reduced oxygen diffusion capacity of 71% (normal range 75–125%).
Considering the patient's presentation in the round we believe the patient had severe tracheobronchitis and an allergic contact dermatitis due to repeated exposure to tear gas. The patient was admitted and given intravenous hydrocortisone, inhaled fluticasone and vilanterol, and 50 mg/day of oral prednisolone. His condition improved and he went home after 4 days.
At follow-up 6 weeks later, the patient's shortness of breath had improved but he still had the cough. We repeated the bronchoscopy, which showed improvement in the tracheobronchitis (figure).
Lung function tests showed a significant bronchodilator response only in small airways: an increase of 18% in forced expiratory flow between 25% and 75% of the forced vital capacity (appendix).
We recommended that he continue with the inhaled fluticasone and vilanterol. Notably, the patient's skin rash recurred following re-exposure to tear gas. He was given three more short courses of oral prednisolone. 4 months later at a follow-up appointment his dermatological and respiratory symptoms had resolved.
