Delayed Complications and Long-Term Effects of SM Poisonings: Experience of Iran-Iraq War

Abstract

Among the weapons of mass destruction, Chemical Warfare Agents (CWAs) are one of the most brutal created by humankind in comparison with biological and nuclear warfare. Sulfur mustard (SM) which has the sobriquet ‘King of the Battle Gases’ has been the most widely used chemical weapons during the wars. SM was the most destructive chemical weapon used during the World War one (WWI). Thereafter, it remained the chemical weapon of choice in modern tactile warfare, as evidenced by widely use during the Iran-Iraq war. Acute and long-term incapacitating properties of SM, in combination with the lack of an antidote, significant environmental persistence, and relative ease of manufacturing, still kept it a potential agent for both military and terrorist use. Delayed complications of SM exposure can still be observed in several thousands of Iranian victims of the Iran-Iraq war. Delayed complications of SM have been reported in several organs, however, the most common delayed complications have been observed in the respiratory tracts of Iranian chemical veterans. Also, the skin lesions as well as the eye disorders have been observed in most of Iranian exposed veterans in the delayed phase of intoxication. This chapter reviewed type, severity and distribution pattern of long-term effects of SM poisoning in different organs among as well as long-term clinical managements and treatments of complications, according to the experimental and Iranian studies and experiences.

Glossary

Anemia

A reduction in the number of circulating erythrocytes or in the quantity of hemoglobin

Aphonia

Complete loss of phonation due to organic disease of the larynx or to nonorganic (i.e., psychogenic) causes

Asthma

A form of bronchial disorder with three distinct components: respiratory hypersensitivity, airway inflammation, and intermittent airway obstruction. It is characterized by spasmodic contraction of airway smooth muscle, wheezing, and dyspnea

Atherosclerosis

A thickening and loss of elasticity of the walls of arteries that occurs with formation of atherosclerotic plaques within the blood vessels

Atrophy

Decrease in the size of a cell, tissue, organ, or multiple organs

Axon

Nerve fibers that are capable of rapidly conducting impulses away from the neuron cell body

Azoospermia

A condition of having no sperm present in the ejaculate (semen).

Bronchiectasis

A disease in which there is permanent enlargement of parts of the airways of the lung

Bronchiolitis obliterans

Inflammation of the bronchioles leading to an obstructive lung disease. Characterized by fibrous granulation tissue with bronchial exudates in the lumens. Clinical features include a nonproductive cough and dyspnea

Carcinogenicity

The ability to produces cancer

Cherry angioma

Also called capillary angioma, De Morgans’s spots, and senile angioma. A small, bright red, clearly circumscribed vascular tumor on the skin. More than 85 % of people over 45 years of age have cherry angiomas on their skin

Clubbing

The rounding of the ends and swelling of fingers found in people with lung disease

Conjunctiva

The mucous membrane that covers the posterior surface of the eyelids and the anterior pericorneal surface of the eyeball

Core pulmonale

Hypertrophy and dilation of the right ventricle of the heart, generally caused by chronic disease and malfunction of the lungs. This condition can lead to heart failure

Cornea

The transparent anterior portion of the fibrous coat of the eye consisting of five layers and serves as the first refracting medium of the eye

Crackles

Abnormal noise, heard on auscultation over any part of the respiratory tract

CWA

Chemical warfare agents: a chemical substance whose toxic properties are used to kill, injure or incapacitate human beings

Cyanosis

A physical sign causing bluish discoloration of the skin and mucous membranes. It is caused by a lack of oxygen in the blood and could be associated with cold temperature, heart failure, lung diseases or something else

Discoid lupus erythematosus

A chronic form of cutaneous lupus erythematosus in which the skin lesions mimic those of the systemic form but in which systemic signs are rare. It is characterized by the presence of discoid skin plaques showing varying degrees of edema, erythema, scaliness, follicular plugging, and skin atrophy. The condition typically involves the face and scalp, but widespread dissemination may occur

Dysphonia

An impairment in the ability to produce voice sounds using the vocal organs

Dyspnea

Shortness of breath or breathlessness or feelings associated with impaired breathing

Ectasia

The condition of an anatomical structure’s being dilated beyond normal dimensions

Eosinophil

Granular leukocytes with a nucleus that usually has two lobes, connected with threads of chromatin and cytoplasm, containing coarse, round granules that are uniform in size and stainable by eosin

