1. Metal Fume Fever (MFF) By: m.mohammadi 86/11/17

2. Introduction An acute, self-limiting, flu-like inhalational fever attributed to exposure to a number of metal oxide fumes An acute, self-limiting, flu-like inhalational fever attributed to exposure to a number of metal oxide fumes Classically associated with zinc oxide (ZnO) fume exposure from welding, cutting or brazing on galvanized steel Classically associated with zinc oxide (ZnO) fume exposure from welding, cutting or brazing on galvanized steel

3. Also in High temperature zinc coating process & metal pouring in brass foundry Also in High temperature zinc coating process & metal pouring in brass foundry A few cases in association with grinding, buffing or sanding of surfaces coated by zinc A few cases in association with grinding, buffing or sanding of surfaces coated by zinc Mg &copper oxide fumes are more rarely causative agent Mg &copper oxide fumes are more rarely causative agent

4. Other names Brass founder ague Brass founder ague Brass chills Brass chills Zinc fever or chills Zinc fever or chills Spelter´s fever Spelter´s fever Metal shake Metal shake brazier´s disease brazier´s disease Foundry fever Foundry fever

5. Mechanism Exact mechanism is unknown Exact mechanism is unknown Direct toxic effect on respiratory tract,chemotaxis of leukocytes & macrophages & release of pyrogens & chemotactic factors (↑PMN in BAL lavage 22h after exposure &TNF-α,IL-6,8 ) Direct toxic effect on respiratory tract,chemotaxis of leukocytes & macrophages & release of pyrogens & chemotactic factors (↑PMN in BAL lavage 22h after exposure &TNF-α,IL-6,8 ) Cause a mixed cellular infiltrate & modify lung proteins or cause release of foreign proteins Cause a mixed cellular infiltrate & modify lung proteins or cause release of foreign proteins A delayed immunologic, hypersensitivity reaction A delayed immunologic, hypersensitivity reaction

6. Exposure level Minimal change in forced expiratory flow observed 1h after a 15-30m exposure to 77mg zn/m ³ as zinc oxide Minimal change in forced expiratory flow observed 1h after a 15-30m exposure to 77mg zn/m ³ as zinc oxide 300-600mg/m ³ from 10m to 3h: shortness of breath, nasal passage irritation, cough, substernal pain, rales of the lung base & ↓VC 300-600mg/m ³ from 10m to 3h: shortness of breath, nasal passage irritation, cough, substernal pain, rales of the lung base & ↓VC Exposure to lower level of zno (acute or chronic) not result in symptoms of MFF Exposure to lower level of zno (acute or chronic) not result in symptoms of MFF No fully manifest until exposure levels reach >75mg/m ³ No fully manifest until exposure levels reach >75mg/m ³ PEL by OSHA :5mg zno fume/m ³ air over an 8h work shift PEL by OSHA :5mg zno fume/m ³ air over an 8h work shift

7. Clinical syndrome of MFF Within 2-10h following inhalational exposure to zinc oxide fumes, workers begin to experience a metallic taste with dryness& soreness in the throat, cough, fever, chill, malaise, headache, dyspnea, myalgia, nausea, vomiting Within 2-10h following inhalational exposure to zinc oxide fumes, workers begin to experience a metallic taste with dryness& soreness in the throat, cough, fever, chill, malaise, headache, dyspnea, myalgia, nausea, vomiting P/E: wheeze and/or rale may be present in acute P/E: wheeze and/or rale may be present in acute phase phase Signs & symptoms peak at 18h & resolve spontaneously within 1-2d Signs & symptoms peak at 18h & resolve spontaneously within 1-2d

8. Clinical syndrome of MFF CBC: elevation of WBC with left shift PFT: decreased FVC&FEV1&Diffusion capacity ABG: Mild hypoxemia CXRay: bilateral diffuse infiltrative pulmonary lesions

9. Diagnosis Clinical suspicion Clinical suspicion Clinical findings Clinical findings Rapid resolution Rapid resolution Occupational history Occupational history Zinc level in blood & urine not correlate with disease severity Zinc level in blood & urine not correlate with disease severity

10.  Monday morning fever: Rapid adaptation to development of syndrome following repeated metal oxide exposure Rapid adaptation to development of syndrome following repeated metal oxide exposure Worker with a history of recurrent MFF often develop a tolerance to fumes Worker with a history of recurrent MFF often develop a tolerance to fumes Tolerance is transient & only persist through the weekend & then it usually disappears Tolerance is transient & only persist through the weekend & then it usually disappears tolerance occurs because of induction of metallothionein protein synthesis which bind to heavy metals preventing toxic metal accumulation tolerance occurs because of induction of metallothionein protein synthesis which bind to heavy metals preventing toxic metal accumulation  Seasonal variation

11. D.Diagnosis Influenza Influenza Acute bronchitis Acute bronchitis Bacterial pneumonia Bacterial pneumonia HP HP

12. Treatment Supportive including: 1)Fluid2)Antipyretics/analgesics 3)Drinking warm milk

13. prognosis Spontaneous recovery occurs within 24-48h Spontaneous recovery occurs within 24-48h No long term complication are known No long term complication are known

14. Prevention Avoid of exposure Avoid of exposure Awareness of presence of a potential hazard Awareness of presence of a potential hazard Engineering control: local exhaust, general ventilation Engineering control: local exhaust, general ventilation Personal protective equipment :respirators Personal protective equipment :respirators education of workers regarding the features of the syndrome education of workers regarding the features of the syndrome

15. How to avoid the hazard Keep your head out of the fumes Keep your head out of the fumes Do not breathe fumes Do not breathe fumes Use enough ventilation, exhaust at the arc, Use enough ventilation, exhaust at the arc, or both, to keep fumes & gases from your or both, to keep fumes & gases from your breathing zone and the general area. breathing zone and the general area. If adequacy of the ventilation or exhaust is If adequacy of the ventilation or exhaust is uncertain, have your exposure measured uncertain, have your exposure measured and compared to TLV in the MSDS for the galvanized material and compared to TLV in the MSDS for the galvanized material

16. How to avoid the hazard If none of this is adequate or practical, wear If none of this is adequate or practical, wear an approved respirator, air–supplied or an approved respirator, air–supplied or otherwise, that adequately removes the otherwise, that adequately removes the fumes from your breathing zone fumes from your breathing zone

17. Any Questions?