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Multiple-chemical sensitivity.

Multiple-chemical sensitivity (MCS), a condition that affects more and more people, has been a subject of discussion in the medical field since the early 1950s. According to Zwillinger (1998), people have been reporting MCS symptoms on an increasing are for the last 50 years. The increase in symptom reporting has been attributed to the fact that the manufacture of synthetic organic chemicals increased from less than 10 billion pounds per year in 1940 to more than 350 billion pounds annually in 1980 (Zwillinger, 1998). MCS can produce a wide range of symptoms, sometimes causing the affected individual to encounter great difficulty functioning in normal working and living environments (Caress & Steinemann, 2003). MCS symptoms can include coughing, wheezing, and chest pains; depression; irritation to the eyes, ears, nose, and throat; fatigue, gastrointestinal problems, and headaches.

What Is MCS?

MCS is characterized by an acute hypersensitivity to low levels of chemicals found in common substances, such as household cleaning agents, pesticides, fresh paint, new carpeting, synthetic building materials, newsprint, perfume, and numerous other petrochemical products (Caress & Steinemann, 2003). MCS is also a clinical description for a cluster of symptoms of unknown etiology that have been attributed by patients to multiple environmental exposures when other medical explanations have been excluded (Tarlo, Poonai, Binkley, Antony, & Swinson, 2002). In 1987, Dr. Mark Cullen, a professor of medicine and epidemiology at Yale University, proposed a definition that has become the one most commonly referenced, and is, for some, the de facto definition of MCS (Interagency Workgroup on Report of Multiple Chemical Sensitivity [IWRMCS], 1998):

Multiple chemical sensitivities is an acquired disorder characterized by recurrent symptoms, referable to multiple organ systems, occurring in response to demonstrable exposure to many chemically unrelated compounds at doses far below those established in the general population to cause harmful effects. No single widely accepted test of physiologic function can be shown to correlate with symptoms.

Background

MCS was first brought to the attention of the medical community when the late Dr. Theron Randolph reported that patients became ill from exposure to a substance at doses far below the levels normally considered safe (Barrett, 1998). In the early 1950s, Dr. Randolph linked chemical sensitivity to the increasing prevalence of chemicals and toxins in the environment, including pesticides in food, heavy metals in water, auto exhaust in the air, gas cooking stoves, and numerous synthetic chemicals in personal hygiene products, cleaning supplies, and building materials (Kail, Lawrence, & Goldberg, 2000). Through simple elimination then re-exposure tests, he discovered the cause of many symptoms and diseases was not only common foods, but also the many extremely small, "safe repeated dose of the millions of untested chemical products most American people use" (Nutrition for Optimal Health Association, n.d., p. 1). Dr. Randolph noted that these products include perfume, aftershave, scented soap, cleaners, air fresheners, fertilizers, pesticides, carpets, pressed wood or plywood, and natural gas (Kail et al., 2000).

According to Woolf (2000), clinicians, researchers, and policymakers cannot agree on the name of this condition. MCS has been described under various names since the 1940s: idiopathic environmental intolerance, environmental illness, environmental hypersensitivity, and universal reactors. MCS is believed by some to overlap with sick building syndrome. The American College of Occupational and Environmental Medicine (ACOEM) (1999) noted that this condition has been identified by 20 additional names. Its very existence has been the subject of controversy; some physicians dismissed MCS-related complaints as psychological in nature. "It defies classification as a disease. It has no consistent characteristics, no uniform cause, no objective or measurable features. It exists because a patient believes it does and a doctor validates that belief" (Barrett, 1998, p. 2).

In 1999, ACOEM also noted that the diagnosis, treatment, and etiologic assessment of MCS have remained a troublesome medical and social concern for individuals, physicians, government, and organizations. Caress and Steinemann (2003) noted that MCS has a physiologic and not a psychologic etiology. Previous research suggested an excess of symptoms of psychological distress consistent with anxiety and depression in many, but not all MCS patients (ACOEM, 1999). ACOEM (1999) also identified problems with diagnosis and treatment of MCS because no specific tests and treatments had proven helpful and further scientific findings were necessary. "The Environmental Protection Agency (EPA), U.S. Consumer Product Safety Commission, and other organizations have ruled that MCS is not a psychosomatic disease and should be diagnosed and treated as any other health disorder" (Kail et al., 2000, p. 138). In addition, MCS is covered under the Americans with Disability Act (Kail et al., 2000). The current consensus is that cases of claimed or suspected MCS should not be dismissed as psychogenic, and a thorough workup is essential. Primary caregivers should determine that an affected individual does not have an underlying physiological problem, and should consider the value of consultation with allergists and other specialists.

