Patient Case: P.V.

University of Maryland - School of Medicine
Baltimore, Maryland

Instructor(s): Keogh, James P.; Gordon, Janie
Subject area: Health / Medicine
Department: Occupational and Environmental Medicine
Level: Undergraduate Medical
Learning objective: Develop Group Skills, Develop Individual Skills, Provide Information
Teaching style: Group Activity, In-class Activity

Please note that the copyright for this course project is retained by the instructor.

This case is presented to medical students at the University of Maryland School of Medicine. Developed by the University of Maryland's Occupational Health Project, this case focuses on bronchitis associated with boilermaker's occupational exposure to vanadium pentoxide. It teaches students to:
- Describe how exposures at home, in the community and at work influence health.
- Derive the elements of an occupational and environmental history.
- Develop an approach to assessing the work relatedness of an illness.
- Identify chemical exposures and find existing toxicological information.
- Learn how to gather more information from employers, co workers, and unions.
- Learn the capabilities and limitations of existing public health and regulatory agencies.
- Practice problem solving skills needed in caring for patients with environmental illnesses.

P.V. Patient History

P.V. is a 23 year old man who presents to the office with two days of cough and a runny nose. He says he was in his usual state of health until two days ago when he began to notice that he was coughing a lot while at work. At the same time he developed a runny nose and watery eyes. His symptoms got better later that day and he felt well the next morning.

Yesterday, the symptoms got worse again. He reports that he had to constantly blow his nose and found himself coughing and short of breath when exerting himself. He got worse as the evening progressed and found himself very symptomatic last night. He complained of wheezing when he lay down last night to go to sleep and he awoke every hour with a cough. He denies any fever or chills. He has had no night sweats. He has never previously noted wheezing. He has no history of allergies or asthma.

Past Medical History: Remarkable only for an appendectomy at age 12.

Physical Examination: Remarkable for slightly injected conjunctivae. There is a watery nasal discharge. The patient's throat is slightly injected with tongue having a faint green coloration. Examination of the chest reveals diffuse wheezing. The patient coughs throughout the examination. Cardiovascular examination, abdominal examination, extremities and neurological examination were all normal.

P.V. Patient

You are a non-smoker. You drink about two cans of beer per weekend. You drink three cups of coffee a day when at work and one cup of coffee a day on weekends. You have never used illicit drugs.

You live at home with your wife and three year old and five year old sons. They are in good health. There is no family history of asthma or allergies.

Home Environment: You live in a semi-detached home in eastern Baltimore County. The home was repainted about five years ago when you first moved in. There have been no major repairs since. You have not been doing any work on your house other than cutting the lawn. You have not been putting any chemicals in the garden or home. Heating is a heat pump with forced air, but the heat is not running at present because it is springtime. There is an Irish Setter who is three years old. Water is city water and you are connected to the city sewer.

Community: There are no major sources of air pollution in the community that you are aware of. There is a landfill that the community has been complaining about located about two miles from your house, but you are not aware of any odors or problems associated with this.

Work: You work as a boilermaker and have done so since age 18 when you joined the union as an apprentice. The work is quite strenuous and is often hot and dusty. You occasionally do some welding on the job, but this involves less than 10% of your time. Older members of your union participated in screening for asbestos exposure. You believe that you have not had much uncontrolled exposure to asbestos during your working career. You once participated in training on safe asbestos removal, but have not been on jobs where it has been required. When asbestos containing materials are encountered on the job other contractors are brought in to remove it before your work proceeds.

During the last week you have been working on a boiler at the "Riverview" power plant. On this job you have been cleaning both boiler tubes. The boiler is a large cylinder structure about 10 feet across. It was converted some years ago to burn fuel oil. For the past three days you have been engaged in cleaning it out.

On the first day, a co-worker cut open an access door which had previously been welded shut. Once the access door was removed, you had to dig out "bottom ash" which had built up at the bottom of the boiler in order to clear an opening. This was the day that you first noticed some symptoms. You had a large vacuum system to help collect the debris and you used disposable dust and mist masks (made of molded rubber with two straps to secure it firmly during the dusty parts of this operation).

The boiler was opened from above and you and a co-worker have climbed down into the boiler to clean built up soot and ash off of the boiler tubes and out of the bottom of the boiler where it had accumulated. On the next day, you climbed down into the boiler with a co-worker wearing protective coveralls and a dust mask to help shovel material over to the access door. On this day you noted your symptoms were worse. Today, before coming to the doctor's office, you were working outside the boiler and your two companions were inside. You were helping with vacuuming the system while they knocked down soot off the boiler tubes.

