[Multiple chemical sensitivity and recurrent lower urinary tract symptoms (LUTS). Contribution with an illustrative urological case.] / Sensibilidad química múltiple y síntomas recurrentes del tracto urinario inferior (STUI). Contribución con caso urológico ilustrativo.

INTRODUCTION AND OBJECTIVES: Multiple chemical sensitivity (MCS) is a disease due to a disproportionate systemic response to chemical agents presentin the environment. ts urinary manifestations are rare and poorly understood. We present a case with recurrent lower urinary tract symptoms (LUTS) and review these symptoms in Spanish and foreign publications. CLINICAL CASE: A 30-year-old woman was referred for study of recurrent lower urinary tract symptoms of 17 years of evolution, triggered by food, perfumes, cleaning products, cosmetics and bleach. Repeated analytical, radiological and functional tests were normal. We suspected that she might suffer from MCS and advised a study in Preventive Medicine. The patient consulted an Environmental Medicine Center, and was diagnosed as having gradeIII-IV/IV MCS. CONCLUSIONS: This is the first case of MCS diagnosed from urinary clinical manifestations. Among the causes of LUTS we should also think of MCS.

INTRODUCCIÓN Y OBJETIVOS: La sensibilidad química múltiple (SQM) es una enfermedad debida a una respuesta sistémica desproporcionada a los agentes químicos presentes en el medio ambiente. Sus manifestaciones urinarias son raras y poco conocidas. Presentamos un caso que cursó con síntomas recurrentes del tracto urinario inferior (STUI) y revisamos estos síntomas en publicaciones españolas y extranjeras.CASO CLÍNICO: Mujer de 30 años remitida para estudio de síntomas recurrentes del tracto urinario inferior de 17 años de evolución, desencadenados por alimentos, perfumes, productos de limpieza, cosméticos y lejía. Repetidas pruebas analíticas, radiológicas y funcionales fueron normales. Sospechamos que podía padecer SQM, aconsejando estudio en Medicina Preventiva. La paciente consultó en un Centro de Medicina Ambiental, diagnosticándole SQM grado III-IV/IV.CONCLUSIONES: Éste es el primer caso de SQM diagnosticado a partir de manifestaciones clínicas del tracto urinario inferior. Entre las causas de STUI deberíamos pensar también en la SQM.

Multiple chemical sensitivity (MCS) - a guide for dermatologists on how to manage affected individuals.

Multiple chemical sensitivity (MCS) is a condition characterized by a subjectively perceived increase in sensitivity to environmental chemicals. Individuals affected report a wide variety of nonspecific complaints, and frequently attribute cutaneous and mucosal symptoms to chemical exposures. Dermatologists should therefore be familiar with this condition. MCS is a diagnosis of exclusion. Other causes for the patients' symptoms should be ruled out by routine laboratory tests, allergy tests and, if indicated, monitoring for toxic (environmental) substances. The primary job of dermatologists is to rule out skin diseases or hypersensitivities as possible causes of the complaints. Interdisciplinary patient management is essential, especially in severe cases in which those affected have problems coping with everyday life. Relevant specialties in this context include environmental medicine, psychosomatic medicine as well as occupational and social medicine. Cutaneous symptoms are usually addressed with symptomatic treatment using basic skin care products. There are currently no evidence-based treatment recommendations for MCS. It is crucial that MCS patients be protected from unnecessary treatments and thus from mental, social and financial strain. In addition to medical skills, managing MCS patients requires communicative and psychosocial competence in particular. Physicians involved in the treatment will benefit from training in psychotherapy. Irrespective of the mechanisms that lead to MCS, diagnosis and treatment of this condition require an actively supportive attitude towards these patients, a good doctor-patient relationship and interdisciplinary cooperation.

¿Podemos descartar que la fibromialgia, el síndrome de fatiga crónica y la sensibilidad química múltiple sean enfermedades psicosomáticas? / Can we rule out that fibromyalgia, chronic fatigue syndrome and multiple chemical sensitivity are psychosomatic diseases?

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Brain responses to olfactory and trigeminal exposure in idiopathic environmental illness (IEI) attributed to smells -- an fMRI study.

