Alteration in serum levels of immunoglobulins in seriously eye-injured long-term following sulfur-mustard exposure.

INTRODUCTION: Sulfur mustard (SM) is a potent toxic agent that cause local and systemic changes in the human body such as dysregulation of the immunological system. This gas affects different organs such as lungs, skin, eyes and the gastrointestinal tract. METHODS: 128 veterans with SM-induced eye injuries were examined and compared to 31 gender- and age-matched healthy controls. Serum levels of IgM, IgE, IgA, IgG, and IgG subclasses were measured using ELISA method. RESULTS: There was no significant difference in IgM level between two groups with abnormal and normal ocular conditions except for those having bulbar conjunctiva-limbal ischemia and bulbar conjunctiva-hyperemia abnormalities. There were not significant difference in IgA, IgE, and IgG levels between two groups with and without ocular problem also between study groups. IgG1 level in some ocular abnormalities were significantly lower than the healthy control groups. IgG2 level in SM-exposed participants with stromal abnormality was higher in the SM-exposed groups without this problem. IgG2 levels in the exposed group with some ocular problems were significantly increased compared with control. IgG3 level in all patients did not reveal any significant changes compared with the controls except the fundus abnormality. IgG4 level was not significantly different between two groups with normal and abnormal ocular conditions. Nonetheless, IgG4 level in the exposed participants with some ocular abnormalities significantly increased compared with the controls. CONCLUSION: The results showed SM exposure could alter immunoglobulins level compared with healthy controls and the changes of IgG2 and IgG1 levels were associated with some ocular problems.

Serum Concentration of Thyroid Hormones Long-Term after Sulfur Mustard Exposure.

BACKGROUND: Despite several reports on the clinical manifestations of sulfur mustard (SM) intoxication, there is no study on serum concentrations of thyroid hormones long-term after SM exposure. In this study, the changes in thyroid functioning parameters 20 yr after SM exposure were evaluated. METHODS: This study is a part of a larger historical cohort study conducted in 2007 following 20 years of the exposure to SM, called Sardasht-Iran cohort study (SICS). We (SICS) comprised an SM-exposed group from Sardasht City, West Azerbaijan Province, Iran (n=169 as hospitalized group and n=203 as non-hospitalized exposed group); and control participants were selected from Rabat, a town near Sardasht (n=126). Peripheral blood samples were taken in fasting state and then the sera were separated. T4, T3, TSH, antithyroglobulin (anti-Tg), and antithyroid peroxidase (anti-TPO) concentrations in the sera were measured by the ELISA method. RESULTS: The mean of T3 concentration was significantly higher in the exposed than control group (0.88 ± 0.26 nmol/L vs 0.8 ± 0.25 nmol/L, P<0.001). The levels of TSH, T4, and T3up were not significantly different between the exposed and control groups. Thyroglobulin level was significantly higher in the exposed non-hospitalized group (56.07 ± 140.22 µg/L vs 17.66 ± 41.49 µg/L, P=0.004), but the level of anti-Tg and anti-TPO showed no significant differences between the two groups. CONCLUSION: More studies are needed on the alterations in thyroid hormones, their gene expressions, and mechanisms involved in SM exposure to clarify the causes of these alterations.

The Association between ocular problems and Serum Testosterone, Prolactin and Thyroglobulin concentrations in Delayed phase of Sulfur Mustard exposure.

