Flavorings-Related Lung Disease

Flavorings-Related Lung Disease

Bronchiolitis obliterans or Constrictive bronchiolitis, one form of which is called Popcorn Workers' Lung or popcorn lung, is a rare and life-threatening form of non-reversible obstructive lung disease in which the bronchioles (small airway branches) are plugged with granulation tissue. Bronchiolitis obliterans is also sometimes used to refer to a particularly severe form of pediatric bronchiolitis caused by adenovirus.

Bronchiolitis means inflammation of the bronchioles and Obliterans refers to the fact that the inflammation of the bronchioles partially obliterates the airways.[1]

Classification
There is no consensus classification scheme for bronchiolitis subtypes. One author[who?] describes four specific subtypes as follows:

cellular bronchiolitis
respiratory bronchiolitis
bronchiolitis obliterans
bronchiolitis obliterans with intraluminal polyps (proliferative bronchiolitis obliterans).

Etiology
Bronchiolitis obliterans has many possible causes, including: collagen vascular disease, transplant rejection in organ transplant patients, viral infection (respiratory syncytial virus, adenovirus, HIV, cytomegalovirus), Stevens-Johnson Syndrome, Pneumocystis pneumonia, drug reaction, aspiration and complications of prematurity (bronchopulmonary dysplasia), and exposure to toxic fumes, including: diacetyl, sulfur dioxide, nitrogen dioxide, ammonia, chlorine, thionyl chloride, methyl isocyanate, hydrogen fluoride, hydrogen bromide, hydrogen chloride, hydrogen sulfide, phosgene, polyamide-amine dyes, mustard gas and ozone. Additionally, the disorder may be idiopathic (without known cause).[1][2][5]

Presentation
Bronchiolitis obliterans is a lung disease characterized by fixed airway obstruction. Inflammation and scarring occur in the airways of the lung, resulting in severe shortness of breath and dry cough.

FEV1 (forced expiratory volume in 1 second) should be above 80% of predicted values to be considered normal. Bronchiolitis obliterans reduces this to 16% to 21%.

Symptoms include:

dry cough
shortness of breath
wheezing

The symptoms can start gradually, or severe symptoms can occur suddenly.[3]

Diagnosis

Bronchiolitis obliterans is often misdiagnosed as asthma, bronchitis, emphysema, or pneumonia

Diagnosis may include the following tests:

Chest X-rays tests.
Diffusing capacity of the lung (DLCO) tests are usually normal.
Spirometry tests show fixed airway obstructions and sometimes restriction.
Lung volume tests may show hyperinflation (excessive air in lungs caused by air trapping).
High-resolution computerized tomography scans of the chest at full inspiration and expiration may reveal heterogeneous air trapping on the expiratory view as well as haziness and thickened airway walls.
Lung biopsies may reveal evidence of constrictive bronchiolitis obliterans (i.e., severe narrowing or complete obstruction of the small airways). An open lung biopsy, such as by thoracoscopy, is more likely to be diagnostic than a transbronchial biopsy. Special processing, staining, and review of multiple tissue sections may be necessary for a diagnosis.[4]

Prognosis/treatment
This disease is irreversible and severe cases often require a lung transplant. Evaluation of interventions to prevent bronchiolitis obliterans relies on early detection of abnormal spirometry results or unusual decreases in repeated measurements.

Industrial inhalants
There are many industrial inhalants that are known to cause various types of bronchiolitis, including bronchiolitis obliterans. [5]

Industrial workers who have presented with bronchiolitis:

nylon-flock workers [6]
workers who spray prints onto textiles with polyamide-amine dyes [6]
battery workers who are exposed to thionyl chloride fumes
workers at plants that use or manufacture flavorings, e.g. diacetyl butter-like flavoring [3][6][7]

Popcorn Workers Lung

In rare instances, bronchiolitis obliterans may be caused by inhalation of airborne diacetyl — a chemical used to produce the butter-like flavoring[2] in many foods such as candy, microwave popcorn and wines. This first came to public attention when eight former employees of the Gilster-Mary Lee popcorn plant in Jasper, Missouri, developed bronchiolitis obliterans. In 2000, the Missouri Department of Health called in NIOSH to make a determination of the cause, and to recommend safety measures. After surveying the plant and each patient's medical history, NIOSH recommended respiratory protection for all workers in microwave popcorn production. Due to this event, bronchiolitis obliterans began to be referred to in the popular media as "Popcorn Lung" or "Popcorn Workers Lung".[4][8][9]

