Chemical poisoning - general principles of diagnosis and treatment

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The diagnosis of chemical poisoning is suspected from a history of exposures resulting in typical clinical syndromes and confirmed by the appropriate medical tests.

There are a series of criteria to be fulfilled to make a confident clinical diagnosis of poisoning by chemicals. The following criteria have to be fulfilled:

  1. The subject was fit and well prior to chemical exposures.
  2. There is evidence of exposure to the putative chemicals and toxins.
  3. The subject initially developed local symptoms which became worse with repeated exposures.
  4. With repeated exposures a typical clinical picture emerges characterised by chronic fatigue syndrome, immune disruption (allergies, autoimmunity, susceptibility to infections), accelerated ageing (so the sufferer gets diseases before their time), neuro-degeneration, diabetes and cancer.
  5. Similar patterns of disease are seen in other people working under similar conditions.
  6. Similar fact evidence from other subjects who have been poisoned such as the Gulf War veterans, sheep dip poisoned farmers, aerotoxic pilots.
  7. There is laboratory evidence of poisoning and effects of that poisoning.
  8. There are no other possible explanations for this pattern of symptoms.
  9. There is a response to treatment with clinical improvements as a result of detoxification, nutritional and immune support.

The Clinical Picture of Chemical Poisoning

It is important to realise that the diagnosis of chemical poisoning relies on recognition of a clinical picture. Let me draw an analogy. If I saw a photograph of the Queen, standing on the balcony at Buckingham palace, surrounded by members of the Royal Family, with the flag flying above, the band playing below and thousands of people cheering, I would be happy to diagnose that it was indeed the Queen I was looking at. To be certain I would have to ask for DNA testing, but this has never been requested and never been done because the clinical picture is so obvious.

We have a similar situation with people who have been chemically poisoned. The clinical picture to those trained and used to seeing it is obvious. The problem arises because these people who are poisoned have only presented in the last few years. This is not a long standing recognisable syndrome, it is a new illness. Doctors are traditionally very slow to recognise new diseases and most not only fail to even look at the clinical picture, many do not accept it exists at all because it does not fit into their paradigm of disease! It really does create a new picture! So for example it has taken the Americans 17 years to recognise the clinical picture of Gulf War Syndrome and ascribe this to pesticide poisoning. Fortunately the 9/11 firemen who were poisoned by the fumes inhaled as they fought the flames and picked over the debris of the destroyed twin towers had their illness quickly recognised and a detoxification centre set up in New York allowed effective and immediate treatment.

So for a diagnosis of chemical poisoning to be made, not only do the above criteria have to be followed, but a doctor experienced in seeing and treating these new diseases must be able to see the picture. Just like in the early days of infectious diseases, Koch’s Postulates had to be fulfilled to make a diagnosis of infection, a series of criteria for the diagnosis of chemical exposures is now emerging.

Symptoms of chronic chemical poisoning

  • Symptoms of chronic fatigue syndrome. Severe, debilitating fatigue which is physical and mental
    • Physical – no stamina, loss of muscular strength (episodic blurred vision), sudden “hitting a wall”, has to rest regularly and pace all activity.
    • Mental – poor short term memory, unable to learn new things, poor concentration, speech difficulty with poor word finding. Long term memory usually fine. See Brain fog - poor memory, difficulty thinking clearly etc
    • Malaise – sufferers feel ill, “hung over”, “poisoned”.
    • Muscle aching – often widespread, flitting from one group of muscles or joints to another, often requiring painkillers; degeneration of handwriting.
    • Drug intolerance (such as alcohol, antidepressants). This is symptomatic of poor ability to detox. See Detoxification - an overview
    • Sleep disturbance
  • Symptoms of multiple chemical sensitivity. Sufferers
    1. become more sensitive to the chemical to which they are exposed, which means that they get bigger reactions with smaller doses.
    2. become sensitive to other chemicals. This is called a “spreading phenomenon” and classically these people start to react to any other chemicals such as diesel fumes, perfumes, cigarette smoke, alcohol and so on.
    3. develop an exquisite sense of smell – they can smell chemicals long before anybody else – they are true “canaries”
  • Personality change with destabilisation of mood (mood swings), increased tearfulness, irritability and aggression, impulsive suicidal thoughts, rage. An extreme version of these symptoms results in psychiatric disorders including depression and psychosis.
  • Other symptoms which may arise as a combined effect of the above problems include:
    • Chest pain,
    • Shortness of breath
    • Muscle twitching or cramp
    • Irritable bowel syndrome (abdominal pain, bloating, diarrhoea/constipation etc)
    • Sweating
    • Poor balance and dizzy spells
    • Numb patches, clumsiness
    • Tendency to pick up infections
    • Many other symptoms.