Epilepsy

A disorder characterized by recurrent episodes of paroxysmal brain dysfunction due to a sudden, disorderly, and excessive neuronal discharge that may be manifested as episodic impairment or loss of consciousness, abnormal motor phenomena, psychic or sensory disturbances, or perturbation of the autonomic nervous system

Exposure

The condition of being subjected to something, as to infectious agents, extremes of weather, radiation, or chemical agent which may have a harmful effect

Hyperaesthesia

Increased sensitivity to cutaneous stimulation due to a diminished threshold or an increased response to stimuli

Hypercapnia

A clinical manifestation of abnormal increase in the amount of carbon dioxide in arterial blood

Hyperinflation

Excessive inflation or expansion, as of the lungs

Hypoesthesia

Absent or reduced sensitivity to cutaneous stimulation

Hypoxemia

Relatively absence of oxygen in one or more tissues

Immunoglobulin

Multi-subunit proteins which function in immunity. They are produced by B lymphocytes from the immunoglobulin genes. They are comprised of two heavy and two light chains with additional ancillary polypeptide chains depending on their isoforms. They are divided by the amino acid sequence of their heavy chains into five classes: Ig A, Ig D, Ig E, Ig G, and Ig M and various subclasses

Intoxication

An abnormal state that is essentially a poisoning

Ischemia

A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation

Lacrimation

The secretion of tears, especially in excess.

Lethal dose 50

The dose amount of poisonous or toxic substance or dose of ionizing radiation required to kill 50 % of the tested population

Leukopenia

Decrease in number of leukocytes

Melanophage

A histiocyte that contains phagocytized melanin

Mitosis

A type of cell nucleus division by means of which the two daughter nuclei receive identical complements of the number of chromosomes of the somatic cells of the species

Mutagenicity

The ability of a chemical or physical agent to cause permanent changes in DNA

Nerve agents

Any of several highly toxic organophosphorus compounds, developed as chemical warfare agents because of their ability to inhibit cholinesterase

Neutrophil

A granular leukocyte having a nucleus with three to five lobes, connected with threads of chromatin and cytoplasm, containing very fine granules and stainable by neutral dyes

Paraesthesia

Subjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation

PFT

Pulmonary function test

Photophobia

Abnormal sensitivity of the eyes to light. This may occur as a manifestation of eye diseases, migraine, subarachnoid hemorrhage, meningitis, depression and other mental disorders

Presbyopia

Known as Old eye: the normal decreasing elasticity of the crystalline lens that leads to loss of accommodation and the eye’s ability to focus on close subjects.

Pruritus

An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief.

Psoriasis

A common genetically determined, chronic, inflammatory skin disease characterized by rounded erythematous, dry, scaling patches. The lesions have a predilection for nails, scalp, genitalia, extensor surfaces, and the lumbosacral region

Pulmonary fibrosis

A process in which normal lung tissues are progressively replaced by fibroblasts and collagen causing an irreversible loss of the ability to transfer oxygen into the bloodstream via pulmonary alveoli

Pulmonary hypertension

Increased vascular resistance in the pulmonary circulation, characterized by increased pressure in the pulmonary artery. It could be secondary to heart diseases or lung diseases

SM

Sulfur mustard: a class of related cytotoxic and vesicant chemical warfare agents with the ability to form large blisters on the exposed skin and in the lungs

Spermatogenesis

The process of germ cell development in the male from the primordial germ cells, through the mature haploid spermatozoa

Spirometry

A test using an instrument called a spirometer, for measurement of the breathing capacity of the lungs, such as in pulmonary function test

Toxicity

The degree to which a substance can damage an organism

Tracheobronchomalacia

A congenital or acquired condition of underdeveloped or degeneration of cartilage in the trachea and the bronchi. This results in a floppy non-rigid airway making patency difficult to maintain

Tremor

Cyclical movement of a body part that can represent either a physiologic process or a manifestation of disease

Vertigo

An illusion of movement, either of the external world revolving around the individual or of the individual revolving in space, in any plane

Vitiligo

A disorder consisting of areas of macular depigmentation, commonly on extensor aspects of extremities, on the face or neck, and in skin folds. Age of onset is often in young adulthood and the condition tends to progress gradually with lesions enlarging and extending until a quiescent state is reached

Wheezing

A high-pitched whistling sound associated with labored breathing. It is most common in exhaling and occurs when an individual tries to breathe deeply through air passages that are narrowed or filled with mucus

Xerosis

Abnormal dryness, as of the eye, skin, or mouth