Correspondence

Aplastic Anemia after Exposure to Burning Oil

N Engl J Med 1994; 331:58July 7, 1994

Article

To the Editor:

During the Persian Gulf war, military personnel were exposed to toxic fumes from burning oil in Kuwait. We report the case of a 23-year-old man who presented with a one-month history of worsening fatigue and shortness of breath on exertion. He reported no recent fever or infection, but had taken an antibiotic (probably metronidazole) for one week because his sexual partner had a vaginal infection. For eight weeks in the summer of 1991, the patient had served on a naval ship eight miles off the coast of Kuwait, during which time he was exposed to smoke from burning oil wells. He stated that the sky was noticeably darkened by the black smoke.

On physical examination the patient appeared healthy. He was afebrile, and his blood pressure was 125/55 mm Hg. He had no lymphadenopathy, a normal cardiac rate and rhythm with a systolic ejection murmer, and no abnormalities on examination of the lungs and abdomen. Stool tests for occult blood were negative. The patient's hematocrit was 14 percent, the platelet count 34,000 per cubic millimeter, the white-cell count 2300 per cubic millimeter, and the absolute granulocyte count 106 per cubic millimeter. The serum vitamin B₁₂ concentration was 441 pg per milliliter. Both a Ham's test and a chromosomal-fragility test for Fanconi's anemia were negative. Bone marrow biopsy confirmed a diagnosis of aplastic anemia with marked hypocellularity (less than 5 percent) and adequate iron stores. Culture of the aspirated marrow was negative for acid-fast bacilli. No donor for bone marrow transplantation was available, so the patient was treated with antithymocyte globulin and methylprednisolone. His cell counts stabilized for a few weeks but then declined, and he has since required transfusions regularly.

We speculate that exposure to the burning oil wells in Kuwait during the Gulf war led to the development of aplastic anemia in this patient. Burning gasoline aerosolizes many pollutants, one of which is benzene. Benzene can be metabolized in the liver to a series of phenolic and open-ring structures, including hydroquinones, which can inhibit the maturation and amplification of bone marrow stem and blast cells1. In addition, the metabolites of benzene alter the function of stromal cells in bone marrow so that they cannot adequately support the growth and differentiation of hematopoietic cells. The net result can be aplastic anemia. The burning oil fields in Kuwait resulted in levels of polycyclic aromatic hydrocarbons in the air that ranged from 3.1 to 9.1 ng per cubic meter (mean, 5.3)2.

Hematologic complications do not typically develop until several years after exposure to benzene, and therefore a data base of Gulf war veterans should be maintained to assess any increased risk from exposure.

Mark A. Stern, M.D.
James Eckman, M.D.
Margaret K. Offermann, M.D., Ph.D.
Emory University School of Medicine, Atlanta, GA 30303

2 References

1. 1

   Snyder R, Witz G, Goldstein BD. The toxicology of benzene. Environ Health Perspect 1993;100:293-306
   CrossRef | Web of Science | Medline

2. 2

   Madany IM, Raveendran E. Polycyclic aromatic hydrocarbons, nickel and vanadium in air particulate matter in Bahrain during the burning of oil fields in Kuwait. Sci Total Environ 1992;116:281-289
   CrossRef | Web of Science | Medline

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