But how the patient spends the day, either with occupation or avocation, may play a particularly important role in raising the suspicion of the practitioner for the emergency practitioner, occupational physician, pulmonologist, or other health care provider. Smoking, alcoholism, and drug use are standard parts of social history. The most important aspect of the workup of these patients is to obtain an occupational history of the patient. Metallothionein-transport proteins, mostly found in the cell's Golgi-apparatus, may modulate the response to metal oxides, and it has been hypothesized that this may impact the clinical response to metal fume fever. The interplay of these immune actors promotes inflammation causing neutrophil recruitment and systemic response, such as fever. The lung is the major source of cytokines and is the organ most affected by these inflammatory agents. The tumor necrosis factor-alpha peaks at 3 hours post-exposure and seems to have a large role in metal fume fever. These cytokine agents may be the pyrogens seen in this syndrome. īronchoalveolar lavage of zinc oxide exposed volunteers demonstrates elevated interleukin 6, interleukin 8, and tumor necrosis factor in the bronchoalveolar lavage fluid.
Pulmonary function testing may show marked bronchospasm. There may be a type 1 hypersensitivity that may manifest as an angioedema allergic reaction. Ultrafine particles less than one micron in size drive much of the pathologic effects of metal fumes. Zinc oxide powder particles are much larger than freshly produced zinc oxide. The difference has been ascribed to the differential in the size of the particles. Interestingly, aerosolized zinc oxide powder does not produce the symptoms, whereas fresh zinc oxide does. National Institute for Occupational Safety and Health (NIOSH) and other exposure limits exist, but in general, zinc oxide fumes of 75 to 600 mg of zinc per cubic meter for 1 to 3 hours are needed to produce the syndrome. Cadmium may produce a syndrome of pneumonitis, hypoxia, and even death, which in many respects is distinct from metal fume fever. Zinc, cadmium, iron, and aluminum oxides are the most common metals involved in metal fume fever. This process protects the steel from oxidation, corrosion, and weakening. Galvanization is a process by which a zinc coating is applied to steel. Exposure is from inhaling fumes during the welding process or cutting galvanized metal. Brazers may also apply coatings to protect against corrosion and wear.Įxposure to metal fumes has caused recognized illness for about 200 years and has been known under several names such as Monday fever, brass founders' ague, welders ague, smelter chills, and zinc shakes. Brazers connect dissimilar metals through the agency of filler material, thereby producing strong joints between multiple metals. Solderers typically work with small metal pieces that must be positioned precisely, for example, transistors or computer chips. Solderers and brazers use a third metal to join two or more other metal objects. Plasma cutters may be involved in dismantling large objects such as ships, railroad cars, and buildings. "Cutters" use an ionized gas called plasma, also of intense heat, to trim metal objects to specific dimensions. Zinc is the most common metal involved in these bonding procedures.
The process chosen depends on the metals to be bonded. Arc welding produces currents to create intense heat, which melts metals and facilitates bonding. The most common is using electric currents to create heat, slightly melt metals, and bond them together. The Bureau of Labor Statistics reports that the syndrome of metal fume fever is seen most often in welders, cutters, brazers, and solderers. The association between metal oxides with symptoms of fever, dyspnea, and muscle aches was proven when Lehmann exposed himself and four volunteers to gaseous products of the welding process, including zinc oxide. For this reason, it is sometimes called "Monday morning fever." The first reported cases were in the 1830s. Improvement occurs over the course of the work week, but re-ex-exposure after return to work results in a return of symptoms, such as fever, malaise, and wheezing. Metal fume fever presents as a flu-like syndrome occurring shortly after these activities and others where metals are bound together. Welders also are involved in filling indentations and seams in the metal. Metal fume fever is a self-limited febrile illness that occurs in those individuals that fuse metals, such as welders.
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