A 4-Year-Old Girl with Manifestations of Multiple Chemical Sensitivities

Environmental Health Perspectives, Dec, 2000 by Alan Woolf

Multiple chemical sensitivities (MCS) syndrome, also known as idiopathic environmental intolerance, is a controversial diagnosis that encompasses a wide range of waxing and waning, subjective symptoms referable to more than one body system and provoked by exposure to low levels of chemicals, foods, or other agents in the environment. Although MCS has been studied extensively, a unifying mechanism explaining the illness remains obscure, and clinicians are divided as to whether such a medical entity exists separately from psychosomatic syndromes. MCS is an adult diagnosis; there is little reference to pediatric cases in the scientific literature. In this case from the Pediatric Environmental Health Subspecialty Unit at Boston's Children's Hospital, I present the case of a preschool child who had suffered from milk allergy and poor weight gain as an infant, and then later developed asthma, allergic symptoms, sinusitis, headaches, fatigue, and rashes precipitated by an expanding variety of chemicals, foods, and allergens. I review definitions, mechanisms, diagnostic strategies, and management, and discuss some uniquely pediatric features of MCS as illustrated by this case. Key word: idiopathic environmental intolerance, multiple chemical sensitivities. Environ Health Perspect 108:1219-1223 (2000). [Online 20 November 2000] http://ehpnet1.niehs,nih.gov/docs/2000/108p 1219-1223woolflabstract.html

Case

A young girl (4 year 11 months of age) was referred to the Pediatric Environmental Health Subspecialty Unit at Boston's Children's Hospital (PEHSU) for evaluation. She had been previously diagnosed by her pediatrician as having allergies, frequent otitis media, congestion, sinusitis, and reactive airway disease, with cough-equivalent bronchospasm especially prominent during upper respiratory infections and exercise. During infancy the patient had been diagnosed with poor weight gain due to a milk allergy and treated with an elemental milk and then soy formula. There was a family history of atopy; the father and secondary relatives had childhood asthma and hay fever. Previous allergy testing was positive only for cat dander; therapy included inhaled bronchodilators, steroids, antihistamines, and cromolyn.

At home, the family allowed no tobacco smoking and had reordered the house to make it more habitable for the patient. They had removed all carpeting and covered the mattress on the child's bed. The house was frequently dusted and the gas-fired furnace and ductwork were regularly cleaned.

The patient's mother was concerned that her daughter's symptoms were becoming worse with a variety of environmental triggers and an expanding list of symptoms. Volatile organic chemicals, cleaning compounds, detergents, perfumes, cigarette smoke, dust, and paints caused new symptoms of pruritis, headache, fatigue, nausea, difficulty breathing, and malaise. The patient was on a restricted and rotating diet, which included goat cheese and duck eggs, because of her food allergies to citrus, seafood, foods containing preservatives, and meats. The parents had purchased only all-cotton clothing for the patient because polyesters and other artificial fibers made her itch and reportedly caused rashes. The parents had also sought help from a naturopath, who had found multiple allergies. The patient was regularly given certain herbal preparations, including echinacea, astralagus, pulsatilla, bryonia, forscolin, and quercidin, with some relief of symptoms, according to the parents.

The child frequently had olfactory warning when chemicals in the environment were going to exacerbate her symptoms; whenever she voiced her anxieties, the family then quickly left the environment. Thus the patient had begun to severely limit her activities because of her multiple chemical sensitivities (MCS). For example, the mother no longer took her daughter into public restrooms or grocery stores because the disinfectants caused dizziness, fatigue, headache, chest tightness, and nausea. After the patient visited the PEHSU, her mother complained that some areas of the hospital had been freshly painted and that the patient had later become symptomatic with an asthma attack. She feared that the patient's imminent transition into public school kindergarten would likely be sabotaged by the school's routine use of pesticides and cleaning products. The school had supplied her in advance with material safety data sheets covering 15 commercial products, which contained more than 35 chemicals applied indoors during the routine maintenance at the school. School officials denied that any renovations were planned, but they promised to work with the parents to limit the patient's contact with chemical exposures.

A physical examination revealed a frail-appearing child with no evidence of rashes or eczema. The eye, nose, and throat exam showed mild nasal turbinate swelling and redness, but no involvement of the conjunctiva or throat. The patient's lungs were clear, and the heart and abdomen, as well as the rest of the exam, were within normal limits. Previous blood work, including peripheral eosinophil count and serum IgE level, was negative or normal.