BACKGROUND AND OBJECTIVE: Aside from direct toxic effects, Sulfur Mustard (SM) induced serum hormone abnormalities may aggravate ocular complaints, including Ocular Surface Discomfort (OSD) (burning, itching, and redness), dry eye sensation, photophobia, blurred vision, foreign body sensation, and pain. The aim of the current study was to investigate the possible association of ocular complaints with serum hormone concentrations in chronic phase of Sulfur Mustard (SM) exposure. METHODS: As a part of Sardasht Iran Cohort Study (SICS), 372 SM-exposed patients and 128 non-exposed participants were enrolled. Ocular complaints and ocular surface biomicroscopic conditions and serum hormones were compared. RESULTS: The exposed with tearing group had significantly higher mean serum levels of testosterone and prolactin (ng/mL) than controls (5.75 vs. 4.75, P=0.031; 11.71 vs. 8.42, P=0.009). The exposed with OSD group had significantly higher mean serum levels of prolactin than controls (12.48 vs. 6.90, P=0.002). The exposed with photophobia group had significantly higher mean serum levels of testosterone than the matched exposed (6.25 vs. 5.65, P=0.013). The exposed with blurred vision group had significantly higher mean serum levels of Thyroglobulin (Tg) (ng/mL) than the matched exposed (65.73 vs. 32.6, P=0.003). CONCLUSION: Higher mean serum levels of testosterone (in exposed with tearing and photophobia) and prolactin (in exposed with tearing and OSD) may play protective roles against SM effects. Higher mean serum levels of Tg may deteriorate the tear film integrity and optical surface, which causes blurred vision. In the chronic phase of SM toxicity, some ocular surface problems are associated with alterations in the serum concentrations of testosterone, prolactin, and Tg.

Association of Sulfur Mustard-Induced Ocular Problems with Serum and Blood Biochemical Parameters Changes.

BACKGROUND & OBJECTIVE: Many biochemical features of sulfur mustard (SM) intoxication have remained unknown. So far, the direct association between biochemical parameter changes and ocular problems in patients exposed to SM is not evaluated. The current study aimed at evaluating the associations between the ocular findings in patients with SM intoxication and the changes of serum and blood biochemical parameters. METHODS: In the current study, 372 patients exposed to SM and 128 matched controls were compared concerning the association between their ocular problems and biochemical parameters. Ocular problems include photophobia, ocular surface discomfort (OSD), etc. Biochemical parameters include uric acid, creatinine (Cr), hematocrit (HCT), total, direct and indirect bilirubin, high-density lipoproteins (HDL), alanine aminotransferase (ALT), calcium (Ca), fasting blood sugar (FBS), mean corpuscular hemoglobin concentration (MCHC), etc. RESULTS: The SM-exposed group with photophobia, OSD, tearing, blurred vision, abnormal tear status, and slit-lamp findings had significantly higher mean serum and blood levels of uric acid, Cr, HCT, and total and indirect bilirubin than the controls. The SM-exposed group with photophobia, tearing, ocular pain, blurred vision, bulbar conjunctival and limbal abnormalities had significantly higher mean serum and blood levels of HDL, ALT, Ca, FBS, MCHC, and HDL, indirect and total bilirubin, compared to the control group. CONCLUSION: The association of photophobia with uric acid, OSD and tearing with Cr, photophobia with HDL, ocular pain with Ca, and blurred vision with FBS may be explained for their known ocular effects in the SM-exposed subjects. SM-induced biochemical changes may intensify the ocular problems induced by the direct effects of SM.

A clinicopathological approach to sulfur mustard-induced organ complications: a major review.

CONTEXT: Sulfur mustard (SM), with an old manufacturing history still remains as potential threat due to easy production and extensive effects. OBJECTIVES: Increasing studies on SM indicates the interest of researchers to this subject. Almost all human body organs are at risk for complications of SM. This study offers organ-by-organ information on the effects of SM in animals and humans. METHODS: The data sources were literature reviews since 1919 as well as our studies during the Iraq-Iran war. The search items were SM and its all other nomenclatures in relation to, in vivo, in vitro, humans, animals, eye, ocular, ophthalmic, lungs, pulmonary, skin, cutaneous, organs and systemic. Amongst more than 1890 SM-related articles, 257 more relevant clinicopathologic papers were selected for this review. RESULTS: SM induces a vast range of damages in nearly all organs. Acute SM intoxication warrants immediate approach. Among chronic lesions, delayed keratitis and blindness, bronchiolitis obliterans and respiratory distress, skin pruritus, dryness and cancers are the most commonly observed clinical sequelae. CONCLUSION: Ocular involvements in a number of patients progress toward a severe, rapid onset form of keratitis. Progressive deterioration of respiratory tract leads to "mustard lung". Skin problems continue as chronic frustrating pruritus on old scars with susceptibility to skin cancers. Due to the multiple acute and chronic morbidities created by SM exposure, uses of multiple drugs by several routes of administrations are warranted.

