The Case of the Patient Who Couldn't Think Straight

A 54 year-old single Hispanic male came in complaining of headaches, dizziness, confusion, fatigue, joint pain, and some pins and needles-like feelings in his arms and legs.

He had worked for many years as an asphalt layer on highways when he was younger but had not worked in that area for 2 decades. He was currently working a desk job for the State Dept. of Transportation but was out on paid sick leave.

He was a never-smoker and didn’t drink alcohol (it made him feel sick) and had a history of hypertension, insomnia, and reflux, now controlled with supplemental magnesium, and dietary avoidance of caffeine and dairy products. His neurologic exam was unremarkable except for a positive Romberg test and decreased sensory perception in his legs. He was not on any prescription medications except for testosterone- prescribed to him by another physician for fatigue and erectile dysfunction, the erectile dysfunction was gone but his fatigue had slowly gotten worse.

Review of his Environmental Health Questionnaire revealed that he lived across the street from a large drycleaning business that had been operating for the last 20 years while he had lived at his present residence. He and his neighbors complained of the smells for years and tried to get the business to install better emission controls with no success. He drinks unfiltered tap water and does not change the filters in his HVAC system more than once a year. He had no other obvious exposures related to his symptoms: no amalgam fillings, did not eat fish, did not have a memory foam mattress, topper or pillow, and had no pesticide exposure (his former wife had been an advocate for organic farming and had convinced the neighborhood to stop spraying pesticides 20 years prior)

His BMI was 24,  BP 135/93, temp 97.3 and a CMP/CBC showed an elevated GGT of 62, ALT 42, AST 53.

His GPLTOX test showed an elevated N-acetyl(propyl)cysteine (NAPR) of 72 mcg/gm creatinine, basically double the 95th percentile for the lab report. The other solvent metabolite markers for benzene, styrene, and xylene were elevated between the 75^th and 95^th percentile levels.

The patient was asked to protect himself from possible airborne exposure to this toxicant by sealing his doors and windows and using an air filter in his home- running it continually. He was also asked to improve his HVAC system by installing MERV16 filters which he purchased at his local home improvement store. Water testing using the National Testing Laboratories water test (watercheck.com) revealed no evidence of solvent exposure through his municipal water, however it did reveal elevated arsenic and he was counseled to use water filtration (reverse osmosis) to lower his risk for arsenic-related health conditions.

At the second visit (when his labs revealed an elevated 1-bromopropane) he was given:

• NAC 2400 mg. daily in two divided doses
• vit. C powder dosed at bowel tolerance which for this patient was 3000 mg. twice daily.
• R-lipoic acid: 300 mg qd
• Selenium- 200 mcg qd
• L-glycine- 1 gram qd
• L-taurine- 1 gram qd
• Vit. E Complex- 1000 IU qd
• Liposomal Glutathione 450 mg bid

He was also encouraged to sauna daily 5 times weekly for 6 weeks using the medical sauna in the office where he was monitored by the staff. He was totally compliant and able to tolerate 1 hour a day and showered afterwards. The sauna included a forced air venting system to eliminate any toxicants released by the patients.

At follow-up 1 month later, he felt much better and had a negative Romberg test. His headaches and brain fog were gone and joint pain significantly diminished, he was able to walk without difficulty and had enough energy to take daily 30 min. walks. He remarked that he “had his brain back” and was able to read again, something he was unable to do for the last year as he had lost his ability to concentrate and remember what he had read only a few minutes prior. His liver labs had “normalized” although still elevated from hepatology standards (his ALT was 35, should be below 30).

The exposure source of 1-bromopropane -the parent compound of urinary N-acetyl(propyl)cysteine- was almost certainly the drycleaning business near the patient’s home. 1-bromopropane ( DrySolv™) has replaced perchlorethylene (“perc”) as a solvent in the drycleaning process in many businesses since the 1990s. Cases of occupational exposure in manufacturing facilities and drycleaning businesses have documented signs and symptoms common for solvent toxicity. PMID: 19052528

Fortunately for this patient and his neighbors the drycleaner went out of business during the time he was being treated. Unfortunately, reason the business shut down was that the owner of the business had passed away from hepatocellular cancer, an occupational hazard for drycleaning workers. PMID: 9139128

This patient had a history of occupational solvent exposure (asphalt workers can be exposed to multiple solvents including 1-bromopropane) and a long history of residential exposure to probably both PCE (perchloroethylene) and 1-bromopropane. He may have been predisposed therefore, to being more vulnerable to the airborne exposure in his neighborhood.