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Metal Fume Fever

Fever Foundry

Metal fume fever is an occupational disease caused by inhalation of metal-containing fumes, most important element being zinc oxide. The clinical presentation comprises of constitutional symptoms developing within several hours after exposure, and in most cases, spontaneous resolution after cessation of exposure is observed. The diagnosis is based on clinical criteria and confirmation of occupational exposure.


Presentation

Metal fume fever (MFF) has been recognized in the past few centuries as an important occupational disorder in the brass and welding industries (particularly in galvanized steel production), and between 1,500-2,000 workers suffer from this condition in the United States on an annual basis [1] [2] [3] [4]. Inhalation of zinc oxide (ZnO), the principal causative agent of MFF, but also iron and copper oxide in the work setting is considered to be toxic and results in the production of various symptoms [1] [4] [5] [6]. The clinical presentation is distinguished by the onset of a dry cough, dyspnea, fever, chills, headaches, myalgias, fatigue, malaise, and arthralgias within 3-12 hours after exposure to metal-containing fumes [1] [2] [3] [5]. In addition, a metallic taste in the mouth, a dry throat, and excessive salivation have been reported as potential symptoms as well [3] [6]. Complaints usually resolve after 24 hours, but they can persist throughout the initial week and completely disappear by the beginning of the next week [1] [5] [6]. The marked improvement of symptoms over the weekend, when workers are removed from the source of exposure, is often referred to as tachyphylaxis, which is not uncommon for metal fume fever [1] [2] [3] [5]. The condition is self-limiting and rarely poses a significant risk for the patient, but reports have documented the development of pericarditis, pneumonitis and even aseptic meningitis in individuals who were exposed to very high amounts of metal fumes [1] [2] [3]. Furthermore, studies have implicated a potential link between occupational asthma and metal fume fever, with further research needed to confirm these claims [2].