Toxic chemicals also accelerate the normal ageing process

This means that diseases which one might expect in patients in their eighties one sees in patients in their fifties and sixties. These diseases include:

  • Degenerative conditions such as Parkinson’s disease, osteoporosis, heart disease and dementia.
  • Genetic and DNA damage causing cancer (and of course birth defects).
  • Immune disruption - this can cause allergies (to foods, inhalants and chemicals), tendency to acquire infections and difficulty getting rid of infections, autoimmunity.

Making a diagnosis of chemical poisoning

(which includes organophosphates, volatile organic compounds, heavy metals, silicones and noxious gases)

Making the diagnosis is all about recognising the clinical picture as above. At the moment there is no single test which will diagnose acute chemical poisoning. This is because the chemicals get into the body, do damage, and are then distributed throughout the body into fatty departments or are excreted. The problem here is that many tests are done on blood levels. This does not reflect the total toxicity outside the blood. This means that by the time a sufferer gets to see a doctor the chemicals are in such low levels in the blood they are not detectable by conventional tests and only the damage remains.

These chemicals are often highly toxic. Every bodily system can be adversely affected by toxic chemicals, therefore sufferers present with a multiplicity of symptoms. These symptoms singly may be ignored or coped with. It is when they come together and are so persistent, that sufferers present to their doctors.

When sufferers come, they may not arrive with a list of all their symptoms, just those symptoms which they believe might be serious. Many sufferers present with chest pain or headaches suspecting heart problems or a brain tumour. They have to be asked specifically for details of other symptoms, or the diagnosis will be missed. Toxic chemical poisoning is a clinical diagnosis made on the basis of past medical history, symptoms, signs and investigations.

Past Medical History

Often there is no serious illness in the past. However when asked, many sufferers will give a history of reactions to other chemicals such as air fresheners, cigarette smoke, perfumes or whatever. Some people may give a similar history of symptoms, following previous flights in aeroplanes, such as headaches, muscle aches, chest pains and nausea.

These symptoms of acute chemical poisoning also occur in sick building syndrome, sheep dip ‘flu, 9/11 syndrome (firemen being poisoned by toxic fumes), Gulf War syndrome, chronic carbon monoxide/hydrocarbon fume poisoning, Aerotoxic pilots, fumes from toxic waste sites and industrial pollution, photographic and printing industry, painting and carpet industry as well as mercury from dental amalgam and so on.

Clinical signs

Standard medical examinations often reveal no clinical signs of disease and the sufferer looks well. Indeed, his looks belie his feelings. These patients feel terrible but look reasonable. One has to rely on the above clinical picture and tests to support the diagnosis. It is a combination of the clinical history plus positive tests which make the diagnosis.

Laboratory Investigations

Also see CFS - Tests to investigate CFS

Chemicals get into the body, cause damage and are then excreted. Conventional medical tests are not sufficiently sensitive to identify these chemicals and pick up the widespread and subtle damage which results from them. Sensitive tests have to be done, most of which are not routinely available and certainly not on the NHS. So many sufferers get the standard “work up” of medical tests which are either inappropriate, or overlook minor abnormalities. For example:

  • Full blood count – usually normal – (there may be a low white cell count)
  • Urea and electrolytes – usually normal
  • Liver function tests – usually normal. There may be slightly raised liver enzymes (often ignored) or a slightly raised bilirubin, suggesting Gilbert’s syndrome.
  • Muscle enzymes – sometimes these are slightly raised
  • Hormone tests – usually interpreted as normal, but actually often show low normal levels
  • X-rays – all normal
  • ECGs – usually normal
  • Nerve conduction studies of the motor and sensory nerves – usually normal. Abnormalities may be found if tests are done within 2 years of the most recent exposure to organophosphates.
  • MRI scan of the brain – often said to be normal

Most chemically poisoned sufferers get this standard battery of tests and are told that there is nothing wrong with them. However, there are abnormalities which would be picked up by the following tests:

