Blood levels y-globulins in

JOURNALOF

Dermatological Science

Journal of Dermatological Science 8 (1994) 91-95

of 2,3,7,8-tetrachlorodibenzo-p-dioxin and a follow-up investigation of employees with

chloracne

Paul-J. Jansing, Rainer Korff *

Der Staatliche Gewerbearzt, Institute of Occupational Medicine, Gurlittstr. 55, D-40223 Diisseldorj Germany

Received 20 October 1993; revision received 28 March 1994; accepted I April 1994

AbStiPCt

In a follow-up investigation of 8 employees who partly contracted chloracne between 1973 and 1976, elevated con- centrations of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD, ‘Seveso dioxin’) were found in blood lipids. The concentra- tions measured were between 163 and 1935 pg TCDD/g blood lipids, other ‘dioxin’ levels being normal or only slightly increased in comparison to the background level in the general population. The cause of this was exposure at work during the manufacture of trichlorophenol (TCP). Apart from high cholesterol levels, there was a conspicuous reduc- tion in y-globulins.

Keywordx 2,3,7,8-tetrachlorodibenzo-p-dioxin; Trichlorophenol; Dose-response-relationship; Chloracne; y-globulins

1. Introduction

In the past there have been a number of acci- dents in which industrial workers and in some cases also the general population have been expos- ed to polychlorinated dibenzodioxins (PCDDs), the best known of which was the Seveso disaster of 1976.

In recent years it has become possible to deter- mine objectively the PCDD exposure by measur- ing the concentrations of these substances in the blood or blood lipids [ 11.

Therefore, within the framework of a follow-up investigation on 8 employees of a chemical plant in the Rhineland who contracted chloracne between 1973 and 1976, in addition to an expert assessment of secondary damage it was to be investigated whether there was a correlation between the PCDD level on the one hand and the findings recorded and reported health disturbances on the other.

2. Materials and methods

2.1. Patient group The investigation was carried out on 8

* Corresponding author. employees involved in the manufacture of tri-

0923-181 U94607.00 0 1994 Elsevier Science Ireland Ltd. All rights reserved SSDI 0923- I8 1 I (94)003 14-S

92 P.-J. Jansing, R. Korff/ J. Dermarol. Sri. 8 (1994) 91-95

chlorophenol (TCP) or in maintenance of the TCP plant between 1963 and the closure of the plant in 1976. Following the tilling of tankers carrying TCP and welding carried out on one of the distilla- tion columns there were skin lesions with cysts, comedones and hyperkeratosis in all cases. Numerous follicule-like bound papules, papulopostules and lumps with abscesses, with a tendency to confluent appeared in the face, above all on the temples, the areas of the cheek bones and on the ears and retro-auricula. Five of the 8 pa- tients also had the same symptoms on their necks and throats as well as on their breast and shoulder

The clean-up was done with standard methods by using modified silica gel and activated charcoal. After separating the individual PCDDs with high resolution gas chromatography (HRGC) the indi- vidual compounds were identified with a mass specific detector.

In addition to the general medical and der- matological examinations the following biochemi- cal parameters were examined: liver enzymes, creatinine, uric acid, triglycerides, cholesterol and protein electrophoresis.

areas. In 2 cases the illness led to many months sick-

leave and in all cases a long recovery time with a tendency to relapse was observed.

To discover whether the immune system had been damaged a count was made of the leukocytes, the lymphocyte subpopulation and the T4/Ts quo- tient apart from detailed case history analysis.

3. Results At the time of current investigation they were

between 43 and 59 years old and comprised 4 chemical workers and 4 works titters (Table 1).

3.1. Blood PCDD level

2.2. Method To measure the exposure of the 8 patients the

levels of PCDD in their blood lipids were analy- sed. To do this 50 ml of blood, diluted with 50 ml deionized water, was mixed with an internal stan- dard solution containing 17 ‘3C12-labelled PCDD isomers. To obtain the lipids the spiked blood- water mixture was dispersed in a column of Chem- Elut (modified silica gel). After elution with hex- ane/isopropanol(3:2) and evaporation through the rotary evaporator and once more weighting the substances, the gravimetrical analysis of the lipids

was made.

