Toluene 2,4-diisocyanate and bowel obstruction: occupational medicine aspect of a case report.

Iread with interest the Case Report on intestinal obstruction due to acute toluene 2,4-diisocyanate (TDI) exposure recently published in The IJOEM. Although considering occupational and environmental etiologies in the clinical assessment of the patient is admirable, some important clues of occupational history have not yet been clarified. Characteristics of an exposure are very important: Was the exposure a work accident or an unexpected work task? Had the exposure happened in an outdoor area or indoors? Accidents usually result in a “big bang” phenomena and a massive exposure, whereas for a sponge production worker a chronic low level exposure to TDI with occasional peak exposures is more likely. Therefore, it seems that a massive exposure could better explain the clinical picture of this patient. Some information about the worker's breathing zone measurement of TDI, preemployment and periodical surveillances, usage and type of the patient's respirator and fitness for work after chemotherapy and the first surgery of this teenage worker could also be helpful. Recommendations about return to work of the patient after the second surgery are another important issue. It is mentioned that “at follow-up visit seven months later, he was completely fine.” Did it happen while he was off work, on modified or changed work, or on the same work? You also mentioned in the Abstract that “TDI toxicity may cause intestinal obstruction”; in the Discussion, it is stated that “intestinal obstruction is an extraordinary manifestation of acute or chronic TDI toxicity” and that “TDI poisoning itself, may affect the intestinal smooth muscle and cause decreased bowel motility.” None of these statements have references. Are these statements drawn from the current Case Report? Reference 6 of the article refers to a non-specific report of non-autonomic neuropathy following chronic exposure to a mixture of organic solvent and I believe it could hardly be applicable to the current patient. According to the best of my knowledge, there is no evidence supporting bowel obstruction in acute or chronic TDI exposure in occupational medicine textbooks or reliable online sources. Nonetheless, gastrointestinal symptoms and respiratory obstructions are commonly reported among victims of TDI poisoning. Furthermore, a comprehensive Web search with Google Scholar, revealed no similar case reports (search terms: intestinal obstruction + toluene diisocyanate). This Case Report reflects diagnostic and therapeutic challenges in occupation-