Irritant vocal cord dysfunction and occupational bronchial asthma: differential diagnosis in a health care worker

Stefano Tonini, Antonio Dellabianca, Cristina Costa, Andrea Lanfranco, Fabrizio Scafa, Stefano M Candura
International Journal of Occupational Medicine and Environmental Health 2009, 22 (4): 401-6

OBJECTIVES: Vocal cord dysfunction (VCD) is an uncommon respiratory disease characterized by the paradoxical adduction of vocal cords during inspiration, that may mimic bronchial asthma. The pathogenesis of VCD has not been clearly defined but it is possible to recognize non-psychologic and psychologic causes. The majority of patients are female but, interestingly, a high incidence of VCD has been documented in health care workers. A misdiagnosis with asthma leads to hospitalisation, unnecessary use of systemic steroids with related adverse effects, and sometimes tracheostomy and intubation. In a subset of VCD patients, the disease can be attributed to occupational or environmental exposure to inhaled irritants.

MATERIALS AND METHODS: We report the case of a 45-year-old woman, working as a nurse, who complained of wheezing, cough, dyspnoea related to inhalation of irritating agents (isopropylic alcohol, formaldehyde, peracetic acid). She underwent chest radiography, pulmonary function assessment both in the presence and in the absence of symptoms, bronchial provocation with methacholine and bronchodilation test with salbutamol to recognize asthma's features, allergy evaluation by skin prick tests and patch tests and video-laryngoscopy.

RESULTS: VCD diagnosis was made on the basis of video-laryngoscopy, that visualized the paradoxical motion of the vocal cords during symptoms, in the absence of other pathologic processes.

CONCLUSIONS: This case fulfils the proposed criteria for the diagnosis of irritant VCD (IVCD). This is the first report of VCD onset following exposure to several irritants: formaldehyde, glutaraldehyde, sopropylic alcohol, peracetic acid-hydrogen peroxide mixture. These substances are used as cleaning and antiseptic agents in healthcare settings and some ones can also be found in many indoor environments. A correct diagnosis is important both to give the appropriate treatment and for medical legal implications.

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