OBJECTIVE: Idiopathic environmental intolerance (IEI) to smells is a prevalent medically unexplained illness. Sufferers attribute severe symptoms to low doses of non-toxic chemicals. Despite the label, IEI is not characterized by acute chemical senses. Theoretical models suggest that sensitized responses in the limbic system of the brain constitute an important mechanism behind the symptoms. The aim was to investigate whether and how brain reactions to low-levels of olfactory and trigeminal stimuli differ in individuals with and without IEI. METHODS: Brain responses to intranasally delivered isoamyl acetate and carbon dioxide were assessed in 25 women with IEI and 26 non-ill controls using functional magnetic resonance imaging. RESULTS: The IEI group had higher blood-oxygenated-level-dependent (BOLD) signal than controls in the thalamus and a number of, mainly, parietal areas, and lower BOLD signal in the superior frontal gyrus. The IEI group did not rate the exposures as more intense than the control group did, and there were no BOLD signal differences between groups in the piriform cortex or olfactory regions of the orbitofrontal cortex. CONCLUSIONS: The IEI reactions were not characterized by hyper-responsiveness in sensory areas. The results can be interpreted as a limbic hyperreactivity and speculatively as an inability to inhibit salient external stimuli.

Safety survey of intranasal glutathione.

PURPOSE: Glutathione depletion has been documented in several disease states, and exogenous administration has been hypothesized to have therapeutic potential for some conditions. In an effort to reach target tissues of the sinuses and central nervous system (CNS), glutathione is being prescribed as an intranasal spray, although no literature exists to support this mode of administration. The objective of this study was to describe patient-reported outcomes in a population of individuals who have been prescribed intranasal reduced glutathione, (in)GSH. METHODS: A survey was designed to assess individuals' perception of tolerability, adverse events, and health benefits associated with (in)GSH use. Using a pharmacy database, 300 individuals were randomly selected to receive a survey; any individual who had received one or more prescriptions for (in)GSH between March 2009 and March 2011 was eligible for participation. RESULTS: Seventy (70) individuals returned the survey (23.3% response rate) from 20 different states. Reported indications for (in)GSH prescriptions were multiple chemical sensitivity (MCS) (n=29), allergies/sinusitis (n=25), Parkinson disease (PD) (n=7), Lyme disease (n=3), fatigue (n=2), and other (n=10). Of the respondents, 78.8% (n=52) reported an overall positive experience with (in)GSH, 12.1% (n=8) reported having experienced adverse effects, and 62.1% (n=41) reported having experienced health benefits attributable to (in)GSH use. Over 86% of respondents considered the nasal spray to be comfortable and easy to administer. CONCLUSIONS: This is the first study to evaluate patient-reported outcomes among individuals across the country who have been prescribed (in)GSH. The majority of survey respondents considered (in)GSH to be effective and without significant adverse effects. (in)GSH should be further evaluated as a method of treating respiratory and CNS diseases where free-radical burden is a suspected contributor to disease progression.

The search for reliable biomarkers of disease in multiple chemical sensitivity and other environmental intolerances.

Whilst facing a worldwide fast increase of food and environmental allergies, the medical community is also confronted with another inhomogeneous group of environment-associated disabling conditions, including multiple chemical sensitivity (MCS), fibromyalgia, chronic fatigue syndrome, electric hypersensitivity, amalgam disease and others. These share the features of poly-symptomatic multi-organ cutaneous and systemic manifestations, with postulated inherited/acquired impaired metabolism of chemical/physical/nutritional xenobiotics, triggering adverse reactions at exposure levels far below toxicologically-relevant values, often in the absence of clear-cut allergologic and/or immunologic involvement. Due to the lack of proven pathogenic mechanisms generating measurable disease biomarkers, these environmental hypersensitivities are generally ignored by sanitary and social systems, as psychogenic or "medically unexplained symptoms". The uncontrolled application of diagnostic and treatment protocols not corresponding to acceptable levels of validation, safety, and clinical efficacy, to a steadily increasing number of patients demanding assistance, occurs in many countries in the absence of evidence-based guidelines. Here we revise available information supporting the organic nature of these clinical conditions. Following intense research on gene polymorphisms of phase I/II detoxification enzyme genes, so far statistically inconclusive, epigenetic and metabolic factors are under investigation, in particular free radical/antioxidant homeostasis disturbances. The finding of relevant alterations of catalase, glutathione-transferase and peroxidase detoxifying activities significantly correlating with clinical manifestations of MCS, has recently registered some progress towards the identification of reliable biomarkers of disease onset, progression, and treatment outcomes.

The capsaicin cough reflex in patients with symptoms elicited by odorous chemicals.