One heavy consumer of microwaved popcorn has been diagnosed with this disease, which is the first known case involving a consumer.[13]

On 27 August 2007, Weaver Popcorn Company of Indianapolis promised to replace the diacetyl butter flavor ingredient in Pop Weaver popcorn with another flavoring.[14]
In September 2007, Dr. Cecile Rose, pulmonary specialist at Denver's National Jewish Medical and Research Center, warned federal agencies that consumers, not just flavoring or food factory workers, may be in danger of contracting bronchiolitis obliterans. David Michaels, of the George Washington University School of Public Health, first published Rose's warning letter on his blog.[10][11][12]

On 4 September 2007, the Flavor and Extract Manufacturers recommended reduction of diacetyl in butter-like flavorings. The next day ConAgra Foods announced that it would soon remove diacetyl from its popcorn products.[15]

On 16 January 2008, it was announced that Wayne Watson, the Denver consumer who developed "popcorn lung" after inhaling microwaved popcorn, was suing the Kroger grocery store chain and its affiliates. In the lawsuit, filed in U.S. District Court, Watson's attorney claimed that the companies "failed to warn that preparing microwave popcorn in a microwave oven as intended and smelling the buttery aroma could expose the consumer to an inhalation hazard and a risk of lung injury."[16]

Diacetyl is approved by the Food and Drug Administration as a safe flavor ingredient, but there is evidence to suggest that inhalation in large amounts is dangerous. There are currently no warnings from federal regulators about diacetyl.