Fever
  • The primary treatment for both metal fume fever and polymer fume fever is supportive and directed at symptom relief.[doi.org]
  • Low-grade fever after inhalation exposure is not explicable by hydrogen chloride inhalation and therefore appeared to be caused by titanium dioxide inhalation, manifesting as metal fume fever.[ncbi.nlm.nih.gov]
  • Workplace safety and education is key to prevention of metal fume fever. Medical profession education may help prevent occurrences of metal fume fever at home, at school and in the workplace.[ncbi.nlm.nih.gov]
  • After 24 hrs of symptomatic treatment (oxygen therapy and acetaminophen), the fever was subsided and the patient discharged home in a good clinical condition. The presented symptoms could be interpreted as a form of metal fume fever.[ncbi.nlm.nih.gov]
  • Abstract Metal fume fever is an acute self-limited illness induced most commonly by inhalation of zinc oxide fumes.[ncbi.nlm.nih.gov]
Malaise
  • The illness is of short duration and produces symptoms of cough, fever, chills, malaise, and myalgias. Its etiology is uncertain, and its diagnosis is difficult because symptoms resemble a number of pulmonary illnesses.[ncbi.nlm.nih.gov]
  • Symptoms include fever, chills, cough, dyspnea, headache, myalgia, and malaise.[ncbi.nlm.nih.gov]
  • The patient typically experiences symptoms of cough, fever, chills, malaise, and myalgia that are self-limited and of short duration.[ncbi.nlm.nih.gov]
  • Possible MFF (at least one of fever, feelings of flu, general malaise, chills, dry cough, metallic taste, or shortness of breath) was reported by 39.2% of apprentices.[ncbi.nlm.nih.gov]
  • Metal fume fever Metal fume fever includes a variety of symptoms like general feeling of ill health (malaise), chills, and fever. Individuals affected may have excessive thirst and a metallic taste in their mouth.[imedpub.com]
Exposure to Metal Fumes
  • The diagnosis of metal fume fever is primarily based on the history of exposure to metal fumes and the occurring of symptoms shortly afterwards.[ntvg.nl]
  • ", number "6", } TY - JOUR T1 - Copper exposure and metal fume fever T2 - Journal of Occupational and Environmental Hygiene AU - Borak, J. AU - Cohen, H. AU - Hethmon, T. A.[utah.pure.elsevier.com]
  • Key points Metal fume fever is generally a benign flu-like illness following exposure to metal fume. Severe symptoms may occur if there is poor exposure control.[doi.org]
  • When they return to work, it is important to limit exposure to metal fumes, because they can be more vulnerable to future episodes of illness.[wisegeek.com]
  • Key points Metal fume fever is a diagnosed with exposure to metal fumes within the last 48 hours and 'flu-like' symptom development with resolution within 1–2 days.[racgp.org.au]
Metal Worker
  • Abstract Metal fume fever is an ancient occupational disease still encountered among metal workers. The delay between exposure and onset of non-specific symptoms makes this an elusive diagnosis.[ncbi.nlm.nih.gov]
  • Mortality from infectious pneumonia in metal workers: a comparison with deaths from asthma in occupations exposed to respiratory sensitizers.[hse.gov.uk]
  • Metal workers have a high incidence rate of musculoskeletal problems including back injuries, shoulder pain, tendonitis, carpal tunnel, white finger and knee joint issues. Work postures and heavy lifting contribute significant to these problems.[ehs.ua.edu]
Shivering
  • Forty-five minutes later, he developed flu-like symptoms, shivering, muscle stiffness, dizziness, central chest pain and a metallic taste.[doi.org]
  • Metal fume fever Icd10: T59.9 Metal fume fever, also known as brass founders' ague, brass shakes, [1] zinc shakes, galvie flu, metal dust fever, Welding Shivers, or Monday morning fever, [2] is an illness primarily caused by exposure to chemicals such[everything.explained.today]
Cough
  • The MFF is characterized by fever, cough, sputing, wheezing, chest tightness, fatique, chills, fever, myalgias, cough, dyspnea, leukocytosis with a left shift, thirst, metallic taste, and salivations.[ncbi.nlm.nih.gov]
  • The presence of at least one welding related respiratory symptom (cough, wheezing, or chest tightness) suggestive of welding related asthma was reported by 13.8%.[ncbi.nlm.nih.gov]
  • The illness is of short duration and produces symptoms of cough, fever, chills, malaise, and myalgias. Its etiology is uncertain, and its diagnosis is difficult because symptoms resemble a number of pulmonary illnesses.[ncbi.nlm.nih.gov]
  • Symptoms include fever, chills, cough, dyspnea, headache, myalgia, and malaise.[ncbi.nlm.nih.gov]
  • The patient typically experiences symptoms of cough, fever, chills, malaise, and myalgia that are self-limited and of short duration.[ncbi.nlm.nih.gov]
Dyspnea
  • He was referred to the emergency department of our hospital with low-grade fever, dyspnea, headache, fatigue and myalgia.[ncbi.nlm.nih.gov]
  • Symptoms include fever, chills, cough, dyspnea, headache, myalgia, and malaise.[ncbi.nlm.nih.gov]
  • Symptoms most commonly reported were fever (21), dyspnea (23), chills (21), headache (21), and nausea (19). Fourteen of the workers experienced the symptom of an unusual sweet or metallic taste in the mouth.[ncbi.nlm.nih.gov]
  • The MFF is characterized by fever, cough, sputing, wheezing, chest tightness, fatique, chills, fever, myalgias, cough, dyspnea, leukocytosis with a left shift, thirst, metallic taste, and salivations.[ncbi.nlm.nih.gov]
  • Fourteen students and staff complained of nausea, dyspnea, or respiratory irritation immediately after inhaling the gas. On arrival at Saint Luke's International Hospital, more than half of the patients presented with low-grade fever.[ncbi.nlm.nih.gov]
Dry Cough
  • Possible MFF (at least one of fever, feelings of flu, general malaise, chills, dry cough, metallic taste, or shortness of breath) was reported by 39.2% of apprentices.[ncbi.nlm.nih.gov]
