Toxic Oil Syndrome: A new disease A perspective of interaction between host and environment

1. Toxic Oil Syndrome:A new diseaseA perspective of interaction between host and environment Manuel Posada de la Paz, M.D. Toxic Oil Research Centre Centro de Investigación sobre el Síndrome del Aceite Tóxico (CISAT) Instituto de Salud Carlos III

2. In 1981 when the epidemic started, and in my position as a specialist in internal medicine I had to face a strange lung disease. Inmediately, my colleagues and I were surprised by an illness with the appearance of an infectious disease but presenting a clinical course that could not be improved by the use of antibiotics. Most of our patients came from the same family and same geographical areas. The evolution of the disease with scleroderma and neuropathy arouse my interest as we had been working in scleroderma and this situation gave us the opportunity to try to know what could be the cause and pathogenesis of this type of illness Later, I was involved in clinical investigation and finally I was introduced in the epidemiology field. Since then, I have been devoted to the study of the etiology and pathogenesis of this interesting disease.

3. Mystery: What is this Disease? What is its origin? How can we prevent it?

4. TOXIC OIL SYNDROME: A Brief Summary Rate of Toxic Oil Syndrome Cases by Province • New Disease • Spain, 1981 • Point Source Epidemic • Rapeseed Oil Denatured with 2% Aniline • Systemic Disease • Three Clinical Phases • Vasculopathy (Endothelium) • Evolution Unknown Number of cases per 100.000 >290 211-290 141-210 140-71 1-71 no

5. Descriptive Epidemiology • First Case 1st May, 1981 • 20,643 affected • 10,000 hospital admissions • 80 deaths in the first month • 303 deaths as to 31 Dec 1982 • 2,500 deaths by all causes • Ratio M/F= 1.5/1 • Central and northwestern areas Males Females 0-9 40-49 >80 20-29 60-69 Epidemic Curve for TOS May 1 June 10 August 1 October 15 1981, weeks

6. Toxic Oil Syndrome: Acute Phase • Rash • Interstitial pattern in X-ray • Pruritus • Eosinophilia • Fever • Cramps • Cephalea

7. Toxic Oil Syndrome: Chronic Phase • Scleroderma • Neuropathy • Contractures • Hepatopathy • Pulmonary Hypertension • Sicca Syndrome

8. Frequency of Major Events in TOS Acute Lung disease 70.0 Sclerodermiform changes 21.3 Neuropathy 32.0 Pulmonary Hypertension 8.2 Liver disease 7.2 Sicca Syndrome 35.0 Eosinophilia 78.0 Myalgias 80.0

9. First Case-Control study: Hospital Niño Jesús Case Control Consumed fraudulent oil Did not consume 62 4 0 58 Odds Ratio > 1,000 CI 95% ( 145.6 - Inf)

10. Second Group of Studies: Navas del Marqués study Study number 1 Study number 2 Case Control Case Control Consumed fraudulent oil Did not consume Bought oil from “good woman” in April or May,1981 Bought oil from other salesmen or other time 24 5 12 18 27 0 30 108 Odds Ratio=194 Odds Ratio=7.2 CI 95% (19.2 - Inf) CI 95% (2.2 - 23.2)

11. Case Control Studies Made at the Beginnig of the TOS Outbreak after the Official Anouncement of the Cause Location Cases Controls OR (CI) or “p” value • Pozuelo 42/48 32/96 21 (7.7-64.8) • Chozas (León)19/19 15/19 Inf. (p=0.05) • Cerezo (Seg) 13/13 25/44 Inf (p=0.002) • San Cristobal 10/10 8/19 Inf (p=0.002) • Bocigas (Soria)11/11 22/33 Inf (p=0.03) • Arconada (Pal)18/18 9/21 Inf (p=0.001) • Colmenar (Mad)16/20 6/20 9.3 (1.8-52.7) • Madrid 52/58 615/1,725 15.6 (6.7-44.8) • Madrid (nuns) 23/35 0/56 Inf (p=4x10-13) • Madrid (nuns) 42/43 0/70 Inf (p=2.3x10-31)

12. Ethiologic ResearchToxi-Epi Study • Accuracy in the definition of the vehicle of exposure • Dose-Response relationship 0 200 400 600 800 1000 1200 1400 Oleyl Anilide (m g / g )

13. 1 2 3 4 Typical Bottle (number 1) and Contents in Oleyl-anilide positive negative Potential Misclassification Bias in the First Case-Control Studies

14. TOXI-EPI- I study TOXI-EPI- II study (Oleyl-anilides) (Oleyl-anilides) Case Control Case Control 18 11 16 48 30 10 29 60 + - Odds Ratio=4.91 Odds Ratio=6.21 CI 95% (1.74-14.01) CI 95% (2.50-16.04)

16. Dose-Response: OOPAP against Oleyl-anilide OOPAP Log Odds Ratio Oleyl Anilide Oleyl Anilide and OOPAP( g / g) m

17. Rapeseed oil not denatured sold in France Refineries OA OOPAP Contents Contents <100 ppm Not detectable Catalonian Circuit Sabater France Danesa-Bau 450 ppm Not detectable Central Circuit Aniline added ITH- Seville 1,900 ppm 150 ppm

18. DANESA-BAU EPIDEMIC CURVE FOR TOS New cases ITH Weeks May 1 June 10 August 1 October 15 Weeks May 1 June 10 August 1 October 15 1981

19. IMMUNOLOGICAL MECHANISM(S) LIKELY INVOLVED Some humoral evidence - Eosinophilia - In acute phase of soluble IL-2 receptor - Serum Major Basic Protein increased in all phases - Major Basic Protein deposits in tissues from acute phase (eosinophile degranulation) - GM-CSF in acute phase T-Cell activation

20. IMMUNOLOGICAL MECHANISM(S) LIKELY INVOLVED- II Some histological evidence • IL-4 and IL-5 deposits in cases pulmonary tissues from the deceased in the acute phase • High proportion of HLA DR2 in death patients • Controversial findings with HLA DR3-DR4 and DQ3-8 • CD4 lymphocytes surrounded the main lesions • NAT2 genotype is a risk factor of the disease

21. TOS COHORT: Standart Mortality Ratio

22. Conclusions • Our data suggest that TOS is a Point Source Epidemic. This assertion is based on: • Linkage between rapeseed oil denatured with 2% aniline and the disease • Presence of a chemical marker (OOPAP) in the oil refined in ITH (Seville) • The OOPAPs are new chemical compounds very difficult to obtain in a regular refining process • Causal agent responsible for this disease is produced by only one or various compounds from OOPAPs derivatives • Further studies in toxicologyare being performed