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Thorax,
1979,
34,
767-770
Hypersensitivity
pneumonitis
in
a
technician
using
Pauli's
reagent
W
V
EVANS
AND
A
SEATON
From
Llandough
Hospital,
Penarth,
South
Glamorgan,
UK
ABSTRAcr
A
technician
working
in
a
medical
laboratory
used
a
spray
of
sodium
diazobenzenesulphate
(Pauli's
reagent)
in
chromatography.
She
developed
a
respiratory
illness
with
both
airways
obstruction
and
radiographic
and
physiological
evidence
of
interstitial
pneumonitis.
An
occupational
type
of
challenge
test
was
followed
by
both
immediate
and
late
bronchial
obstructive
responses,
by
a
fall
in
arterial
oxygen
tension,
and
by
increased
radiographic
shadowing.
Histology
of
a
lung
biopsy
specimen,
a
low
serum
C3,
and
a
positive
skin
prick
test
to
the
reagent
suggested
that
the
illness
was
a
hypersensitivity
reaction
to
Pauli's
reagent.
Pauli's
reagent
is
the
sodium
salt
of
diazobenzene-
sulphonic
acid,
which
is
produced
by
the
reaction
between
cold
sulphanilic
acid,
hydrochloric
acid,
and
sodium
nitrite.
The
sodium
salt
of
the
rela-
tively
unstable
diazobenzenesulphonic
acid
is
formed
by
adding
sodium
carbonate.
The
reagent
is
widely
used
in
laboratories
throughout
the
world
for
identifying
aryl
amines
and
phenols.
This
patient
was
using
the
reagent
as
a
spray
in
chro-
matography
work.
Case
history
A
33-year-old
medical
school
laboratory
technician
first
developed
retrosternal
discomfort
in
1969.
She
was
released
from
work
for
a
week,
prescribed
an
antibiotic,
and
her
symptoms
disappeared.
In
1974
she
developed
further
chest
discomfort
associated
with
a
non-productive
cough.
Her
symptoms
gradually
progressed,
and
by
the
summer
of
1977
she
had
become
breathless
on
moderate
exertion.
Eventually
she
related
her
cough
and
dyspnoea
to
the
chemicals,
and
in
particular
the
spray,
used
at
her
work.
At
this
time
she
was
referred
for
further
investigation.
Detailed
inquiry
into
her
work
showed
regular,
twice
weekly,
use
of
Pauli's
reagent
(fig
1).
She
mixed
the
cold
sulphanilic
and
hydrochloric
acids
with
sodium
nitrite
on
an
open
bench,
then
placed
the
mixture
in
a
refrigerator
for
ten
minutes
before
adding
the
sodium
carbonate.
The
reagent
was
immediately
sprayed
on
to
chromatography
NH3+
t+
HC1
SO3
Sulp.haniIic
acid
N-N
+
NaNO2
+
Na2CO3
-OJ
S03
Na
Sodium
diazobenzenesulphonate
(Paulis
reagent
)
Fig
1
Reaction
producing
Pauli's
reagent.
plates
in
a
fume
cupboard.
A
paper
face
mask
was
used
throughout
this
procedure,
which
she
per-
formed
for
two
years
before
she
developed
any
symptoms.
In
1969
her
first
attack
of
retrosternal
discomfort
followed
a
period
of
increased
exposure
to
the
reagent,
when
the
fume
cupboard
was
found
to
be
defective.
Nitroaniline
was
substituted
for
the
sodium
nitrite
from
1972
until
1974,
and
during
this
period
she
was
symptom
free;
there-
after
the
original
process
was
used,
and
her
symptoms
returned.
There
was
no
relevant
past
medical
history.
She
had
not
been
exposed
to
birds,
and
did
not
smoke
cigarettes.
Physical
examination
was
normal.
The
chest
radiograph,
however,
showed
a
fine
nodular
shadowing
at
both
lung
bases.
Full
blood
count
was
normal
without
eosinophilia.
The
sedimenta-
tion
rate
was
37
mm/h
Westergren.
Liver
function
test
results
were
normal
and
the
DAT
and
ANF
were
negative.
Protein
electro-
phoresis
showed
an
increase
in
gammaglobulin.
767
group.bmj.com on July 10, 2011 - Published by thorax.bmj.comDownloaded from
W
V
Evans
and
A
Seaton
Precipitating
antibodies
to
Aspergillus
fumigatus,
A
niger,
Micropolyspora
faeni,
as
well
as
budgeri-
gar
and
pigeon
serum
and
droppings
were
absent.
Sputum
did
not
contain
allergic
stigmata
(Saner-
kin
and
Evans,
1965).
Skin
prick
tests
to
house
dust
extract,
Dermatophagoides
pteronyssinus
and
mixed
grass
pollen
were
positive
with
an
immediate
weal
and
flare
response.
Lung
function
test
results
showed
a
restrictive
pattern
with
a
reduced
carbon
monoxide
transfer
factor
(table).
To
make
a
diagnosis
it
was
decided
to
perform
an
occupational-type
challenge
test
and
a
drill
biopsy.