  • The clinical presentation is distinguished by the onset of a dry cough, dyspnea, fever, chills, headaches, myalgias, fatigue, malaise, and arthralgias within 3-12 hours after exposure to metal-containing fumes.[symptoma.com]
  • Patients also frequently complain of a sweet or metallic taste in the mouth, irritated or dry throat, and chest pain. flu-like illness with a metallic taste in the mouth, leucocytosis (high white blood cell count) throat irritation, and dry cough;[online-vitamins-guide.com]
  • Abstract A 50-year-old man with a 30-year occupational history of welding presented with low-grade fever, fatigue and persistent dry cough.[doi.org]
  • The co-occurrence of possible MFF (defined as having at least two symptoms of fever, feelings of flu, general malaise, chills, dry cough, metallic taste, and shortness of breath, occurring at the beginning of the working week, 3-10 hours after exposure[ncbi.nlm.nih.gov]
Rales
  • Clinical signs were limited to wheezing or rales in eight patients. Leukocytosis and an increase in band cell forms were noted in 21 and 20 of 24 workers, respectively. The median time interval between exposure and onset of symptoms was five hours.[ncbi.nlm.nih.gov]
Metallic Taste
  • Fourteen of the workers experienced the symptom of an unusual sweet or metallic taste in the mouth. Clinical signs were limited to wheezing or rales in eight patients.[ncbi.nlm.nih.gov]
  • The MFF is characterized by fever, cough, sputing, wheezing, chest tightness, fatique, chills, fever, myalgias, cough, dyspnea, leukocytosis with a left shift, thirst, metallic taste, and salivations.[ncbi.nlm.nih.gov]
  • Possible MFF (at least one of fever, feelings of flu, general malaise, chills, dry cough, metallic taste, or shortness of breath) was reported by 39.2% of apprentices.[ncbi.nlm.nih.gov]
  • Patients also frequently complain of a sweet or metallic taste in the mouth, irritated or dry throat, and chest pain. flu-like illness with a metallic taste in the mouth, leucocytosis (high white blood cell count) throat irritation, and dry cough;[online-vitamins-guide.com]
  • Individuals affected may have excessive thirst and a metallic taste in their mouth. Symptoms usually subside spontaneously in six to 12 hours. A classic case would occur when galvanized steel is welded in a poorly ventilated area.[imedpub.com]
Chest Pain
  • Patients also frequently complain of a sweet or metallic taste in the mouth, irritated or dry throat, and chest pain. flu-like illness with a metallic taste in the mouth, leucocytosis (high white blood cell count) throat irritation, and dry cough;[online-vitamins-guide.com]
  • Forty-five minutes later, he developed flu-like symptoms, shivering, muscle stiffness, dizziness, central chest pain and a metallic taste.[doi.org]
  • Some patients report a metallic taste in their mouths, chest pain, changes in urinary output, and an unusually high white blood cell count. A blood test can reveal abnormally high concentrations of metals in the blood.[wisegeek.com]
  • Hot flashes, cold flashes, sweats, chills, terrible chest pains and stomach pains. And for quite a while after, it tasted like I had a mouth full of pennies. -- Chipmaker ICK![abymc.com]
  • Signs and symptoms The signs and symptoms are nonspecific but are generally flu-like including fever, chills, nausea, headache, fatigue, muscle aches, joint pains, lack of appetite, shortness of breath, pneumonia, chest pain, blood pressure change, and[slideshare.net]
Tachycardia
  • By 18 h, he was apyrexial with residual mild tachycardia, right basal crepitations, right basal shadowing on chest X-ray and a leucocytosis of 13 000 white blood cells/μl. Electrocardiogram, Doppler and computed tomography brain scan were normal.[doi.org]
  • In some cases, affected individuals may exhibit increased salivation; yellowing of the teeth; an unusually rapid heart beat (tachycardia); low levels of iron within the red blood cells (anemia); bluish discoloration (cyanosis) of the skin and mucous membranes[rarediseases.org]
Angioedema
  • This article describes the first case, to my knowledge, of an immediate and a late phase reaction (urticaria and angioedema) to zinc fumes, associated with a metal fume fever-like reaction.[ncbi.nlm.nih.gov]
Flushing
  • Subject A wore a drop-down welder's visor not flush with his chin; subject B wore welding goggles.[doi.org]
Arthralgia
  • The clinical presentation is distinguished by the onset of a dry cough, dyspnea, fever, chills, headaches, myalgias, fatigue, malaise, and arthralgias within 3-12 hours after exposure to metal-containing fumes.[symptoma.com]
  • He also complained of myalgia, arthralgia, feverish sensation, thirst, and general weakness. Symptoms worsened after repeated copper welding on the next day and subsided gradually following two weeks.[jpmph.org]
  • Fever Chills Nausea Fatigue Muscle Ache Joint Pain Thirst “The initial symptoms include a sweet metallic taste associated with throat irritation, dyspnea [shortness of breath] and thirst followed by chills, a low-grade fever, myalgia [muscle pain], arthralgias[sentryair.com]
  • VPIC diagnostic criteria for metal fume fever History of exposure to metal fumes within previous 48 hours AND Febrile illness OR respiratory symptoms PLUS at least one symptoms of: malaise myalgias arthralgias headache nausea AND Other illnesses less[racgp.org.au]
Meningism
  • RESULTS: Our patient is a 25-year-old male welder who had MFF and presented with aseptic meningitis with pericarditis, pleuritis and pneumonitis. To our knowledge, this is the first case of MMF presenting with these signs and symptoms.[ncbi.nlm.nih.gov]
  • The condition is self-limiting and rarely poses a significant risk for the patient, but reports have documented the development of pericarditis, pneumonitis and even aseptic meningitis in individuals who were exposed to very high amounts of metal fumes[symptoma.com]
  • Metal fume fever presenting as aseptic meningitis with pericarditis, pleuritis and pneumonia , Occup Med (Lond) , 2005 , vol. 55 (pg. 638 - 641 ) 12.[doi.org]