Flavorings-Related Lung Disease
Rotavirus Rocky Mountain Spotted Fever Rift Valley Fever Rickettsial Infections Rhinitis Reye's syndrome Respiratory Syncytial Virus Relapsing Fever Rat-Bite Fever Rare Diseases Ragweed Allergy Radiation Therapy Rabies Fragile X Syndrome Foodborne Illness Food Poisoning � Causes, Symptoms And Treatment Food Irradiation Flavorings-Related Lung Disease Filoviruses Fetal Alcohol Spectrum Disorders Overweight and Obesity Ovarian Cancer Ovarian Cancer Symptoms Orf Virus Oral Cancer Onychomycosis- Fungal Nail Infection	Flavorings-Related Lung Disease Bronchiolitis obliterans or Constrictive bronchiolitis, one form of which is called Popcorn Workers' Lung or popcorn lung, is a rare and life-threatening form of non-reversible obstructive lung disease in which the bronchioles (small airway branches) are plugged with granulation tissue. Bronchiolitis obliterans is also sometimes used to refer to a particularly severe form of pediatric bronchiolitis caused by adenovirus. Bronchiolitis means inflammation of the bronchioles and Obliterans refers to the fact that the inflammation of the bronchioles partially obliterates the airways.[1] Classification There is no consensus classification scheme for bronchiolitis subtypes. One author[who?] describes four specific subtypes as follows: cellular bronchiolitis respiratory bronchiolitis bronchiolitis obliterans bronchiolitis obliterans with intraluminal polyps (proliferative bronchiolitis obliterans). Etiology Bronchiolitis obliterans has many possible causes, including: collagen vascular disease, transplant rejection in organ transplant patients, viral infection (respiratory syncytial virus, adenovirus, HIV, cytomegalovirus), Stevens-Johnson Syndrome, Pneumocystis pneumonia, drug reaction, aspiration and complications of prematurity (bronchopulmonary dysplasia), and exposure to toxic fumes, including: diacetyl, sulfur dioxide, nitrogen dioxide, ammonia, chlorine, thionyl chloride, methyl isocyanate, hydrogen fluoride, hydrogen bromide, hydrogen chloride, hydrogen sulfide, phosgene, polyamide-amine dyes, mustard gas and ozone. Additionally, the disorder may be idiopathic (without known cause).[1][2][5] Presentation Bronchiolitis obliterans is a lung disease characterized by fixed airway obstruction. Inflammation and scarring occur in the airways of the lung, resulting in severe shortness of breath and dry cough. FEV1 (forced expiratory volume in 1 second) should be above 80% of predicted values to be considered normal. Bronchiolitis obliterans reduces this to 16% to 21%. Symptoms include: dry cough shortness of breath wheezing The symptoms can start gradually, or severe symptoms can occur suddenly.[3] Diagnosis Bronchiolitis obliterans is often misdiagnosed as asthma, bronchitis, emphysema, or pneumonia Diagnosis may include the following tests: Chest X-rays tests. Diffusing capacity of the lung (DLCO) tests are usually normal. Spirometry tests show fixed airway obstructions and sometimes restriction. Lung volume tests may show hyperinflation (excessive air in lungs caused by air trapping). High-resolution computerized tomography scans of the chest at full inspiration and expiration may reveal heterogeneous air trapping on the expiratory view as well as haziness and thickened airway walls. Lung biopsies may reveal evidence of constrictive bronchiolitis obliterans (i.e., severe narrowing or complete obstruction of the small airways). An open lung biopsy, such as by thoracoscopy, is more likely to be diagnostic than a transbronchial biopsy. Special processing, staining, and review of multiple tissue sections may be necessary for a diagnosis.[4] Prognosis/treatment This disease is irreversible and severe cases often require a lung transplant. Evaluation of interventions to prevent bronchiolitis obliterans relies on early detection of abnormal spirometry results or unusual decreases in repeated measurements. Industrial inhalants There are many industrial inhalants that are known to cause various types of bronchiolitis, including bronchiolitis obliterans. [5] Industrial workers who have presented with bronchiolitis: nylon-flock workers [6] workers who spray prints onto textiles with polyamide-amine dyes [6] battery workers who are exposed to thionyl chloride fumes workers at plants that use or manufacture flavorings, e.g. diacetyl butter-like flavoring [3][6][7] Popcorn Workers Lung In rare instances, bronchiolitis obliterans may be caused by inhalation of airborne diacetyl — a chemical used to produce the butter-like flavoring[2] in many foods such as candy, microwave popcorn and wines. This first came to public attention when eight former employees of the Gilster-Mary Lee popcorn plant in Jasper, Missouri, developed bronchiolitis obliterans. In 2000, the Missouri Department of Health called in NIOSH to make a determination of the cause, and to recommend safety measures. After surveying the plant and each patient's medical history, NIOSH recommended respiratory protection for all workers in microwave popcorn production. Due to this event, bronchiolitis obliterans began to be referred to in the popular media as "Popcorn Lung" or "Popcorn Workers Lung".[4][8][9] One heavy consumer of microwaved popcorn has been diagnosed with this disease, which is the first known case involving a consumer.[13] On 27 August 2007, Weaver Popcorn Company of Indianapolis promised to replace the diacetyl butter flavor ingredient in Pop Weaver popcorn with another flavoring.[14] In September 2007, Dr. Cecile Rose, pulmonary specialist at Denver's National Jewish Medical and Research Center, warned federal agencies that consumers, not just flavoring or food factory workers, may be in danger of contracting bronchiolitis obliterans. David Michaels, of the George Washington University School of Public Health, first published Rose's warning letter on his blog.[10][11][12] On 4 September 2007, the Flavor and Extract Manufacturers recommended reduction of diacetyl in butter-like flavorings. The next day ConAgra Foods announced that it would soon remove diacetyl from its popcorn products.[15] On 16 January 2008, it was announced that Wayne Watson, the Denver consumer who developed "popcorn lung" after inhaling microwaved popcorn, was suing the Kroger grocery store chain and its affiliates. In the lawsuit, filed in U.S. District Court, Watson's attorney claimed that the companies "failed to warn that preparing microwave popcorn in a microwave oven as intended and smelling the buttery aroma could expose the consumer to an inhalation hazard and a risk of lung injury."[16] Diacetyl is approved by the Food and Drug Administration as a safe flavor ingredient, but there is evidence to suggest that inhalation in large amounts is dangerous. There are currently no warnings from federal regulators about diacetyl.
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