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Bronchiolitis Obliterans

Bronchiolitis Obliterans Case Studies from the CDC:

Case 1
A 32 y/o man began working in October 2001 at a facility that manufactures flavoring substances,
including artificial butter flavoring. The patient primarily performed dry powder mixing to make
various products. He would pour diacetyl and other liquid ingredient into a hole on the blender
lid. General room ventilation was inadequate, and no local exhaust ventilation was present. He had
no previous history of lung disease and no respiratory symptoms at the time he was hired. He was
a lifelong nonsmoker. He had no prior jobs or hobbies with exposure to chemicals.
In December of 2003 he saw his primary care provider with a 2-month history of gradually
progressive shortness of breath on exertion, decreased exercise tolerance, intermittent wheezing,
left-sided chest pain and productive cough. He was treated with antibiotics and bronchodilators for
suspected bronchitis and allergic rhinitis. The patient stopped working in January 2004. However,
his shortness of breath became more severe with dyspnea on exertion at 10 to 15 feet. A highresolution
thin-section chest CT showed cylindrical bronchiectasis in the lower lobes, with
scattered peribronchial ground glass opacities. Pulmonary function studies in April 2004 showed a
severe decline in forced expiratory volume in one second (FEV1) of 1.10 liters (28% of the
predicted value). Static lung volumes by body plethysmography were consistent with severe air
trapping. Diffusing capacity was normal. There was no significant response to bronchodilator
administration.
In October 2004 he was referred for occupational pulmonary consultation. A repeat high
resolution thin-section chest CT showed central peribronchial thickening with central airway
dilatation, with subtle areas of mosaic attenuation scattered throughout the lungs, predominantly in
the right lower lobe. No lung biopsy has been performed. The diagnosis of probable work-related
bronchiolitis obliterans was made on the basis of the clinical history, fixed airways obstruction
with normal diffusing capacity, and typical high resolution thin-section CT scan. Over the past 18
months, the patient has continued to have severe shortness of breath without significant
improvement in fixed airways obstruction.

Case 2
A 43 y/o woman began working at a flavorings manufacturing facility in 1998. The patient
performed mixing of dry powders with diacetyl to make artificial butter flavoring. At the time she
was hired, she had no chest symptoms. She was an infrequent cigarette smoker as a teenager. She
had no prior jobs or hobbies with exposure to chemicals.
In August 2005 she saw her primary care provider with a one-month history of nasal congestion
and cough, and was treated with antibiotics and antihistamines. She developed gradually
progressive shortness of breath on exertion, decreased exercise tolerance and nonproductive
cough. She was referred to a pulmonary specialist for consultation in November 2005. She was
suspected to have work-related asthma and was treated with bronchodilators and oral
corticosteroids with minimal improvement in symptoms. A high-resolution thin-section chest CT
showed several small areas of patchy ground glass opacities throughout the lung fields. The patient
stopped working in December 2005. Pulmonary function studies showed severe airways
obstruction with an FEV1 of 0.55 liters (18% of the predicted value). Static lung volumes by body
plethysmography were consistent with severe air trapping. Diffusing capacity was normal. There
was no significant response to bronchodilator administration. Bronchoscopy and left thoracotomy
with wedge resection of the left lower lobe was performed; pathology showed inflammatory
infiltrates in the peribronchial and interstitial areas, with scattered eosinophils. Non-caseating type
granulomas with giant cells, and focal areas of interstitial fibrosis were also seen.
The diagnosis of probable work-related bronchiolitis obliterans was made on the basis of the
clinical history, fixed airways obstruction with normal diffusing capacity, and typical high
resolution thin-section CT scan. Despite treatment with systemic corticosteroids, the patient
continues to have severe shortness of breath with minimal improvement in fixed airways
obstruction.

Diacetyl in Cooking Oil Can Cause Bronchiolitis Obliterans

UNITE HERE, the largest union for hotel, kitchen, and restaurant workers in North America, has demanded cooking oil manufacturers to stop using the harmful chemical diacetyl, according to the Seattle Post-Intelligencer. Diacetyl is a butter-flavor additive which is often found in cooking oils, sprays, and margarine which can be harmful if released as a vapor when heated.

At least three deaths have been attributed to diacetyl from the formation of bronchiolitis obliterans in the victims. Bronchiolitis obliterans is inflammation in the smaller pathways in the lungs. The highest levels of diacetyl are found in cooking oils used by professional chefs.

Congress is concerned about the prevalence of the chemical and has sent a letter to the National Institute of Occupational Safety and Health. The letter stated that “it is urgent that we finally determine the national scope of exposure and illness related to diacetyl-containing food flavoring.”

The FDA cannot take action because, according to the FDA, diacetyl is only harmful when released as a vapor, not when ingested as a food. Therefore, it is the responsibility of OSHA to deal with laws concerning the workplace safety in regards to diacetyl levels. OSHA, however, has been very slow to respond to the growing concern of the chemical and has implemented no new rules to protect workers from potential lung disease.

While scientists and experts are working to figure out the exact effects of diacetyl and at what levels it is most dangerous, states such as California and Washington are already taking action. The two states are working together to develop regulations regarding the use of the chemical and are working on a letter to send to all professional chefs and restaurants to warn of the dangers of diacetyl. Because of the increased publicity of its harmful effects, many companies are already producing diacetyl-free products.

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Food Poisoning Lawyer Fred Pritzker has appeared on national television and has been quoted by national publications, including The New York Times, The Wall Street Journal, Associated Press and Lawyers USA. He has been named a "Super Lawyer" by Law and Politics magazine. He is also listed in the current edition of The Best Lawyers in America. To contact Fred Pritzker about a food poisoning lawsuit or food safety advocacy, please call 1-888-377-8900 (toll free) or submit the firm's free consultation form.

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