Correspondence

Asthma Induced by a Thermal Printer

N Engl J Med 2009; 360:2375-2376May 28, 2009

Article

To the Editor:

Point-of-sale terminals are devices used worldwide for credit-card or debit-card transactions or to print a variety of coupons. These machines print receipts on thermal paper covered with N-propyl-acrylamide and acrylate tints.

We report on a nonsmoking 62-year-old woman without atopy in whom asthma symptoms developed after she had worked for 20 years selling lottery tickets inside a 4-m³ kiosk. For the past 3 years, she had been using a point-of-sale terminal to print lottery tickets. She had a 2.5-year history of rhinoconjunctivitis, facial edema, cough, shortness of breath, and wheezing. These symptoms occurred within 30 to 60 minutes after she arrived at her workplace and diminished during days away from the workplace. She controlled the symptoms by using inhaled bronchodilators and pulses of oral corticosteroids. She required emergency treatment on three occasions: 8, 6, and 4 months before we examined her.

On evaluation at our clinic, there were no signs of atopy; baseline spirometric measurements were normal, as was the fraction of exhaled nitric oxide (Fe_NO), at 14 ppb. The provocative concentration of inhaled methacholine required to reduce the forced expiratory volume in 1 second (FEV₁) by 20% (PC₂₀) was 6.18 mg per milliliter (normal value, >16.0 mg per milliliter). Patch tests that included several acrylates (Martí Tor) were negative. We performed a bronchial challenge in a 7-m³ chamber, as previously described.1 The patient painted on a cardboard for 30 seconds with the tint provided by the lottery company, which contained trimethylolpropane triacrylate; a decrease in the FEV₁ of 19% was observed (Table 1Table 1Baseline Characteristics of the Patient and Results of Bronchial-Challenge Tests.). A new exposure for 90 seconds elicited a decrease in the FEV₁ of 45% (from 1.96 to 1.10 liters). No late asthmatic reaction was observed. Twenty-four hours after the challenge, the methacholine PC₂₀ was still low and the Fe_NO was elevated. The eosinophil count in induced sputum after the challenge was higher than the count at baseline. Eight days later, a challenge was performed in which the patient's work environment was simulated; using her own point-of-sale terminal, the patient printed tickets for 90 seconds. A decrease in FEV₁ of 15% was observed 1 minute after exposure, with no late asthmatic reaction. Twenty-four hours after the challenge, she still showed methacholine hyperresponsiveness but had a normal Fe_NO (Table 1). She no longer works in the kiosk and is now asymptomatic without the use of any medication. We have no data on the mechanism leading to this reaction.

Acrylates are known causative agents of occupational asthma,3,4 and workers in printing facilities may be affected.3,5 However, this description of occupational asthma in a worker using a point-of-sale terminal indicates that such a diagnosis should be considered in cases of adult-onset asthma in workers exposed to these devices.

Silvia Sánchez-Garcia, M.D.
Mar Fernández-Nieto, M.D.
Joaquín Sastre, M.D., Ph.D.
Fundación Jiménez Díaz, 28040 Madrid, Spain
jsastre@fjd.es

Dr. Sastre reports serving as a consultant to Phadia, Schering-Plough, and GlaxoSmithKline, receiving lecture fees from Novartis, GlaxoSmithKline, and Stallergenes, and receiving grant support from Phadia, GlaxoSmithKline, and ALK-Abelló. No other potential conflict of interest relevant to this letter was reported.

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Citing Articles (2)

Citing Articles

1. 1

   Santiago Quirce, Jonathan A. Bernstein. (2011) Old and New Causes of Occupational Asthma. Immunology and Allergy Clinics of North America 31:4, 677-698
   CrossRef

2. 2

   Santiago Quirce, Joaquín Sastre. (2011) New causes of occupational asthma. Current Opinion in Allergy and Clinical Immunology 11:2, 80-85
   CrossRef