- Case study
- Open Access
Diffuse alveolar hemorrhage after use of a fluoropolymer-based waterproofing spray
© Kikuchi et al. 2015
- Received: 4 January 2015
- Accepted: 2 June 2015
- Published: 17 June 2015
A 30-year-old man developed chills, cough and dyspnea a few minutes after using a fluoropolymer-based waterproofing spray in a small closed room. He visited our hospital 1 h later. Examination revealed that the patient had incessant cough, tachypnea, fever and decreased peripheral arterial oxygen saturation. Blood tests revealed leukocytosis with elevated serum C-reactive protein levels. Chest radiographs and computed tomography (CT) scan showed bilateral ground glass opacities, mainly in the upper lobes. Bronchoalveolar lavage (BAL) fluid obtained from the right middle lobe showed a bloody appearance. Microscopic examination of a BAL cytospin specimen revealed the presence of numerous red blood cells associated with extreme neutrophilia. Microbiological studies of the BAL fluid were negative. The patient was observed without corticosteroid therapy, and his symptoms and abnormal shadows on the chest radiographs and CT improved. On day 7 after admission, the patient was discharged from the hospital. Accidental inhalation of waterproofing spray may cause diffuse alveolar hemorrhage, a rare manifestation of acute lung injury. Supportive treatment may be effective and sufficient.
- Alveolar hemorrhage
- Waterproofing spray
- Respiratory insufficiency
Laboratory data on admission
White blood cells
Blood urea nitrogen
341 U/l (H)
3.14 mg/dl (H)
Brain natriuretic peptide
Bronchoalveolar lavage (rt.B4a)
53.3% (80/150 ml)
1.2 × 106/μl
Accidental inhalation of waterproofing spray has been reported to cause lung injury (Vernez et al. 2006). Diffuse alveolar hemorrhage (DAH) is a rare, but serious manifestation of acute lung injury (Fukui et al. 2011). DAH in this patient was unlikely to be due to immune causes such as microscopic polyangiitis, systemic lupus erythematosus or Goodpasture’s syndrome, because of the absence of weight loss, arthralgia, proteinuria, hematuria, anti-nuclear antibody, anti–anti-GBM antibody or ANCA (Picard et al. 2010). Furthermore, neither congestive heart failure nor coagulopathy could be considered as the likely cause of the DAH, because the serum BNP level and coagulation profile were normal.
The toxicity of waterproofing sprays is thought to be due to their content of water-repellents, such as fluoropolymers and silicon polymers, or of the solvent in which they are delivered (Picard et al. 2010). Among different repelling agents, fluoropolymers have been the most studied with regard to their toxicity following inhalation (Hays and Spiller 2014). An animal study in mice demonstrated that inhalation of fluoropolymers resulted in pulmonary collapse and pneumonia, probably by counteracting the surfactant action in the alveoli of the lung, whereas mice exposed to non-fluoropolymer-containing products showed less severe injury (Yamashita and Tanaka 1995). These findings suggest that the fluoropolymer water repellents in waterproofing sprays are responsible for causing the acute respiratory illness following inhalation. The primary structural changes after inhalation of waterproofing sprays in animals include alveolar type I cell necrosis and alveolar type II cell necrosis, with resultant impairment of surfactant secretion, direct counteraction of surfactant action, alveolar atelectasis and hemorrhage (Hays and Spiller 2014). A recent study reported developing an isolated perfused rat lung model to examine the potential of surface tension-active substances in waterproofing sprays to cause pulmonary collapse (Fischer et al. 2012). Other mechanisms of the toxicity of waterproofing sprays include an indirect and complex mechanism requiring metabolic activation with or without interaction with other factors, such as solvents (e.g., n-heptane, hexane and petroleum distillates) and smoking (Hays and Spiller 2014). The mist particle size and the emission rate have also been shown to influence the toxicity of waterproofing sprays (Hays and Spiller 2014; Yamashita et al. 1997).
The commonest symptoms associated with inhalation of fluoropolymer-based waterproofing sprays include non-productive cough and dyspnea, often accompanied by flu-like symptoms (Vernez et al. 2006; Hays and Spiller 2014). The illness develops rapidly, usually within minutes to hours (Vernez et al. 2006; Hays and Spiller 2014). Similar to the case reported herein, there is one previous report of DAH resulting from inhalation of a waterproofing spray (Fukui et al. 2011). Laboratory studies generally reveal evidence of acute inflammation such as leukocytosis and elevated serum CRP (Hays and Spiller 2014). In one previous case report, marked hypocalcemia was observed in the patient, which was attributed to the binding activity of fluoride to cations, such as calcium (Bracco and Favre 1998). Serious outcomes and death are uncommon (Vernez et al. 2006; Hays and Spiller 2014). Most victims, even those that present DAH, like our patient, improved with supportive care, with or without corticosteroid and inhaled β2 adrenergic agonist therapy (Vernez et al. 2006; Fukui et al. 2011; Hays and Spiller 2014).
Accidental inhalation of waterproofing sprays may cause diffuse alveolar hemorrhage, a rare manifestation of acute lung injury. Supportive treatment may be effective and sufficient.
RK and KA wrote the manuscript. MI, TU, HW and HN revised it critically. All authors read and approved the final manuscript.
The authors do not have any financial support to declare.
Compliance with ethical guidelines
Competing interests The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- Baughman RP (2007) Technical aspects of bronchoalveolar lavage: recommendations for a standard procedure. Semin Respir Crit Care Med 28(5):475–485View ArticleGoogle Scholar
- Bracco D, Favre JB (1998) Pulmonary injury after ski wax inhalation exposure. Ann Emerg Med 32(5):616–619View ArticleGoogle Scholar
- Fischer M, Koch W, Windt H, Dasenbrock C (2012) A pilot study on the treatment of acute inhalation toxicity studies: the isolated perfusion rat lung as a screening tool for surface-active substances. Altern Lab Anim 40(4):199–209Google Scholar
- Fukui Y, Tanino Y, Doshita K, Nakano H, Okamoto Y (2011) Diffuse alveolar hemorrhage arising after use of a waterproofing spray. Nihon Kokyuki Gakkai Zasshi 49(5):360–364 (Article in Japanese) Google Scholar
- Hays HL, Spiller H (2014) Fluoropolymer-associated illness. Clin Toxicol 52(8):848–855View ArticleGoogle Scholar
- Picard C, Cadranel J, Porcher R, Prigent H, Levy P, Fartoukh M et al (2010) Alveolar haemorrhage in the immunocompetent host: a scale for early diagnosis of an immune cause. Respiration 80(4):313–320View ArticleGoogle Scholar
- Vernez D, Bruzzi R, Kupferschmidt H, De-Batz Droz P, Lazor R (2006) Acute respiratory syndrome after inhalation of waterproofing sprays: a posteriori exposure-response assessment in 102 cases. J Occup Environ Hyg 3(5):250–261View ArticleGoogle Scholar
- Yamashita M, Tanaka J (1995) Pulmonary collapse and pneumonia due to inhalation of a waterproofing aerosol in female CD-1 mice. J Toxicol Clin Toxicol 33(6):631–637View ArticleGoogle Scholar
- Yamashita M, Yamashita M, Tanaka J, Hirai H, Suzuki M, Kajigaya H (1997) Toxicity of waterproofing spray is influenced by the mist particle size. Vet Hum Toxicol 39(6):332–334Google Scholar