Advances in treatment of acute sulfur mustard poisoning – a critical review

Abstract

Sulfur mustard (SM) is a blistering chemical warfare agent that was used during the World War I and in the Iraq–Iran conflict. The aim of this paper is to discuss and critically review the published results of experiments on the treatment of SM poisoning based on our clinical and research experience. The victims must remove from the contaminated zone immediately. The best solution for decontamination is large amounts of water, using neutral soap and 0.5% sodium hypochlorite. Severely intoxicated patients should be treated according to advanced life support protocols and intensive care therapy for respiratory disorders and the chemical burn. Sodium thiosulfate infusion (100–500 mg/kg/min) should be started up to 60 min after SM exposure. However, N-acetyle cysteine (NAC) is recommended, none of them acts as specific or effective antidote. The important protective and conservative treatment of SM-induced pulmonary injuries include humidified oxygen, bronchodilators, NAC as muculytic, rehydration, mechanical ventilation, appropriate antibiotics and respiratory physiotherapy as clinically indicated. Treatment of acute SM ocular lesions start with topical antibiotics; preferably sulfacetamide eye drop, continue with lubricants, and artificial tears. Treatment for cutaneous injuries include: moist dressing; preferably with silver sulfadiazine cream, analgesic, anti-pruritic, physically debridement, debridase, Laser debridement, followed by skin autologous split-thickness therapy as clinically indicated. The new suggested medications and therapeutic approaches include: anti-inflammatory agents, Niacinamide, Silibinin, Calmodulin antagonists, Clobetasol, full-thickness skin grafting for skin injuries; Doxycycline; Bevacizumab, and Colchicine for ocular injuries. Recommended compounds based on animal studies include Niacinamide, Aprotinin, des-aspartate-angiotensin-I, Gamma-glutamyltransferase, vitamin E, and vitamin D. In vitro studies revealed that Dimethylthiourea, L-nitroarginine, Methyl-ester, Sodium pyruvate, Butylated hydroxyanisole, ethacrynic acid, and macrolide antibiotics are effective. However, none of them, except macrolide antibiotics have been proved clinically. Avoidance of inappropriate polypharmacy is advisable.

Keywords:

• Sulfur mustard
• acute poisoning
• intoxication
• sodium thiosulfate
• decontamination
• chemical warfare agents
• N-acetyl cysteine

Acknowledgements

The authors gratefully acknowledge the advice of the editor and constructive comments of reviewers who were selected by the Editor and anonymous to the authors. They helped us to improve the final version of the manuscript.

Declaration of interest

There are no conflicts of interest associated with this publication and there has been no financial support for this work that could influence its outcome. The author’s affiliations are as shown on the cover page. The authors have sole responsibility for the writing and content of the paper. Preparation of this review was conducted during the normal course of the authors' employment without any external support

Author contributions

LE and MM searched the literatures in databases, wrote the drafts, MBM reviewed the drafts and supervised revisions, edited and acted as the corresponding author.