Chemokines, MMP-9 and PMN elastase in spontaneous sputum of sulfur mustard exposed civilians: Sardasht-Iran Cohort Study.

Chemokines play an important role in acute and chronic pulmonary diseases. The aim of this study was to evaluate the levels of chemokines, MMP-9, and PMN elastase in spontaneous sputum and serum of patients 20 years after SM exposure. In context of Sardasht-Iran Cohort Study (SICS) 40 male volunteers with a history of SM exposure in June 1987 and complain of excessive sputum were recruited. The volunteers were clinically examined and their history was collected by internists. Sputum and serum levels of IL-8, fractalkine, MCP-1, RANTES, MMP-9, and PMN elastase were measured using ELISA kits (R&D System). Spirometries were performed on all the participants. Sputum level of fractalkine was significantly lower in the hospitalized group (N=16, Median=1.05; IQR=0.41-2.62) than non-hospitalized group (N=18, 4.031; IQR=0.947-8.203) (p=0.042). However, serum levels of fractalkine were higher in the hospitalized group (Mean±SD=2.08±5.09) than in the non-hospitalized (Mean±SD=0.53±0.87) group (T-test, p=0.03). Serum levels of PMN-elastase were also higher in the hospitalized group (Mean±SD; 64,794.43±26,820.08) than in the non-hospitalized group (Mean±SD=44,049.33±17,675.85) (p=0.017). There was no relationship between the cytokines and the studied factors in sputum and the GOLD classification, but the serum levels of fractalkine and MMP-9 were significantly higher in the more severe (grades 3-4) group. There was no significant correlation between sputum and serum levels of measured inflammatory mediators and pulmonary complications in the patients who were exposed to SM 20 years earlier. Pathophysiologic process involved in SM induced pulmonary problems might be different from those in other chronic pulmonary diseases such as COPD and asthma.

Association of chemokines and prolactin with cherry angioma in a sulfur mustard exposed population--Sardasht-Iran cohort study.

Exposure to SM leads to short and long term adverse effects on various organs including the skin. Cherry angioma is one of the late skin disorders in SM exposed individuals. The pathogenesis of abnormal angiogenesis in cherry angioma is not well known but the role of inflammatory mediators and certain hormones, including prolactin, in the regulation of angiogenesis in other diseases has been reported. Alterations in serum levels of prolactin and chemokines in SM-exposed victims and the impact on angiogenesis are indications of the role in SM-induced cherry angioma. As part of the SICS, this study seeks to evaluate the possible association of prolactin and chemokines in the emergence of SM-induced cherry angioma. The serum concentrations of prolactin, IL-8/CXCL8, RANTES/CCL5, MCP-1/CCL2, and fractalkine/CX3CL1 were titrated using sandwich ELISA technique. There was a significant difference in the level of prolactin between the exposed subgroups (with cherry angioma n=72; mean: 10.13) and without cherry angioma (n=268; mean: 13.13, p<0.0096). Median of the serum levels of CCL2 in the exposed patients with cherry angioma was significantly higher than exposed patients without cherry angioma (median=203.5 pg/ml and median=187.10 pg/ml respectively, p=0.035). There was no significant difference in the serum levels of IL-8, RANTES and CX3L1 between the exposed subgroups with cherry angioma and without cherry angioma. This finding serves as a basis for further research on the molecular mechanisms and pathways involved in the pathogenesis of cherry angioma and other related disorders.

Association of ophthalmic complications in patients with sulfur mustard induced mild ocular complications and serum soluble adhesion molecules: Sardasht-Iran Cohort Study.