Workup

Recognition of metal fume fever may significantly improve the quality of the patient's life and a comprehensive workup is necessary in order to make the diagnosis. A detailed patient history is perhaps the single most important component of the workup, as identification of the patient's occupancy, exact job description, and confirmation regarding the substances and risks the patient is exposed to is vital in raising clinical suspicion toward MFF [1] [3] [6]. Furthermore, the rapid onset and resolution of symptoms can point to an occupational disease. A complete physical examination that will document all typical signs and symptoms should follow, after which several laboratory studies may be performed. As many patients will have a high leukocyte count and an elevated erythrocyte sedimentation rate (ESR), a complete blood count (CBC) and evaluation of serum inflammatory markers are recommended tests [1] [2] [5]. In addition, serum and urine levels of zinc are often elevated [1]. If an occupational etiology is suspected in patients with constitutional symptoms, plain radiography of the chest is mandatory, and normal findings are observed in most cases, but a diffuse patchy infiltration is seen in severe cases [5]. Because direct tests to confirm MFF do not exist, the physician must gather all the necessary information through history taking, physical examination and laboratory studies and make the diagnosis based on his/her clinical judgment [1] [6].

Pulmonary Infiltrate
X-Ray Abnormal
  • Chest X-ray abnormalities may also be present. [10] An interesting feature of metal fume fever involves rapid adaptation to the development of the syndrome following repeated metal oxide exposure.[everything.explained.today]
Chest X-Ray Abnormal
  • Chest X-ray abnormalities may also be present. [10] An interesting feature of metal fume fever involves rapid adaptation to the development of the syndrome following repeated metal oxide exposure.[everything.explained.today]

Treatment

  • The treatment of MFF is entirely symptomatic, no specific treatment is indicated for MFF. The mainstay of management of MFF is prevention of sub-sequent exposure to harmful metals.[ncbi.nlm.nih.gov]
  • Treatment. The primary treatment for both metal fume fever and polymer fume fever is supportive and directed at symptom relief.[doi.org]
  • Supportive treatment, with bed rest, analgesics, and fever control is used for symptomatic relief. Emergency medicine physicians must differentiate the clinical picture from other common respiratory illnesses.[ncbi.nlm.nih.gov]
  • After 24 hrs of symptomatic treatment (oxygen therapy and acetaminophen), the fever was subsided and the patient discharged home in a good clinical condition. The presented symptoms could be interpreted as a form of metal fume fever.[ncbi.nlm.nih.gov]
  • The treatment is symptomatic with bed rest, analgesics, and antipyretics and oxygen therapy if necessary. Case description A male 35-year old construction worker had cut galvanized steel plates in a closed environment.[ntvg.nl]

Prognosis

  • Prognosis. Metal fume fever is typically a benign and self-limited disease entity that resolves over 12–48 h following cessation of exposure. Conclusions.[doi.org]
  • PROGNOSIS: Metal fume fever is typically a benign and self-limited disease entity that resolves over 12-48 h following cessation of exposure.[ncbi.nlm.nih.gov]
  • We undertook a review of the peer-reviewed medical literature as it relates to these two disease entities in order to describe their epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, prevention, and prognosis.[ncbi.nlm.nih.gov]
  • Prognosis The symptoms of metal fume fever are usually self-limiting, and dissipate rapidly upon removal from the source of metal fumes.[everything2.com]