Prevalence of MCS

Kutsogiannis and Davidoff (2001) provided preliminary evidence that suggests, "MCS syndrome tends to be both commonly misdiagnosed and under-diagnosed by physicians--even by physicians who have a special interest in the condition" (p. 15). The exact prevalence of MCS is unknown because of misdiagnosed cases and conditions not reported as MCS. The National Academy of Sciences estimates that up to 15% of the American public could be experiencing a heightened sensitivity to common chemical products; this was confirmed in a 1999 study on hypersensitivity to low levels of common chemicals (Caress & Steinemann, 2003). Women are believed to be more affected with MCS than men; the median age of MCS sufferers is 40 years, and most affected individuals experience symptoms before they are 30 years old (Thivierge & Frey, 2004).

Causes of MCS and Symptoms

MCS is a disorder triggered by exposures to chemicals in the environment. Affected individuals can have symptoms from chemical exposures at concentrations far below the levels tolerated by most people. Current research suggests that MCS exhibits a two-step process of initiation (causation) and triggering (subsequent reactions) (Caress & Steinemann, 2003). In the first step, contact with a chemical induces lack of tolerance to it. Triggering then occurs, which involves reactions to a wider range of substances. The reaction can be mild to severe and include a wide variety of symptoms, such as mucous membrane irritation of the eyes, nose, and throat; chest tightness; dry and itching skin; and nasal congestion (Kail et al., 2000). Initiation can be the result of indoor air contaminants, chemical spills, or pesticide applications. Triggers can include but are not limited to perfumes, perfume products, cleaners, air fresheners, fertilizers, pesticides, carpets, pressed wood or plywood, and natural gas.

It is important to note that chemical spills occur infrequently and primarily affect those in hazardous occupations. Pesticide exposure also is limited. Therefore, people who work or live near farms and forests appear to be particularly vulnerable to these initiators. For those who spend most of their time inside buildings, indoor air contamination is more likely to cause the initiation process of MCS (Kail et al., 2000).

The U.S. Environmental Protection Agency (USEPA) noted a growing body of scientific evidence that indicated the air within homes and other buildings can be more seriously polluted than the outdoor air in even the largest and most industrialized cities. Other research indicates that people spend approximately 90% of their time indoors (USEPA, 1995). Therefore, the risks to health may be due more to exposure to air pollution indoors than outdoors. In addition, people who may be exposed to indoor air pollutants for the longest periods of time are often those most susceptible to the effects of indoor air pollution. Often, the main culprit in indoor air contamination is a sick building, a tightly sealed, energy-efficient structure with various toxins and biological pollutants trapped inside and repeatedly circulated via central heating and cooling systems (Kail et al., 2000). Sick buildings have high levels of volatile organic compounds released from particleboard desks, furniture, carpets, glues, paints, and office machine toners (including those from printers and photocopiers). Constant, low-grade exposure to these chemicals and debris leads to sick building syndrome (SBS), a condition characterized by mucous membrane irritation of the eyes, nose, and throat; chest tightness; skin complaints (dryness, itching, and redness); headaches; fatigue; lethargy; coughing; asthma; chronic nasal congestion; infections; and emotional irritability. Researchers (Jones, 1998) have analyzed these complaints and confirmed that SBS can lead to full-blown MCS and even asthma. According to the USEPA (1994/2004), SBS can be the result of several factors; poor design, maintenance, and/or a faulty ventilation system. It also can be the result of very low levels of specific pollutants; humidity may also be a factor. Other contributing elements may include poor lighting and adverse ergonomic conditions, temperature extremes, noise, and psychological stresses that may have both individual and interpersonal impact.

Similarly, MCS symptoms can include breathing problems such as coughing, wheezing, and dyspnea; chest pain; depression; eye, ear, nose, or throat irritation; gastrointestinal problems; headache; inability to concentrate; joint and muscle pain; fatigue, malaise; memory loss or confusion; dizziness; and skin disorders. An individual can suffer with any number of symptoms of MCS, and two individuals can have entirely different symptoms (IWRMCS, 1998).

Diagnosing MCS

MCS has no consistent diagnostic criteria, and no single diagnostic test. Identification of MCS is based largely on the patient's description of the symptoms and the relationship of these symptoms to environmental exposures (IWRMCS, 1998). According to the Cleveland Clinic Health Information Center (2004), "There are no tests to diagnose MCS. A doctor generally bases his or her diagnosis on the person's description of symptoms, usually following a complete medical history and physical examination. The doctor may use diagnostic tests, such as X-rays and blood tests, to rule out true allergies and other physical or mental health disorders as the cause of the symptoms." Because there are no definitive diagnostic tests for MCS, the primary caregiver must rely heavily on patient complaints and history of chemical exposures. Therefore, the evaluation of an individual for MCS should begin with a complete and detailed history, including a comprehensive exposure history. A number of tests have been suggested for evaluating complaints of MCS, or have been used in studies of patients with MCS or chemical sensitivities. Such tests include immunologic assays, quantitative electroencephalography, brain electrical activity mapping, evoked potentials, positron emission tomography, and single photon emission computed tomography.