The aim of this study was to evaluate possible association between ophthalmic complications in sulfur mustard (SM) exposed patients with mild ocular injuries and serum soluble adhesion molecules. Serum levels of sICAM-1, sL-selectin, sP-selectin and sE-selectin in 367 SM-exposed individuals with or without eye injuries were checked and compared with 128 unexposed controls. All participants underwent ocular examinations. Serum sICAM-1 level in SM exposed with blurred vision, was significantly (p=0.021) higher than in SM exposed with no blurred vision. Serum sL-selectin level was significantly (p=0.024) higher in SM exposed with photophobia than SM exposed with no photophobia. Serum P-selectin level in exposed without any slit lamp findings was significantly (p=0.003) lower than the matched control groups. Similar finding was seen in exposed group without ocular problem compared with the control groups. Serum sE-selectin level in exposed with normal ocular condition except for photophobia and blurred vision was significantly (p<0.05) higher than the matched controls. Serum E-selectin level in exposed with photophobia condition was significantly (p=0.047) higher than the control group with photophobia. In conclusion it seems that the changes in the E- and P-selectins is a regulatory mechanism for inhibition of SM induced ocular problems, although the local levels are more important and further investigations required in more severe ocular problems in SM exposed patients.

Are serum levels of immunoglobulin classes and IgG subclasses involved in delayed pulmonary complications induced by sulfur mustard? Sardasht-Iran Cohort Study.

Respiratory complications are the foremost long term debilitating effects after sulfur mustard toxicity. The underlying immunological mechanisms of sulfur mustard induced lung damage are still poorly understood. The question of the involvement of immunoglobulin classes and subclasses in delayed pulmonary complications induced by SM was addressed in this study as a part of Sardasht-Iran Cohort Study (SICS).In SICS, 372 male participants who were exposed to SM 20 years earlier were compared with 128 unexposed age-matched controls. At the time of study (2007), the clinical evaluations and spirometry was performed for all subjects according to the American Thoracic Society Criteria, and at the same time, the sera were isolated, labeled and aliquots were kept frozen in -80°C. Serum immunoglobulin (Ig) levels including IgM, IgA, IgE, IgG, and IgG subclasses (IgG1, IgG2, IgG3 and IgG4) were measured using quantitative Elisa method. It was found that among immunoglobulin classes and IgG subclasses only IgM and IgG4 were significantly decreased in the peripheral blood of exposed cases. IgM level also positively correlated with FEV1 only in the SM exposed group. These results indicated a weak but significant role for IgA in control of the delayed pulmonary complications. There were no strong correlations between other immunoglobulin classes or IgG subclasses with pulmonary disease severity in sulfur mustard intoxicated subjects. The authors proposed that systemic levels of immunoglobulins do not exert essential roles in severity of delayed pulmonary complications following SM toxicity. However, more studies on local and systemic levels of immunoglobulins in more severe groups are suggested.

Long term impact of sulfur mustard exposure on peripheral blood mononuclear subpopulations--Sardasht-Iran Cohort Study (SICS).

The most important long-term morbidity problem of sulfur mustard (SM) toxicity is pulmonary complications but the pathogenesis of these complications is not clearly understood. This study evaluates the peripheral blood mononuclear sub-sets and their correlation with pulmonary function in SM exposed civilian cases 20 years post-exposure as gathered in the context of the Sardasht-Iran Cohort Study (SICS). Samples were randomly selected from two groups, SM-exposed (n=372) and control (n=128), with the same ethnicity, culture, and demography. Three color flow cytometry was applied for peripheral blood mononuclear sub-population determination. Results indicated a significant decrease in CD45+/CD3+, CD45+/CD3+/CD4+, and an increase in CD3+/CD16+56+ percentages. It was also found that absolute count of NK cells was highly increased in peripheral blood of exposed cases. There was a significant increase in NK cell count of SM exposed group with pulmonary problems as compared to the same group without pulmonary problems (p-value<0.04) based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The findings showed a significant negative correlation between absolute numbers of T lymphocyte and FVC % and positive correlation with FEV1/FVC%. The results also demonstrated that absolute numbers of monocytes had a negative correlation with FVC %. We propose that NK and T cells are probably involved in the pathogenesis or immune reactions to the delayed pulmonary complications induced by SM. This hypothesis should be tested in a more severe pulmonary complicated group.

Association of physical activity and IL-10 levels 20 years after sulfur mustard exposure: Sardasht-Iran cohort study.