  • Finding the toxic chemical - this can be done with fat biopsies to identify pesticides and volatile organic substances.
  • Mitochondrial Testing via AONM
  • Heavy metals (including mercury) can be detected by measuring blood toxic metals or analysing urine - see Comprehensive Urine element Profile
  • Immune function tests – most of these are research only tests, but, if available, look for low levels of natural killer cells, low levels of B cells, abnormal T suppressor/helper lymphocyte ratios, raised C reactive protein and hypogammaglobulinaemia. ANCA, TNF and interleukin 6 may also be abnormal.
  • Sensitive tests of liver function (glutathione S transferase, red cell glutathione), and tests of the liver’s ability to detoxify (caffeine, paracetamol loading) – often abnormal.
  • Hormonal studies suggest a suppression of the pituitary gland with borderline underactivity of the thyroid (hypothyroidism), mild Addison’s disease. Tested for by doing Adrenal stress profile - salivary, inappropriate ADH secretion, poor melatonin levels resulting in sleep problems, low levels of testosterone etc. The thyroid abnormality is interesting, classically with low TSH and low T4 (in the lowest 20% of the “normal” range). Thyroxine can be very helpful. See Thyroid profile: free T3, free T4 and TSH
  • Osteoporosis – bone density scan at the wrist, hip and spine is mandatory. All people with significant exposure to chemicals should have this investigations. Urine tests may show abnormal levels of metabolites of bone namely deoxypyridinoline (Dpd) and N-telopeptides (NTx) indicating faulty bone metabolism. See Osteoporosis - practical nutritional considerations
  • Psychometric testing – this often shows severe impairment of memory, information processing, learning, concentration etc. This is not easy to get on the NHS but should be demanded – available via consultant neurologists. It should be possible for your GP to refer you to a neurologist because you are suspected to be suffering from a “sub-cortical dementia”. The neurologist has to be asked to refer you on for psychometric testing. This may take several hours to do (if it doesn’t you are not getting the right test!). These tests are an objective assessment of brain function and can be very helpful for getting street credibility (with your GP – there is often a dramatic change of attitude when it is discovered there is something really the matter!) and for getting benefits (as you are suffering from a pre-senile dementia). Indeed Doctor Sarah McKenzie Ross (please see Dr Sarah McKenzie Ross's website is the most experienced neuro-psychologist in this field and she has identified a pattern of brain damage that is particular to chemical poisoning and different from say dementia or depression.
  • Nerve conduction studies of the autonomic nervous system – Drs Jamal and Julu conducted a Clinical Evaluation of a Sample of Participants in the SHAPE Survey of Heath and Pesticides Exposure, using nerve conduction techniques. Their report can be located here:

Clinical Evaluation of a Sample of Participants in the SHAPE Survey of Heath and Pesticides Exposure, 2007

The autonomic nervous system controls automatic functions such as temperature, sweating, blood pressure, heart and respiratory rate, gut function etc. Abnormalities are commonly found in OP poisoned sufferers and are persistent.

  • Brain scans to demonstrate function (such as SPECT scanning) may show poor perfusion of particular areas of the brain. Most of this work has been done on Gulf War veterans who were similarly poisoned.
  • Trace elements levels – often deficiencies of magnesium and selenium found.
  • Vitamin deficiencies – particularly of the B vitamins – in fact, this is so common that I do not bother to do tests, but use multivitamins routinely.
  • Antibodies to brain proteins (cytoskeletal antibodies) sometimes raised (test not available in UK).
  • Conduction abnormalities in the heart – arrange 24 hour ECG monitoring for symptoms such as chest pain or palpitations (needs referral to cardiologist).

Treatment – the environmental approach

The priority is to recognise the illness and stop further exposure to toxic chemicals. Not all people are equally susceptible to the toxic effects of chemicals – those that get symptoms are more susceptible and need to be doubly careful to avoid further exposure. See Chemical poisons and toxins for a list of common toxins - it is not a case of avoiding the chemical which initially poisoned you, but all the others as well!

  • Chronic fatigue syndrome - see the Category section on fatigue to the left panel. In the short, medium and sometimes long term the commonest problem is a chronic fatigue syndrome. This is just a symptom and the name of the game is to identify and treat the underlying causes. Please see CFS/ME - my book Diagnosis and Treatment of Chronic Fatigue Syndrome and Myalgic Encephalitis. It is vital to go through this step by step and address all the issues. Do not be tempted to cherry pick the easy things or you will slow your recovery. In particular the diet – dietary changes are the most difficult to make and people often leave these till last whereas actually they should be done first.
  • Acceleration of the normal aging process See Anti-ageing - Slow the Ageing Process. The mechanism by which chemicals cause damage is to interfere at a fundamental level with biochemical processes and in effect accelerate the normal ageing process. This is what makes these victims of chemical poisoning difficult to detect by a discrete syndrome – sufferers get normal diseases suffered by normal people but before their time. So for example, the Gulf War veterans have a greatly increased risk of cancer, heart disease and degenerative conditions like osteoporosis, arthritis, prion disorders such as Alzheimer’s disease, Parkinson’s disease and motor neurone disease and so on, none of which constitutes a recognisable and different syndrome but is all symptomatic of an accelerated ageing process.

What can you expect from your GP?