Etiology

  • Its etiology is uncertain, and its diagnosis is difficult because symptoms resemble a number of pulmonary illnesses. Supportive treatment, with bed rest, analgesics, and fever control is used for symptomatic relief.[ncbi.nlm.nih.gov]
  • If an occupational etiology is suspected in patients with constitutional symptoms, plain radiography of the chest is mandatory, and normal findings are observed in most cases, but a diffuse patchy infiltration is seen in severe cases.[symptoma.com]
  • Mill fever Symptoms: flu-like illness with rhinitis; Signs: leucocytosis; normal chest x-ray; Onset after exposure; 1-6 hours; Heavy exposure to: dusts of cotton, flax, soft hemp, or kapok; Resolution: few hours to few days; Comments: A common etiology[haz-map.com]

Epidemiology

  • This review is followed by a description of MFF cases reported by the Louisiana Poison Control Center to the Louisiana Office of Public Health's Section of Environmental Epidemiology and Toxicology during a two-year period.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To determine the epidemiology of metal fume fever over an extended period in Victoria, Australia. METHODS: A retrospective case review of all metal fume fever related calls to the Victorian Poisons Information Centre.[ncbi.nlm.nih.gov]
  • Epidemiology. Metal fume fever occurs most commonly as an occupational disease in individuals who perform welding and other metal-joining activities for a living.[doi.org]
  • Subjects: Public Health and Epidemiology. See all related items in Oxford Index » Users without a subscription are not able to see the full content. Please, subscribe or login to access all content.[oxfordindex.oup.com]
  • EPIDEMIOLOGY: Metal fume fever occurs most commonly as an occupational disease in individuals who perform welding and other metal-joining activities for a living.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Initial manifestations of the two forms are similar but their pathophysiologies and managements are different. Mild MFF patients recover within 48 hours and rarely require hospitalization.[ncbi.nlm.nih.gov]
  • PATHOPHYSIOLOGY: While the precise pathophysiology associated with the development of metal fume fever is yet to be elucidated, suggested pathophysiologic mechanisms include pro-inflammatory cytokine release, neutrophil activation, and oxygen radical[ncbi.nlm.nih.gov]
  • While the precise pathophysiology associated with the development of metal fume fever is yet to be elucidated, suggested pathophysiologic mechanisms include pro-inflammatory cytokine release, neutrophil activation, and oxygen radical formation.[ncbi.nlm.nih.gov]
  • Approximately 2000 cases are reported annually in the United States. 2, 3 The pathophysiology is unclear but seems to reflect a direct toxic effect.[doi.org]

Prevention

  • Workplace safety and education is key to prevention of metal fume fever. Medical profession education may help prevent occurrences of metal fume fever at home, at school and in the workplace.[ncbi.nlm.nih.gov]
  • The mainstay of therapy for MFF consists of recognizing the disease and preventing subsequent exposure to harmful metals.[ncbi.nlm.nih.gov]
  • Cadmium also injures the renal tubules resulting in acute renal dysfunction. 1 Preventative strategies for MFF are aimed at reducing fume exposure concentrations. 7 “Toxic” levels have not been established.[doi.org]
  • Nonetheless, as any worker who has experienced a full-blown case will likely testify, metal fume fever remains one of the more noxious short-term illnesses contracted in the workplace, and its prevention deserves serious attention.[ncbi.nlm.nih.gov]
  • In this report, we present an overview of MFF's history, pathogenesis, clinical presentation, regulatory guidelines, and prevention recommendations.[ncbi.nlm.nih.gov]

References

Article

  1. Wardhana, Datau EA. Metal fume fever among galvanized welders. Acta Med Indones. 2014;46(3):256-262.
  2. El-Zein M, Infante-Rivard C, Malo J, Gautrin D. Is metal fume fever a determinant of welding related respiratory symptoms and/or increased bronchial responsiveness? A longitudinal study. Occup Environ Med. 2005;62(10):688-694.
  3. Hassaballa HA, Lateef OB, Bell J, Kim E, Casey L. Metal fume fever presenting as aseptic meningitis with pericarditis, pleuritis and pneumonitis. Occup Med (Lond). 2005;55(8):638-641.
  4. Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2016.
  5. Greenberg MI, Vearrier D. Metal fume fever and polymer fume fever. Clin Toxicol (Phila). 2015;53(4):195-203.
  6. Kaye P, Young H, O’Sullivan I. Metal fume fever: a case report and review of the literature. Emerg Med J. 2002;19(3):268-269.

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Last updated: 2018-06-22 07:38