The determinations of PCDD levels in blood lipids revealed a high concentration in all 8 cases, levels of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD, ‘Seveso dioxin’) being by far the highest. Evidently, during their work in TCP production these people had been exposed predominantly to this substance, which is formed especially when there is an increase in the reaction temperature [2]. The same constellation has been found in similarly exposed populations [3].

The blood TCDD levels measured in this study were between about 30 and more than 400 times the background level in the general population [4]. Because of the long biological half-life of this com-

pound (tiR - 5-10 years) [5], the TCDD level

Table 1 List of employees investigated with details of occupation, period of employment, and onset of chloracne

Ser. No. Age Occupation Period of employment at TCP plant

Onset of the condition

1 46 Chemical worker 1965-1976 2 46 Works titter 1973-1974 3 57 Works titter 1963-1974 4 57 Chemical worker 1960-1976 5 44 Works titter 1963-1974 6 59 Works titter 1965-1976 7 45 Chemical worker 1966-1976 8 43 Chemical worker 1968-1976

June 1973 August 1974 August 1974 July 1973 August 1974 August I974 January 1975 November 1976

P.-J. Jansing, R. KorfflJ. Dermarol. Sci. 8 (1994) 91-95

Table 2 Exposure period, internal loading and duration of chloracne in the employees investigated

No. Date of birth Time of TCDD meas. TCDD eval. Duration of investigation (pp/g)” (pg/g) b chloracne

08.44 12.90 1935 9894 06.73-06.83 10.44. 12.90 734 3667 08.74-08.78

01.33 12.90 716 3577 08.74-06.83

06.33 02.89 526 2447 07.73-07.76

10.45 02.89 287 1203 08.74-07.76

02.31 12.90 276 1367 08.74-10.81

02.45 02.89 196 777 01.75-12.75

10.46 02.89 163 545 11.76-12.78

“TCDD meas., TCDD level measured. t’TCDD eval., TCDD level evaluated to the time of exposure.

declines only slowly. As a result the currently measured TCDD level can be used to evaluate the degree of exposure at the time. If the TCDD half- life of 7 years proposed by Neuberger et al. [6] is applied to our patient population, the TCDD levels at the time of exposure were somewhere between 545 and 9894 pglg blood lipids.

Table 2 provides an overview of the TCDD level measured and evaiuated to the time of exposure, The table also includes information on the dura- tion of chloracne.

8

6

2 + V fcun=l l-M.578 qx)_0,006069%+1,209 +

fOrn=6 1=+9.973 f7+=0,004682x+0,670

500 1000 1500 2000 TCDD level [pg/g blood lipids]

Fig. I. Duration of chloracne as a function of the TCDD level. Two of the subjects (marked with an ‘0’ - see text) showed a certain hypersensitivity, but otherwise there was a good corre- lation between the duration of the disease and the blood TCDD level.

This shows that, when individual factors are taken into account, the higher the blood TCDD level the longer was the duration of the disease. This is also shown clearly in the following diagram (Fig. 1).

It should be noted that in the employees marked ‘0’ there was evidence of a particular disposition to hypersensitive skin reactions. If a regression analy- sis is carried out on all the employees there is only a loose correlation. However, if the particularly ‘skin sensitive’ employees are picked out, there is a very close correlation between the TCDD level

I Ganm-globulins [g/13

____________________~~____~~~~~~___ 1s

t wm l,o +

t

__ l $-___t__________________________

++ + 03

t 4 m

500 1000 1500 2000 TCDD level [pg/g blood lipids]

Fig. 2. y-globulins as a function of the TCDD concentrations measured. The persons exposed to higher concentrations par- ticularly showed low y-globulin values, in some cases below the normal range.

94 P.-J. Jansing, R. Korfl/J. Dermatol. Sci. 8 (1994) 91-95

Table 3 TCDD, y-globulins and cholesterol levels in the employees investigated

Ser.