Treatment

Treatment regimens recommended for treating MCS include antihistamines, analgesics, and other medications such as allergy shots, nasal spray, and ophthalmic solutions to combat the symptoms (Thivierge & Frey 2004). The most effective treatment is to avoid the chemicals which may trigger the symptoms. However, this has become increasingly difficult in a chemical-dependent society. According to Norman (2003), the most important treatment for MCS is complete avoidance of toxins that cause the person to react; unlike with some allergies, there is no way to medicate the reaction and allow the person full exposure to the substance. Norman (2003) also noted it is important to avoid chemicals that may further injure the body even though the person is not reacting obviously to them.

Illustrative Case

A 53-year-old woman with no prior history of asthma was seen by her family physician in 2003. She complained of severe coughing episodes followed by shortness of breath and a feeling that her airway was closing with the inability to speak clearly, followed by wheezing. She informed her doctor that this only occurred whenever she came in contact with perfumed products, such as colognes, lotions, and bath and body wash. She also informed her physician that the first time this happened to her she was at a local hospital and she went to the emergency room. She was treated in the emergency room with oxygen via nasal cannula, nebulizer treatment with albuterol (Proventil[R], Ventolin[R], Volmax[R]), oral diphenhydramine (Benadryl[R]), and dexamethasone (Decadron[R], AK-Dex[R], Maxidex[R]). Her past history included hypertension, cholecystectomy, bilateral bunionectomy, hysterectomy, sinusitis, and multiple allergies. Her family physician requested that she have allergy testing and a consult with a pulmonologist. The specialist ordered chest X-ray, pulmonary function test, and IgE (blood test for immunoglobin E) to evaluate her condition. According to the pulmonologist, all of the test results were within normal limits except the IgE, which indicated that she had asthma. At that point, she was put on several inhalers to treat the asthmatic condition and provide immediate relief of symptoms.

Currently, her respiratory episodes occur when she comes in contact with products that contain any form of a chemical. These products include but are not limited to, perfumed products such as colognes, lotions, bath and body wash; household cleaners; and paints. She also identifies cigarette smoke as a trigger. She is now 56 years old and continues to suffer with the effects of exposure to multiple chemicals. She believes that her current medical condition developed over 20 years from repeated exposure to a variety of chemicals in her work environment. In her home, she believes the repeated use of chemical-laden household cleaners and fragrant products contributed to her exposure.

Discussion

This case illustrates how repeated long-term exposure to chemicals can result in a wide variety of symptoms. It also reinforces the fact that an exposure history is needed to diagnose the condition of MCS. The most important fact illustrated from this case is that exposure to chemicals can occur over a long period of time prior to development of hypersensitivity. This case also illustrates how an apparently healthy individual with no prior history of asthma can begin to have attacks after becoming sensitized to the chemicals in fragrance products (Franz & Prall, 2000).

Implications for Nursing

Nurses should recognize fragrances as a major source for indoor air pollution that can present a health risk for individuals who suffer with MCS. They should act to protect both their patients and their co-workers by creating a fragrance-free workplace. Nurses should take the lead in providing education about the adverse health effects of chemicals, including fragrances. Policies and protocols should be developed to protect patients' health, as well as that of professional care providers.

In addition, when completing a patient's allergy history, the nurse should further question the patient about any signs of sensitivity to fragrances, household cleaning agents, pesticides, fresh paint, new carpet, synthetic building materials, newsprint, perfume, and numerous other petrochemical products. The patient may be unaware of any hypersensitivity, but key questions will help identify an at-risk individual.

In an inpatient facility, a patient who has sensitivities to fragrances should not room with a patient who uses scented products. A patient who is sensitive to cigarette smoke should not live in the same room with a patient who smokes. Although there is no smoking allowed in the hospital, a patient's ability to smoke in designated areas could trigger a reaction in a hypersensitive roommate upon returning. In addition, supplies used to clean the room of the patient with MCS should be chemical-free, staff caring for the patient should not wear scented products, and air fresheners or furniture polish should not be used in the patient room. Only non-toxic cleaning products should be used to clean the patient room.

The patient chart should be clearly labeled to indicate the patient's hypersensitivity. Care should be taken when the patient is transported to other areas of the medical center because the patient could come in contact with a trigger and have a severe reaction. The patient should be given the option to wear a mask or use a towel as a protective barrier to decrease inhalation of possible triggers.

Conclusion

MCS remains a very controversial condition because it is something of a medical mystery, and the medical community is divided over whether or not MCS exists. Eichhorn (2004) noted that it is difficult to scientifically identify a patient with MCS; there are no identifying criteria, no diagnostic symptoms, and no readily available tools to prove the condition of a person who complains of adverse symptoms when exposed to chemicals. Diagnosis without objective test methods, however, remains a problem (Ternesten-Hasseus, Bende, & Millqvist, 2002).