Patients with multiple chemical sensitivity and eczema patients with airway symptoms elicited by odorous chemicals have enhanced cough reflex to capsaicin when applying the tidal breathing method. The aims of the present study were to test whether the capsaicin induced cough reflex was enhanced when applying the single breath inhalation method in similar groups of patients with symptoms related to odorous chemicals e.g. other persons wearing of perfume; and to investigate to what extent the reporting of lower airway symptoms influenced the cough reflex. Sixteen patients fulfilling Cullen's criteria for multiple chemical sensitivity and 15 eczema patients with airway symptoms elicited by odorous chemicals were compared with 29 age-matched, healthy controls. We measured C5--the capsaicin concentration causing five coughs or more--using the single breath inhalation test. No difference was found between groups in age, body mass index or pulmonary function. The median C5 were 129 micromol/L (control group), 48 micromol/L (multiple chemical sensitivity patients), 32 micromol/L (eczema patients). The reporting of lower airway symptoms from odorous chemicals was significantly (p<0.05) correlated to increased cough reflex sensitivity to capsaicin, independent of patient group or co-existence of asthma. The results suggest that the C5 is not reliable for diagnosing MCS but C5 can be used to verify presence of lower airway symptoms related to odorous chemicals.

The German Multicentre Study on Multiple Chemical Sensitivity (MCS).

In this multicentre study on multiple chemical sensitivity (MCS) 291 consecutive environmental medicine (EM) outpatients were examined in several environmental medicine outpatient centres/units throughout Germany in 2000/2003. Of the EM outpatients, 89 were male (30.6%) and 202 were female (69.4%), aged 22-80 (mean 48 years, S.D.=12 years). The sample was representative for university-based environmental outpatient departments and represented a cross-sectional study design with an integrated clinical-based case-control comparison (MCS vs. non-MCS). Three classifications of MCS were used: self-reported MCS (sMCS), clinically diagnosed MCS (cMCS), and formalised computer-assisted MCS with two variants (f1MCS, f2MCS). Data were collected by means of an environmental medicine questionnaire, psychosocial questionnaires, the German version of the Composite International Diagnostic Interview (CIDI), and a medical baseline documentation, as well as special examinations in partial projects on olfaction and genetic susceptibility markers. The hypothesis guided evaluation of the project showed that the patients' heterogenic health complaints did not indicate a characteristic set of symptoms for MCS. No systematic connection could be observed between complaints and the triggers implicated, nor was there any evidence for a genetic predisposition, or obvious disturbances of the olfactory system. The standardised psychiatric diagnostics applying CIDI demonstrated that the EM patients in general and the subgroup with MCS in particular suffered more often from mental disorders compared to an age and gender matched sample of the general population and that in most patients these disorders commenced many years before environment-related health complaints. Our results do not support the assumption of a toxicogenic-somatic basis of the MCS phenomenon. In contrast, numerous indicators for the relevance of behavioural accentuations, psychic alterations or psychosomatic impairments were found in the group of EM-outpatients with subjective "environmental illness".

[Multiple chemical sensitivity (MCS) -- a case series]. / Multiple Chemikalienüberempfindlichkeit (MCS) - eine Fallserie.

BACKGROUND AND OBJECTIVE: The phenomenon of Multiple Chemical Sensitivity which generally cannot be explained organically is frequently associated with psychic impairment. This case series deals with the question if in addition to a standardized interview a routine psychiatric-psychosomatic examination alters the classification if a patient suffers from symptoms compatible with MCS or not. METHODS: Nine consecutive outpatients (m = 3, f = 6, mean age 44 yrs) of the environmental medicine centre were investigated. Somatic diseases were evaluated by standard medical procedures and emotional disturbances were assessed by the Munich Composite International Diagnostic Interview (M-CIDI) and a psychiatric-psychosomatic examination. RESULTS: In all but one patients emotional disturbances (F-codes of the ICD-10) were diagnosed by the M-CIDI and the psychiatric-psychosomatic examination. The diagnoses of the M-CIDI and the psychiatric-psychosomatic examination often did not match. MCS was ruled out in seven patients. CONCLUSIONS: According to the criteria defined by Cullen (5), emotional disturbances must be ruled out before MCS is diagnosed. Therefore, an examination by a specialist in psychiatry or psychosomatics is mandatory because evaluation solely based on the M-CIDI is insufficient. Performing a routine psychiatric-psychosomatic examination, MCS could be ruled out much more often than previously.

[Validation of a screening instrument for multiple chemical sensitivity (MCS): the chemical odor sensitivity scale (COSS)]. / Validierung eines Screeninginstruments zur Identifizierung von Multiple Chemical Sensitivity (MCS): Die Chemische Geruchssensitivitätsskala (CGSS).