No. TCDD

(pg/g)

y-globulins Cholesterol (mmol/Ba

Relative Absolute (“XI)” (fl)b

1 1935 9.3 0.700 6.37 2 134 9.9 0.730 1.94 3 716 11.3 0.800 6.39 4 526 12.3 0.935 5.51 5 287 15.5 1.310 7.90 6 216 12.5 0.910 2.10 I 196 11.5 0.850 6.37 8 163 14.0 1.040 7.19

aMethod-specific normal range IO-20% (0.9-1.6 fl). bElevated from 6.2 mmol/l (male, 40-60 years) [7].

and the duration of chloracne (correlation coefftc- ient r = 0.97).

Even though 15 years had passed since the time of exposure, slight residual states of chloracne were established in 2 cases. In the others the condi- tion had disappeared.

3.2. Laboratory tests One of the most interesting findings of the labo-

ratory tests was in the electrophoresis study. In the employees with greater exposure the -y-globulins were reduced, whereas in the less exposed employees they were in the normal range. This revealed a tendency towards a reduction in the protein fraction where TCDD levels were elevated, but it is not currently possible to derive any clini- cal relevance from this (Fig. 2).

Cholesterol levels were either borderline or above the upper limit of the norm in nearly all those investigated (Table 3).

Liver function disturbances were diagnosed in 3 cases, but for a variety of reasons (isolated eleva- tion of bilirubin, time course of the liver enzymes) it seemed unlikely that these were connected with the earlier exposure at work.

4. Discussion

Fifteen years after occupational exposure to TCDD high concentrations of TCDD were still

found in the blood in all employees. If the half-life is taken as 7 years, it can be assumed that at the time of exposure the ‘dioxin levels’ were about 4 times greater, and it is therefore very likely that these employees suffered considerable dioxin con- centration which is still persisting. Slight residual states of chloracne were diagnosed in 2 cases.

Although some influence was exerted by indi- vidual sensitivity, the present data do reveal a cor- relation between the duration and expression of chloracne on the one hand and the blood TCDD level on the other hand. Indications of an especial- ly percutaneous absorption and accumulation as discussed by Neuberger et al. [6] were not observed in our collective.

Some laboratory deviations in the sense of a stress reaction indicate a persisting high TCDD level, and this is illustrated particularly clearly in the connection between the TCDD level and the y- globulin fraction, as shown in Fig. 2.

We found no indications of any disease of the immune system either in the case histories or in the chemical laboratory tests. The analysis of the lym- phocyte subpopulation resulted in a variable pic- ture but no pathological findings were observed. Especially the T$Ts quotient of all patients was within the normal range. This means that the sig- nificance of the above mentioned conspicuous chemical laboratory results are unclear and require further investigation.

Since there are, to date, only small numbers of case reports, both in these specific cases and in the literature, this constellation is certainly reasonable enough to justify medical supervision aimed at sec- ondary prevention in people who have suffered similar exposure.

References

1 Thoma H, Miicke W, Kretschmer E: Untersuchung von Humanfettproben auf PCDDIF. VDI-Berichte 634: 383-387, 1987.

2 Umwehbundesamt: Sachstand Dioxine, Berichte 5185 Erich Schmidt Verlag, Berlin, 1986.

3 World Health Organization: Polychlorinated dibenzo-p- dioxins and dibenzofurans. Environmental Health Cri- teria 88, Geneva, 1988.

4 Wittsiepe J, Ewers M: Kieselrotstudie Humanmedizin- ische Untersuchungen. Hygiene-Institut des Ruhrgebiets;

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im Auftrag des Ministeriums fiir Arbeit, Gesundheit und 6 Neuberger M, Landvoigt W, Derntl F: Blood levels of Soziales des Landes Nordrhein-Westfalen, 1991. 2,3,7,8-tetrachlorodibenzo-p-dioxin in chemical workers

5 Pirkle JL, Wolfe WH, Patterson DG jr., Needham LL, after chloracne and in comparison groups. Int Arch Michalek JE, Miner JC, Peterson MR. Phillips DL: Gccup Environ Health 63: 325-327, 1991. Estimates of the half-life of 2,3,7,8-tetrachlorodibenzo-p- 7 Doerner K: Klinische Chemie. 2nd ed., Enke Verlag, Stut- dioxin in Vietnam veterans of operation Ranch Hand. J tgart, 1992. Toxicol Environ Health 27: 165-171. 1989.