The
patient
gave
consent
to
these
pro-
cedures
after
full
explanation
and
was
challenged
with
the
chemicals
and
spray,
following
the
same
procedure
as
that
used
at
her
work.
Peak
expir-
atory
flow
rates
were
monitored
at
15-minute
intervals
for
the
first
hour,
and
hourly
thereafter
(fig
2).
Lung
volumes
and
transfer
factor
measure-
ments
were
repeated
after
four
hours
(table).
There
was
both
an
immediate
and
late
(eight
hours)
fall
in
PEFR,
and
17
hours
after
the
challenge
her
sleep
was
disturbed
by
dyspnoea.
Examination
of
her
chest
showed
widespread
in-
spiratory
crackles,
and
a
chest
radiograph
(fig
3)
showed
an
increase
in
the
nodular
shadowing.
The
PEFR
during
this
episode
was
240
I/min,
a
value
lower
than
any
previous
measurement.
She
was
hypoxaemic
with
a
Pao2
7-5
kPa
(56
mmHg),
Paco2
4-5
kPa
(34
mmHg),
and
pH
7.42.
Dyspnoea
was
relieved
by
treatment
with
40%
oxygen
via
a
Ventimask.
A
percutaneous
drill
biopsy
was
performed
24
hours
after
the
challenge-the
histology
(fig
3)
showed
an
interstitial
mononuclear
cell
infiltrate
with
lymphoid
foci,
without
germinal
centres,
and
prominence
of
type
2
alveolar
lining
cells
some
of
which
were
desquamated.
No
epithelioid
cell
granulomas
were
seen,
but
a
very
occasional
giant
cell
was
present.
There
was
a
slight
increase
in
collagen
in
intra-alveolar
septa,
but
there
was
no
PEFR
480
440
400
360'
320
280
240
0~
0/.
0~
*..//
8
10
12
2
4
6
8
10
12
3
a
m.
p.m.
O.m.
Challenge
-Time--4-_
Sleep
disturbed
24
hrs
Drill
lung
biopsy
7
14
Days
Fig
2
Peak
expiratory
flow
rates
following
occupational
type
challenge
test
to
Pauli's
reagent.
Fig
3
Chest
radiograph
17
hours
after
challenge
to
Pauli's
reagent
showing
bilateral
diffuse
small
nodular
opacities.
Lung
function
tests
before
and
after
challenge
to
Pauli's
reagent
PEFR
FEV,
FVC
FEV/FVC
%
VC
RV
TLC
R
V/TI,C
%
Transfer
factor
(I/min)
(1)
(1)
(1)
(1)
(1)
((mmol/min/kPa)
Predictednormal
415
2-65
3-11
85
3-11
1-52
4-88
31
8-7
11.5.77
420
2-21
2-21
100
18.5.77pre-challenge
460
2-16
2-16
100
1-54
1-56
3-10
50%
4-0
18.5.774hpost-challenge
400
1-74
1-75
99
1-43
1-67 3
1
54%
3-8
25.5.77
440
2-00
2-00
100
1-76
1-60
3-36
48%
4-9
1.6.77
475
2-4
2-65
91
2-31
1-41
3-72
38%
5-1
13.7.77
490
2-6
2-75
95
2-42
1-2
3-62
33%
5-5
13.9.77
495
2-9
3-1
94
3-1
1-29
4-29
29%
6-3
10.1.78
500
2-75
3-14
88
3-1
1-13
4-21
27%
6-7
18-7-78
520
2-75
3-00
92
3-19
1-46
4-65
31%
7-4
Conversion
mmol/min/kPa
x
2-98
=ml/min/mm
Hg.
768
group.bmj.com on July 10, 2011 - Published by thorax.bmj.comDownloaded from
Hypersensitivity
pneumonitis
in
a
technician
using
Pauli's
reagent
F.4~~K
*
::~~~~~~~~~~~~~~~~~~~~~~~~~.
:.:.
'E;::
..
.W
:>m
1:
.........
Fig
4
Drill
biopsy
specimen
of
lung
tissue
showing
lym
phocytic
infiltration
of
thickened
alveolar
walls
and
occasional
desquamated
type
2
alveolar
cells.
Haematoxylin
and
eosin
X
120
(original
magnification).
evidence
of
emphysema
or
obliterative
bronchi-
olitis.
A
peroxidase
preparation
showed
fine
immunoglobulin
deposits
within
the
alveolar
walls.
After
the
challenge
serum
complement
concen-
trations
were
CH50,
25
units
(normal
range
26-35
units),
C3
420
mg/l
(700-1600
mg/l),
and
factor
B
200
mg/l
(100-400
mg/l).
Total
levels
of
IgG,
IgA,
and
IgM
were
normal
but
IgE
was
not
assayed.
Skin
prick
tests
using
control
solution,
sodium
nitrite,
sulphanilic
acid
1%,
and
the
diazo
reagent
were
performed
on
two
normal
subjects
and
the
patient.
All
were
negative
apart
from
the
diazo
reagent
skin
test
in
the
patient,
which
produced
an
immediate
5
mm
weal
and
flare.
