(105) Uncharted skies: validating the controversial diagnosis of aeortoxin syndrome

Presenting Author(s)

Mehgan Oswald, DMD, MD

Resident
Northwell Mather Hospital
Port Jefferson, New York

Co-Author(s)

JT

Jenna Taglienti, MD

Psychiatry Residency Training Director at Mather Hospital
Northwell Health
Port Jefferson, New York
SK

Saad Khan, DO FAPA

Senior Medical Officer
Optum Home Based Medical Care
Woodbury, New York

Disclosure(s):

Mehgan Oswald, DMD, MD: No financial relationships to disclose

Abstract: Background/Significance: Aerotoxic syndrome (AS) is a controversial diagnosis which encompasses symptoms experienced by pilots and cabin crew following exposure to airborne contaminants. Acute manifestations include eye, skin, and respiratory irritation, headaches, and gastrointestinal issues. Chronic symptoms include cognitive impairment, gastrointestinal problems, myalgias, palpitations, fatigue, apathy, PTSD and anxiety (Hageman, 2020). Here we present a case of AS referred to psychiatry for new-onset neuropsychiatric symptoms after suspected toxin exposure.

Case: A 59-year-old female flight attendant with no past medical or psychiatric history was working a flight when she noticed a mist from a vent which smelled like "dirty socks". Upon toxin exposure, she developed confusion, shortness of breath, chest/neck pressure, palpitations, headache, and dizziness. Subsequentially, she developed cognitive deficits, insomnia, anxiety, weight loss, fatigue, and gait instability. She was referred to occupational medicine by the airline and diagnosed with AS. She was referred to psychiatry for further evaluation. Due to late onset of symptoms and extensive physical symptoms, a comprehensive medical work-up was indicated. She was referred for neurological evaluation. Despite notable cognitive deficits, gait abnormalities, and positive Romberg's sign on neurologic exam, no primary neurologic disorder was diagnosed. Neuropsychiatric testing revealed deficits in various cognitive domains lower than expected for level of education and professional attainment. Lab work yielded serum antibodies against neuronal proteins (MAP-2 and MAG) and glial protein (GFAP). Throughout this evaluation period, the patient was treated with fluoxetine for anxiety and referred for cognitive behavioral therapy with only mild improvement in symptoms.

Discussion: This case highlights the complex nature of AS and potential long-term consequences on both physical and mental health. Many of the neurobehavioral symptoms associated with AS, have been documented in agricultural workers, pesticide sprayers and veterans who served in the Gulf War. In these scenarios, the neurological symptoms are attributed to organophosphate exposure (Burdon, 2023). To our knowledge, there are no evidence-based treatment guidelines for neuropsychiatric management of these symptoms. The presence of antibodies against MAP-2 and GFAP in our patient is consistent with brain injury (Burdon, 2023). We suspect the chemical exposure contributed to her chronic physical and neuropsychiatric symptoms. With no pertinent predisposing psychological factors evident on evaluation, we determined her psychiatric symptoms were less likely due to a primary psychiatric disorder but secondary to AS, allowing the patient to retire with disability from the airline.

Conclusion: This case highlights the complex interplay between environmental factors and neuropsychological health, particularly in the context of early-onset cognitive disturbances. Psychiatry can play a vital role in validating the diagnosis of organic etiology through interdisciplinary collaboration. More research is needed to develop effective therapies for the neuropsychiatric symptoms of AS.

References:
Burdon J, et al. Health consequences of exposure to aircraft contaminated air and fume events: a narrative review and medical protocol for the investigation of exposed aircrew and passengers. Environ Health. 2023 May 16;22(1):43.

Hageman G, et al. Aerotoxic syndrome, discussion of possible diagnostic criteria. Clin Toxicol (Phila). 2020 May;58(5):414-416. 64.

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: Aerotoxic syndrome (AS) is currently a controversial diagnosis. It's important to note that controversy surrounding these diagnoses can impact individuals' experiences, including their ability to access appropriate care, social support, and validation of their symptoms. The study of AS can shed light on the environmental health risks associated with airline travel. By understanding the health impacts of air quality on airline workers, healthcare providers can advocate for regulations, benefiting all individuals who rely on air travel. Lastly, raising awareness of AS can lead to improved medical care and support for affected individuals, regardless of their socioeconomic status or background.