At least 15% of Americans suffer with MCS, but diagnosis is still not based on defined symptoms. Nurses need to understand MCS in order to talk knowledgeably with patients about the effects of exposure to chemicals. When caring for patients with MCS, the nurse should recognize that fragrances present a major health risk for them. Another important intervention is for nurses to avoid wearing or using fragrance products while at work. Additional research is needed to improve understanding of the prevalence, treatment, and early diagnosis of MCS.

References

American College of Occupational and Environmental Medicine (ACOEM). (1999). ACOEM position statement: Multiple chemical sensitivities: Idiopathic. Retrieved May 29, 2004, from http://www.acoem.org/guide lines/article.asp?ID=46

Barrett, S. (1998). Multiple chemical sensitivity: A spurious diagnosis. Retrieved August 1, 2004, from http://www. quackwatch.org/01QuackeryrelatedTo pics/mcs.html

Caress, S.M, & Steinemann, A.C. (2003). A review of a two-phase population study of multiple chemical sensitivities. Retrieved June 22, 2004, from http://www.emagazine.com/september-october_1998/0998feat2.html

Cleveland Clinic Health Information Center. (2004). Multiple chemical sensitivity: Fact of fiction? Retrieved August 8, 2005, from http://www.clevelandclin ic.org/health/healthinfo/docs/2900/29 91.asp?index=10021

Eichhorn, N. (2004). Multiple chemical sensitivity alters fives. Retrieved August 8, 2005, from http://www.immunesup port.com/library/showarticle.cfm/ID/60 89/e/1/T/CFIDS_FM/

Franz, D., & Prall, H. (2000). Smelling good but feeling bad. Synthetic perfumes, colognes, and scents are turning up noses. Retrieved April 14, 2004, from http://www.geocities.com/fragrance allergy/EGreen0100glhealth.html

Interagency Workgroup on Report of Multiple Chemical Sensitivity (IWRM CS). (1998). A report on multiple chemical sensitivity. Retrieved April 1, 2004, from http://www.health.gov/en vironment/mcs/toc.htm

Jones, A.P. (1998). Asthma and domestic air quality. Social Science and Medicine, 47(6), 755-764.

Kail, K., Lawrence, B., & Goldberg, B. (2000). Allergy free: Alternative medicine definitive guide. Tiburon, CA: AlternativeMedicine.com, Inc.

Kutsogiannis, D.J., & Davidoff, A.L. (2001). A multiple center study of multiple chemical sensitivity syndrome. Retrieved June 22, 2004, from, http://www.findarticles.com/p/art icles/mi_m0907/is_3_56/ai_77276221

Norman, C. (2003). Introduction to multiple chemical sensitivities. Retrieved August 9, 2005, from http://www. immuneweb.org/articles/mcsintro.htm

Nutrition for Optimal Health Association, Inc. (n.d.). Theron G. Randolph, MD. Retrieved June 6, 2004, from http://www.nutrition4health.org/NOHA news/Biographies/RandolphBio.html

Tarlo, S.M., Poonai, N., Binkley, K., Antony, M.M., & Swinson, R.P., (2002). Responses to panic induction procedures in subjects with multiple chemical sensitivity/idiopathic environmental intolerance: Understanding the relationship with panic disorder. Retrieved April 1, 2004, from http://ehp.niehs. nih.gov/docs/2002/suppl-4/669-671 tarlo/abstract.htm

Ternesten-Hasseus, E., Bende, M., & Millqvist, E. (2002). Increased capsaicin cough sensitivity in patients with multiple chemical sensitivity. Journal of Occupational and Environmental Medicine, 44(11), 1012-1017.

Thivierge, B., & Frey, R.J. (2004). Multiple chemical sensitivity. Retrieved August 5, 2004, from http://www.healthatoz. com/Atoz/ency/multiple_chemical_ sensitivity.jsp

U.S. Environmental Protection Agency (USEPA). (1995). The inside story: A guide to indoor air quality. Retrieved June 22, 2004, from http://www. epa.gov/iaq/pubs/images/the_inside_ story.pdf

Woolf, A. (2000). A 4-year-old girl with manifestation of multiple chemical sensitivities. Environmental Health Perspectives, 108(12), 1299.

Zwillinger, R., (1998). No safe haven: People with multiple chemical sensitivity are becoming the new homeless. Retrieved June 22, 2004, from http://www.emagazine.com/septem ber-october_1998/0998feat2.html

Gloria J. Glinton, MSN, RN, is a Nursing Instructor, Broward Community College, Coconut Creek, FL.
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Author:Glinton, Gloria J.
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Date:Dec 1, 2005
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