There
was
little
local
itching
and
no
late
or
dual
response.
The
weal
lasted
for
12
hours
and
disappeared
with-
out
leaving
any
scar
or
induration.
After
the
challenge
test
the
patient
was
treated
with
prednisone
40
mg
daily
for
a
week,
and
then
in
reducing
dosages
for
a
month
when
it
was
with-
drawn.
The
chest
radiograph
cleared
after
five
days.
Her
lung
function
tests
gradually
improved
and
after
several
months
returned
to
normal
though
the
improvement
in
the
transfer
factor
was
slow
(table).
She
has
had
no
further
exposure
to
Pauli's
reagent,
and
for
the
past
nine
months
has
been
entirely
symptom
free.
Discussion
Pauli's
reagent
is
widely
used
in
laboratories
as
a
dye
in
chromatography
and
other
work
to
detect
aryl
amines
and
phenols.
Despite
this
regular
usage
it
has
not
previously
been
reported
as
producing
pulmonary
damage,
and
the
precise
mechanism
in
this
patient
remains
unclear.
Benzenesulphonic
acid
is
chemically
related
to
the
sulphonamide
nucleus,
and
these
drugs
are
well
known
to
pro-
duce
pulmonary
eosinophilia
(Fiegenberg
et
al,
1967;
Feinmann,
1975).
There
have
also
been
re-
ports
linking
the
sulphonamides
with
both
poly-
arteritis
nodosa
(Symmers,
1958)
and
a
systemic
lupus-like
syndrome
(Lee
and
Siegel,
1968),
and
more
recently
Thomas
et
al
(1974)
described
a
combined
bronchial
and
alveolar
response
to
the
sulphonamide
component
in
salazopyrine.
Azo
dyes
have
also
been
responsible
for
producing
sen-
sitisation
reactions
in
both
allergic
and
non-allergic
subjects
(Ferris
et
al,
1977;
Alanko
et
al,
1978;
Neuman
et
al,
1978).
In
fact
azo
compounds
have
for
a
long
time
been
used
for
their
immunogenic
properties
in
animal
research
work.
In
this
patient
hypersensitivity
to
the
reagent,
as
opposed
to
a
direct
toxic
effect,
was
suggested
by
the
fact
that
colleagues
working
in
the
same
en-
vironment
failed
to
suffer
from
any
adverse
effects
after
exposure
to
the
sprays,
and had
normal
lung
function
tests.
The
histological
findings
of
im-
munoglobulin
deposits
within
the
alveolar
walls,
the
positive
bronchial
challenge,
and
the
positive
skin
prick
test
indicate
an
immunologically
medi-
ated
hypersensitivity
mechanism.
The
low
C3
component
of
the
complement
system
with
normal
factor
B
suggest
activation
of
the
classical
path-
way,
as
found
in
antigen-antibody
reactions.
Although
nitrous
acid
is
produced
as
an
inter-
mediary
in
the
formation
of
Pauli's
reagent,
there
was
no
histological
evidence
of
the
emphysema
or
obliterative
bronchiolitis
that
follows
repeated
ex-
posure
to
nitrous
fumes
(McAdams,
1955;
Beck-
lake
et
al,
1957;
Jones
et
al,
1973).
The
skin
test
response
was
reaginic
in
type
such
as
those
seen
in
classical
IgE
and
IgG
short-term
sensitisation
(IgGsts)
mediated
reactions
(Parish,
1970;
Bryant
et
al,
1973;
Dolovich
et
al,
1973).
Interestingly
this
patient
had
both
an
immediate
and
late
reaction.
She
is
atopic
and
as
such
the
immediate
reaction
was
more
likely
to
have
been
mediated
via
IgE
rather
than
IgGsts.
The
late
reaction
and
low
C3,
however,
indicate
that
IgG
was
involved
in
part
of
her
response.
Probably
the
increased
exposure
to
the
reagent
when
the
fume
cupboard
was
defective
in
1969
led
to
sensitisation
and
the
production
of
IgE
antibody,
and
that
fur-
ther
low
dose
but
regular
exposure
resulted
in
the
production
of
IgG
antibody
and
thus
the
alveolitis.
The
fact
that
this
reaction
has
not
previously
been
reported
in
a
process
so
commonly
used
is
prob-
ably
a
reflection
of
her
atopic
state
with
its
in-
creased
susceptibility
to
sensitisation.
769
group.bmj.com on July 10, 2011 - Published by thorax.bmj.comDownloaded from
W
V
Evans
and
A
Seaton
We
thank
Dr
Roger
Seal
for
reporting
on
the
lung
biopsy
and
Mr
Kelvin
Houston
and
staff
of
the
pulmonary
function
laboratory,
Llandough
Hospital,
for
their
help.
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8
Roxburgh
Place,
Edinburgh.
770
group.bmj.com on July 10, 2011 - Published by thorax.bmj.comDownloaded from
doi: 10.1136/thx.34.6.767
1979 34: 767-770Thorax
W V Evans and A Seaton
reagent.
in a technician using Pauli's
Hypersensitivity pneumonitis
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