IL-10 is an anti-inflammatory cytokine that is important in the regulation of inflammatory processes in different conditions. Sulfur mustard (SM) intoxicated patients are suffering from different inflammatory diseases in their lung, skin and eyes. Physical activity (PA) is reported to control inflammation by reducing pro-inflammatory and inducing anti-inflammatory cytokines. Our previous study revealed lower PA and more sedentary lifestyle among SM exposed population. This study aimed to determine the relationship of PA with IL-10 production in SM exposed subjects. Baseline, mitogen-induced and the serum levels of IL-10 were evaluated. In a historical cohort study, Sardasht-Iran Cohort Study (SICS), 372 SM exposed participants were studied 20 years after exposure and were compared with 128 unexposed control participants. The Global Physical Activity Questionnaire (GPAQ; developed by WHO) was used to obtain a self-reported measure of physical activity. Whole blood culture supernatants and serum samples were used for IL-10 measurement by ELISA technique. In both the control and exposed groups mitogen-induced IL-10 production was significantly elevated with severity of PA intensity (p<0.05). In the control subjects with moderate PA intensity, the mitogen-induced IL-10 production was higher than the corresponding in the exposed group (p<0.05). In the exposed group, mitogen-induced IL-10 production had significant positive correlation with total PA, total transport PA, total recreational PA and total moderate intensity work (p<0.05). The positive relationship between high PA and the levels of anti-inflammatory cytokine IL-10 indicates a need to encourage a more active lifestyle among the SM exposed subjects who have various inflammatory complications.

Sardasht-Iran cohort study of chemical warfare victims: design and methods.

BACKGROUND: Insights into long-term clinical consequences of sulfur mustard have emerged from some investigations but less is known about the basic and molecular mechanisms of these complications. Sardasht-Iran Cohort Study is a comprehensive historical cohort study on Sardasht chemical victims' population which was designed to find out the long-term complications of sulfur mustard exposure and the basic mechanisms underlying clinical manifestations. This paper describes the design and methodology of Sardasht-Iran Cohort Study. METHODS: In Sardasht-Iran Cohort Study, 500 individuals including 372 subjects from Sardasht, as the exposed group, and 128 subjects from Rabat, as the unexposed age-matched control group were evaluated. The exposed group was divided into two groups based on the severity of clinical complications at the time of exposure. Different samples including blood, sputum, saliva, tear, urine, and semen were collected for immunologic, hematologic, biochemical, and other laboratory analysis. Data were gathered from medical records, clinical examinations, laboratory tests, and questionnaires for psychological and lifestyle situations. CONCLUSION: The important distinctions setting this study apart from the previous ones are discussed. The Sardasht-Iran Cohort Study provides important information on various aspects of long-term consequences of sulfur mustard exposure. This database will provide a better position to suggest guidelines for the diagnosis, treatment, and prevention of delayed complications in the patients exposed to sulfur mustard.

Long-term ocular complications of sulfur mustard in the civilian victims of Sardasht, Iran.

Eyes are very sensitive to sulfur mustard (SM) gas because they have wet surfaces. The severity of ocular damage is related to the dose and duration of exposure to SM, and recovery may take up to several years after the exposure. We conducted a large cohort study to evaluate the ocular signs and symptoms of 367 chemical war victims in Sardasht City, Iran, 20 years after their exposure to mustard gas. The results of these chemical war victims (i.e., the cases) were compared with the results for 128 unaffected civilians (i.e., the controls). Photophobia was the most significant symptom in the cases (36.8%) (compared with 20.3% in the controls) (p < or = .001). Ocular surface discomfort (burning, itching, and redness) was the second most significant symptom in the cases (29.2%) (compared with 19.5% in the controls) (p = .034). Other symptoms such as foreign-body sensation, tearing, pain, blurring of vision, and dry eye sensation were not significantly different between the 2 groups. In the slit-lamp findings, bulbar conjunctival abnormality was the most significant sign in the cases (9.3%) (compared with 1.6% in the controls) (p = .004). Limbal tissue changes were the second most significant sign in the cases (3.0%) (compared with 0.0% in the controls) (p = .048). Other slit-lamp findings related to tearing and abnormalities in the lids and cornea were not significantly different between the 2 groups. Our findings in the present study showed that photophobia and ocular surface discomfort (burning, itching, and redness) were the most significant symptoms. In addition, bulbar conjunctival abnormalities and limbal tissue changes were the most significant signs among the sulfur mustard chemical war victims.