Probable Green Tobacco Sickness from Occupational Preparation of E-Cigarette Products

Details

• Personal Author:
  Irobi EO ; Jaramillo GM ; Morrow GD ; Seifert SA ; Smolinske SC ; Warrick BJ
• Description:
  Background: The use of liquid nicotine products is widespread and home compounding of liquid nicotine solutions is becoming more popular. Highly concentrated solutions are readily available for preparation of custom flavors and proprietary products. Green Tobacco Sickness (GTS), systemic nicotine poisoning from dermal exposure to nicotine in workers harvesting tobacco, is well documented. A common case definition is nausea or vomiting plus dizziness or headache and occupational dermal exposure to tobacco within the past day, with patients often having repeated episodes. We report a case of systemic nicotine toxicity with presentation similar to GTS associated with occupational preparation of "e-cigarette" solutions. Case Report: A 35 year-old man was admitted to the hospital on three separate occasions over a two-week period with a diagnosis of nicotine poisoning. His occupation was operation of a home business preparing and distributing liquid nicotine solutions for e-cigarettes. Presenting symptoms on each visit included hypertension, dehydration, profound vomiting, dizziness, restlessness, and diaphoresis. Abraded hands were noted on one admission, and the patient reported relief with hot showers. Onset and duration were consistent with GTS. The patient denied any ingestion or inhalation use of the product and was treated with skin decontamination, antiemetics, intravenous fluids and minimal sedation. No information on use of skin barrier protection was available. A serum cotinine level of 3 ng/mL was obtained on the second visit more than 36 hours after admission, with a negative serum nicotine level. Case Discussion: We report a patient with signs and symptoms of systemic nicotine toxicity following occupational exposure to concentrated e-cigarette solution. Other diagnoses were felt less likely, including drug withdrawal, anxiety disorder, marijuana hyperemesis syndrome, and akathisia from repeated iatrogenic administration of phenothiazine anti-emetics, although these may have had some contribution to his findings. If extrapolated back two halflives, his serum cotinine level reflected recent exposure to nicotine. He required only 1-2 doses of morphine and/or lorazepam during hospitalization, had a negative UDS for THC on 1 of 3 visits, and onset of restlessness was more than 2 days after administration of neuroleptics in each case. Conclusion. Preparation of liquid nicotine may result in systemic toxicity from dermal absorption. Counseling patients about effective personal protective equipment and decontamination with tepid, not hot water, should be considered in anyone with repeated dermal exposure to e-cigarette solutions. [Description provided by NIOSH]
• Subjects:
  Electrical Equipment And Supplies Nicotine Occupational Health Personal Protective Equipment Poisoning Safety Skin Tobacco Products
• Keywords:
  Author Keywords: Nicotine; Electronic Cigarettes; E-cigarettes Nicotine; Electronic Devices; Tobacco; Poisons; Dermal Exposures; Toxic Vapors; Protective Measures; Personal Protective Equipment;
• ISSN:
  1556-3650
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Abstract or Summary
• Place as Subject:
  New Mexico ; OSHA Region 6
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Volume:
  53
• Issue:
  7
• NIOSHTIC Number:
  nn:20050301
• Citation:
  Clin Toxicol 2015 Jul; 53(7):750
• Email:
  ssmolinske@salud.unm.edu
• Federal Fiscal Year:
  2015
• Performing Organization:
  New Mexico State Department of Health
• Peer Reviewed:
  False
• Start Date:
  20150701
• End Date:
  20160630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:8fcc1d8c2af031459272a23f305d86be3e99db07944a482c461cbfdae78cd875c39638f8b352be49d98501406abc3547a3b8353d26f2f15b7c7a33f7345f4b20
• Download URL:
  https://stacks.cdc.gov/view/cdc/231614/cdc_231614_DS1.pdf
• File Type:
  [PDF - 352.27 KB ]