Multiple Chemical Sensitivity (MCS) -- also known as Idiopathic Environmental Intolerances (IEI) -- is defined as a disorder with multiple somatic and psychological symptoms attributed to low levels of various, chemically unrelated substances in the environment. Self-reported chemical odor sensitivity is an important feature of MCS. We describe the construction and the reliability and validity properties of a short questionnaire for the assessment of chemical odor sensitivity (COSS). The 11 items of the COSS were factor analytically derived from the Questionnaire of Chemical and General Environmental Sensitivity (CGES). Test statistical properties of the COSS were examined in college students, unselected community members, environmental medicine outpatients and chemically sensitive subjects. The COSS achieved good internal consistency in all samples (Cronbach's alpha = 0.89 - 0.93). Women and subjects from samples with higher MCS risk showed elevated COSS scores. The scale showed adequate construct validity and proved useful as an economic screening instrument for persons at risk for MCS.

Are syndromes in environmental medicine variants of somatoform disorders?

To date, relatively little is known about the etiology, pathophysiology, diagnosis, therapy, prevention and prognosis of environment-related syndromes like multiple chemical sensitivity (MCS), idiopathic environmental intolerance (IEI), sick building syndrome (SBS), chronic fatigue syndrome (CFS), candida syndrome (CS) and burnout syndrome (BS). Part of the reason is that these syndromes have not been clearly defined and classified in scientific categories distinct from each other, and that they show clinical similarities to classified somatoform disorders. Furthermore, there are at least three possible explanations for the existence of these syndromes: (1) The syndromes may result from the interaction of environmental factors, individual susceptibility and psychological factors (i.e., how they are perceived and seen by the patient); (2) they may reflect socially and culturally accepted methods of expressing distress; and/or (3) they may be iatrogenic. Despite all the uncertainties in evaluation of environmental syndromes, physicians have the duty to take the affected person's problems seriously. A comprehensive systematic classification which better accounts for these complex clinical manifestations is long overdue. Until these syndromes are well defined, the terms used for them should definitely not be applied to connote a specific disease process.

Psychiatric and somatic disorders and multiple chemical sensitivity (MCS) in 264 'environmental patients'.

BACKGROUND: An increasing number of individuals with diverse health complaints are currently seeking help in the field of environmental medicine. Multiple chemical sensitivity (MCS) or idiopathic environmental intolerances (IEI) is defined as an acquired disorder with multiple recurrent symptoms associated with environmental chemicals in low concentrations that are well tolerated by the majority of people. Their symptoms are not explained by any known psychiatric or somatic disorder. METHOD: Within a 2-year period we examined 264 of 267 consecutive patients prospectively presenting to a university based out-patient department for environmental medicine. Patients underwent routine medical examination, toxicological analysis and the structured clinical interview for DSM-IV psychiatric disorders (SCID). RESULTS: Seventy-five per cent of the patients met DSM-IV criteria for at least one psychiatric disorder and 35% of all patients suffered from somatoform disorders. Other frequent diagnoses were affective and anxiety disorders, and dependence or substance abuse. In 39% a psychiatric disorder, in 23% a somatic condition and in 19% a combination of the two were considered to provide sufficient explanation of the symptoms. Toxic chemicals were regarded as the most probable cause in only five cases. The suspected diagnosis of MCS/IEI could not be sustained in the vast majority of cases. CONCLUSION: This investigation confirms previous findings that psychiatric morbidity is high in patients presenting to specialized centres for environmental medicine. Somatoform disorders are the leading diagnostic category, and there is reason to believe that certain 'environmental' or MCS patients form a special subgroup of somatoform disorders. In most cases, symptoms can be explained by well-defined psychiatric and medical conditions other than MCS, which need specific treatment. Further studies should focus on provocation testing in order to find positive criteria for MCS and on therapeutic approaches that consider psychiatric aspects.

The influence of health beliefs on the presentation and consultation outcome in patients with chemical sensitivities.