You worked around boiler cleaning operations in the past, but this is the dustiest one you have been around. You attribute this to a long period of time since this boiler was opened for cleaning. You feel sure that the exposure to the dust made you cough, but you also wonder whether the dust itself might have caused your illness. You note that both of your co-workers were complaining of a cough and runny nose and neither had previously been ill.

P.V 's Co-worker P.T.

You are a co-worker of Mr. P.V. at R.K.P. Service . You were also working this week cleaning out the boiler with Mr. P.V. You cut the access door during your first day on the job. Mr. P.V. and another co-worker had been there the day before and had been inside the boiler, you believe, surveying the situation.

You used a negative pressure respirator with an organic vapor cartridge while you were doing the burning. You noted a somewhat acrid smell and taste while you were burning.

After you had the door open and were helping to shovel materials out into the vacuum collecting system, you found yourself sneezing and coughing quite a bit, but this got better. On the second day you spent a short period of time inside the boiler doing some shoveling, but found that in spite of the negative pressure respirator, you were coughing and your eyes were watering. You found yourself continuing to be short of breath after work that day and went to the emergency room where you were told that you had a bronchitis and were given erythromycin. You took the next two days off work and are feeling substantially better.

You smoke about one pack of cigarettes a day since age 18 (you are now 35) and you have had one previous episode of bronchitis last winter.

F.D. Business Agent

You are the business agent for the boilermakers' local. Mr. P.V. and Mr. P.T. are members of your local union. They have been working for a service company that repairs and maintains boilers. The company frequently is involved in cleaning boilers.

You are well aware that fuel oil and coal can contain vanadium and there is frequently a build up of vanadium in bottom ash and soot, especially after the burning of fuel oil.

Last year, nearly a dozen members of your union became ill while working on a boiler in southern Maryland. On this job employees of another contractor were using abrasive blasting to clean off boiler pipes during the evening shift. Your workers were entering the same boiler to make repairs, but found the work area heavily contaminated with dust.

Many of the workers were from Baltimore and were staying at a local motel rather than commute. When they became ill with runny noses and cough, they initially thought it was related to a viral illness. An older worker raised the issue of vanadium exposure and contacted you. On the third day of the job, several workers were so ill that they were seen in the emergency room in LaPlata (the nearest hospital) where a diagnosis of bronchitis caused by vanadium pentoxide was made. None of the workers on the current boiler job were involved in this previous episode and a different utility company was involved.

Baltimore Gas and Electric Company

You are the hygienist for the Baltimore Gas and Electric Company. You have not previously been involved with episodes of illness from vanadium, but you are aware that it is a potential hazard. In this case, the bottom ash was sampled as part of a decision making process related to its eventual disposal in a landfill. It was found to contain a significant percentage (6% by weight) of vanadium among other metals and was treated as a toxic waste. You have not been involved with the contractor doing the job and it is corporate policy not to provide direct health and safety training for contractors and employees. This is the responsibility of the contractor who you believe is aware of the hazardous nature of the material.

K. P. . Manager of R.K.P. Service Company

You are the manager of R.K.P. service company which is owned by you and your brother, R.P. You do maintenance work on boilers, including cleaning them. You have a vacuum system connected to a truck which is quite useful in sucking up and cleaning out the bottom ash on large jobs.

The boiler that your employees have been working on is larger and dirtier than most.

You are aware that there is a potential hazard from the dust when cleaning out boilers and are, therefore, providing respirators and protective clothing. You are concerned that frequently employees are not using respirators even though they are being provided. On any given day your company is running 3-4 different jobs and you can't be everywhere, all the time.

OSHA - concerning BG&E Riverside Power Plant

You are not aware of this job. You are aware of the hazards of boiler cleaning and the potential for exposure to vanadium pentoxide. You know that vanadium pentoxide is a respiratory irritant and that it characteristically causes a green tongue.

Last year, one of your inspectors spent three days inspecting the Morgantown Power Plant of the Pepco Company where a number of workers developed cough and wheezing and were evaluated in the emergency room during the clean out of the boiler. In that case, you believe that workers may not have been using their negative pressure respirators all of the time, but you also were suspicious that levels of dust within the boiler were extremely high at times.

This document was last modified on 06/14/2000 03:07:57 PM

This resource was acquired by CEEM (Consortium for Environmental Education in Medicine), a program of Second Nature, under the auspices of a NIEHS grant to gather and disseminate environmental health educational resources over the internet in order to help medical and allied health sciences faculty identify, locate and use resources for incorporating environment and health perspectives into their curricula. CEEM has authorized the use of these materials on this website for archival purposes. Please note that the copyright for this material is retained by the instructor and/or contributing institution.