The problem with GPs is that they are not trained to look for toxicological (poisoning) as a cause of illness. You may be referred to the Poison’s Units (now called Medical Toxicology Units). The Poison’s units have not made a single diagnosis of chronic organophosphate poisoning in the ten year period to 2010 (data available from 2000 to 2010). I suspect because funding for the Poison’s Units comes, in part, from the chemical companies. This is an issue I have written about in the Journal of Nutritional and Environmental Medicine, which the Poison’s Units have failed to refute.

You can expect your GP to do a series of blood tests and tell you there is nothing abnormal and therefore nothing wrong. The next step might be referral to a neurologist who again will trot out the party line – chronic chemical poisoning does not exist. The next port of call is usually the psychiatrists who do not have a “toxicological” diagnostic pigeon hole and will squeeze you into the next nearest fit, ie chronic depression. The treatment of this, namely anti-depressants, will make the poor sufferer worse, he will refuse to take them and be discharged as an unco-operative patient. The chemically poisoned person is left to sort out his life as best as he can and usually ends up with declining health.

Fortunately most chemically poisoned people are intelligent and realise the above state of affairs. But the lack of street credibility and help from Government Agencies make this illness a social and financial disaster area.

The carcinogenic potential of low-dose exposures to chemical mixtures in the environment

A major new review entitled "Assessing the carcinogenic potential of low-dose exposures to chemical mixtures in the environment: the challenge ahead" has recently (January 31 2015) been published in Carcinogenesis, 2015, Vol. 36, Supplement 1, S254–S296. There is a very impressive array of authors and academic institutions involved in this review and a total of 508 papers are referenced. The Abstract of this paper states that:

"Lifestyle factors are responsible for a considerable portion of cancer incidence worldwide, but credible estimates from the World Health Organization and the International Agency for Research on Cancer (IARC) suggest that the fraction of cancers attributable to toxic environmental exposures is between 7% and 19%. To explore the hypothesis that low-dose exposures to mixtures of chemicals in the environment may be combining to contribute to environmental carcinogenesis, we reviewed 11 hallmark phenotypes of cancer, multiple priority target sites for disruption in each area and prototypical chemical disruptors for all targets, this included dose-response characterizations, evidence of low-dose effects and cross-hallmark effects for all targets and chemicals. In total, 85 examples of chemicals were reviewed for actions on key pathways/ mechanisms related to carcinogenesis. Only 15% (13/85) were found to have evidence of a dose-response threshold, whereas 59% (50/85) exerted low-dose effects. No dose-response information was found for the remaining 26% (22/85). Our analysis suggests that the cumulative effects of individual (non-carcinogenic) chemicals acting on different pathways, and a variety of related systems, organs, tissues and cells could plausibly conspire to produce carcinogenic synergies. Additional basic research on carcinogenesis and research focused on low-dose effects of chemical mixtures needs to be rigorously pursued before the merits of this hypothesis can be further advanced. However, the structure of the World Health Organization International Programme on Chemical Safety ‘Mode of Action’ framework should be revisited as it has inherent weaknesses that are not fully aligned with our current understanding of cancer biology."

The complete paper can be accessed and downloaded here:

Assessing the carcinogenic potential of low-dose exposures to chemical mixtures in the environment: the challenge ahead

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Quoted from the back cover:

"Chemical Exposures: Low Levels and High Stakes" explains how day-to-day variations in chemical exposure may cause unusual and seemingly unpredictable symptoms, including many that have been termed psychosomatic in the past. It describes how everyday, low-level chemical exposures may cause fatigue, memory impairment, headaches, mood changes, breathing difficulties, digestive problems, and a host of chronic unexplained illnesses including chronic fatigue syndrome, Gulf War syndrome, and sick building syndrome. The authors are the first writers to clearly describe and document the process of adaptation, a concept that provides a rational and scientific basis for understanding these symptoms. In the Second Edition of this professionally acclaimed work, the authors offer evidence for an emerging new theory of disease-toxicant-induced loss of tolerance-which may have far-reaching implications for medicine, public health, and environmental policy. Based on a report commissioned by the New Jersey Department of Health that won the World Health Organizations Macedo Award, Chemical Exposures is the most comprehensive book ever written on sensitivity to low level chemical exposure and the many health effects associated with it. This work clarifies the nature of chemical sensitivity, shows how it differs from traditional allergies and toxicity, and suggests how federal and state governments can help those who are affected. The book identifies four major groups of people with hypersensitivity to low levels of chemicals: occupants of tight buildings, industrial workers who handle chemicals, residents of communities exposed to toxic chemicals, and individuals with random and unique exposures to various chemicals. The fact that similar symptoms are being reported by members of these demographically diverse groups not only points to a serious problem, it may also contribute to a better understanding of chemical sensitivity."

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