Approach

Identification of exposure to mycotoxins requires knowledge of potential routes of exposure and recognition of the key signs and symptoms. The likelihood of developing adverse effects following exposure varies with factors such as dose and duration of exposure.

With any suspected mycotoxin event (other than chronic food exposures), clinicians must contact local or national authorities. Reporting to regional poison information centres is also strongly encouraged for toxicovigilance purposes.

Decontamination and personal protective equipment (PPE)

In the event of aerosol exposure, first responders should wear PPE (protective clothing and mask) and evacuate the adjacent area.[20][21][22] The contaminated area covered with aerosolised mycotoxins is likely to be small. A filtering mask that blocks the penetration of aerosol particles 3 to 4 micrometres or larger will provide respiratory protection against mycotoxins. 

Patients with dermal exposure should be decontaminated with soap and water.

History

A history of exposure to T-2 mycotoxin via consumption of contaminated grains and/or droplet exposure is key for the diagnosis. A deliberate release of T-2 mycotoxin should be suspected if patients with acute respiratory symptoms and blistering, painful rash present in large numbers. Laboratory workers in contact with T-2 mycotoxin are at high risk due to the toxicity and because it can be absorbed through intact skin; however, these workers usually deal with extremely low amounts (and concentrations) and use protective measures to minimise risk. First responders who are unaware of a potential aerosol exposure are at risk.

Symptoms will depend on the route of exposure.

  • Skin contact: immediate burning pain and redness with blister formation (including exposed mucosal surfaces). People may report seeing yellow-coloured droplets or aerosol haze just prior to the onset of symptoms. Onset of symptoms may be immediate or up to about 20 minutes post-exposure.[11]

  • Ingestion: vomiting and diarrhoea.

  • Ocular exposure: burning pain, redness, and blurred vision.

  • Inhalation: nasal irritation and cough.

Systemic symptoms can develop with all routes of exposure (especially with inhalation). These include weakness, mild ataxia, hypotension, coagulopathy, and death.

Chronic exposure to T-2 mycotoxin can result in a presentation similar to radiation sickness, known as alimentary toxic aleukia (ATA) with haematological or immune symptoms.

Physical examination

Early signs of T-2 poisoning will reflect route of exposure. However, as any route of exposure may lead to systemic symptoms, all patients require monitoring for progression of toxicity over 24 to 48 hours.

Examination for signs of dehydration should occur in people presenting with vomiting or diarrhoea.

Respiratory signs (especially with inhalational exposure):

  • Nasal pain, rhinorrhoea, epistaxis

  • Blood-tinged saliva and sputum

  • Cough (possibly with haemoptysis)

  • Dyspnoea

  • Widespread wheezes and crackles indicating bronchospasm and pulmonary oedema.

Skin and mucosal contact signs:

  • Blistering and bullous lesions

  • Burning pain

  • Necrosis

  • Ocular exposure might result in blurred vision and corneal damage.

Gastrointestinal signs:

  • Vomiting and diarrhoea.[23] 

In more severe cases, the following may be seen:

  • Tachycardia

  • Hypotension and shock in severe toxin exposure

  • Severe dizziness

  • Mild ataxia

  • Prostration

  • Hypothermia.

Initial investigations

Laboratory studies and imaging studies are usually unrevealing in T-2 mycotoxin exposure. There are no commonly available tests for the toxin in human blood or urine. In the US, there are some commercial laboratories that offer urine mycotoxin testing directly to patients; however, these are not validated by the US Food and Drug Administration (FDA) and the results are of questionable clinical significance.

Diagnosis is clinical, based on signs and symptoms, and a history of possible exposure.

Other investigations

Confirmation of T-2 mycotoxin exposure may be biological or environmental; samples need to be sent to a reference laboratory.[24] Urine samples can be tested for the presence of mycotoxin using a liquid chromatography/electrospray ionisation tandem mass spectrometry method.[24][25] Environmental samples can be checked by the appropriate authorities for identification of the toxin; however, there is no standard method for detection.[15][24] This type of testing is not readily available and often takes days or weeks to accomplish, making clinical recognition and supportive management key to the initial management of cases of T-2 mycotoxin exposure. 

Pulse oxymetry, capnography, pulmonary function tests (such as peak expiratory flow rate and end-tidal CO₂), and arterial blood tests are useful to evaluate severity of poisoning and monitor for the need for airway control and ventilator support.

Other investigations to consider include:

  • Chest x-ray in patients with signs of pulmonary oedema

  • Serum electrolytes in patients with significant gastrointestinal complaints and possible dehydration

  • Initial baseline full blood count with ongoing monitoring for risk of bone marrow suppression

  • Coagulation studies in patients with signs of bleeding, which may also help identify those patients at risk of severe coagulopathy.

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