OBJECTIVE: This study was carried out to investigate the impact of the physical effects of a chemical exposure, health and chemical beliefs, and chemical sensitivities treatment preferences on the consultation outcome at a tertiary liaison clinic. METHOD: Eighty-five patients exposed to a range of chemicals were assessed at a joint medical toxicology and psychiatric clinic. Patient's beliefs about chemicals and health, chemical sensitivities and their treatment preferences were assessed using a 23-item questionnaire. RESULTS: Fifty-seven patients (69%) had suffered from a range of initial or delayed symptoms that were probably a clear physical consequence of the exposure (Group A), whereas 26 patients (31%) had not (Group B). There were no significant differences found between groups A and B in terms of their diagnosis and their beliefs about health, food, chemicals and chemical sensitivities treatment preferences. However, patients in Group A were significantly more likely to report moderate to severe symptoms in comparison to Group B. Consultation outcome too did not differ between the two groups. The only predictors of consultation outcome were the patients' chemical sensitivities treatment preferences. Patients who at the outset thought that their treatment should comprise of complete avoidance to chemicals, regular monitoring and the use of alternative rather than conventional medicine were significantly less likely to achieve a favourable consultation outcome. Patients' chemical sensitivities treatment preferences were related to the more general beliefs on health, food and the harmful nature of chemicals and were not related to the chemical exposure variables. CONCLUSION: These findings suggest that addressing patients' treatment preferences and the general beliefs on chemicals, food and health may enhance outcome and perhaps ought to be the target for intervention in context of such a liaison clinic.

The Iowa follow-up of chemically sensitive persons.

Clinical symptoms and self-reported health status in persons reporting multiple chemical sensitivities (MCS) are presented from a 9-year follow-up study. Eighteen (69%) subjects from a sample of 26 persons originally interviewed in 1988 were followed up in 1997 and given structured interviews and self-report questionnaires. In terms of psychiatric diagnosis, 15 (83%) met DSM-IV criteria for a lifetime mood disorder, 10 (56%) for a lifetime anxiety disorder, and 10 (56%) for a lifetime somatoform disorder. Seven (39%) of subjects met criteria for a personality disorder using the Personality Diagnostic Questionnaire-IV. Self-report data from the Illness Behavior Questionnaire and Symptom Checklist-90-Revised show little change from 1988. The 10 most frequent complaints attributed to MCS were headache, memory loss, forgetfulness, sore throat, joint aches, trouble thinking, shortness of breath, back pain, muscle aches, and nausea. Global assessment showed that 2 (11%) had "remitted", 8 (45%) were "much" or "very much" improved, 6 (33%) were "improved", and 2 (11%) were "unchanged/worse". Mean scores on the SF-36 health survey showed that, compared to U.S. population means, subjects reported worse physical functioning, more bodily pain, worse general health, worse social functioning, and more emotional-role impairment; self-reported mental health was better than the U.S. population mean. All subjects maintained a belief that they had MCS; 16 (89%) acknowledged that the diagnosis was controversial. It is concluded that the subjects remain strongly committed to their diagnosis of MCS. Most have improved since their original interview, but many remain symptomatic and continue to report ongoing lifestyle changes.

Development of a brief questionnaire for screening for multiple chemical sensitivity syndrome.

The objective of this study was to identify a parsimonious set of questions that has high sensitivity and specificity for screening for individuals with multiple chemical sensitivity (MCS) syndrome. We performed a cross-sectional survey using a case-control design. Subjects were derived from patients seen at an academically based Occupational and Environmental Medicine Clinic. Cases consisted of patients who fulfilled the Cullen definition for MCS. Controls were patients who had diagnoses excluding MCS and asthma and who were matched to cases by age and sex. Cases and controls filled out a screening questionnaire that, among things, elicited responses as to whether and how subjects reacted to 122 different types of environmental exposures. Data from 44 pairs of cases and controls were available for analysis. The average age of cases was 50.2 years, and 91% was female. Among cases, the most common exposure that was purported to incite MCS was 'indoor air quality contaminants (unspecified)' (59%), followed by solvents (27.3%). After randomly excluding five cases and controls, a stepwise selection procedure for two-group discriminant analysis revealed that the main contributors to the discrimination of the remaining cases and controls were self-reported reactions to copy machine emissions, marking pens, aftershave, window cleaner, nylon fabric, pine-scented products, and rayon material. When a positive response to these factors was used as the sole method for discriminating cases from controls, only one of 41 cases was misclassified as a control while none of the controls was misclassified as a case. When the same method was applied to the five excluded cases and five excluded controls, only one of the five cases was misclassified while none of the five controls was misclassified as a case. Among patients with MCS defined by the Cullen criteria in this clinical setting, having a reaction to these seven common potential exposures comprised a parsimonious set of factors that discriminated between MCS patients and age- and sex-matched normal controls. These questions may have utility in screening for individuals with MCS in general population survey studies.