Metal fume fever

Metal fume fever also known as ‘galvaniser’s poisoning’, ‘smelter’s chills’ or ‘Monday morning fever’ is considered a historical occupational disease associated with the inhalation of metal fumes. Metal fume fever is associated with inhalation of freshly formed oxides of a number of metals including zinc, iron, steel, aluminium, cadmium and copper ¹. The most common metal involved was zinc (40% of known cases) ². Steel (an iron/carbon or other metal alloy), then iron were the next two most frequently reported metal reported in another study ³. The metal type involved was not specified in just under a quarter of cases, but is not essential in making the diagnosis. The clinical symptoms, signs and investigation findings of metal fume fever include fever, chills, myalgia, chest pain, nonproductive cough, metallic taste in the mouth, leucocytosis, headache and malaise. These clinical features are similar to those caused by respiratory viruses such as influenza or the common cold, which are seen frequently in general practice and can be misdiagnosed if an occupational history is not taken or the differential diagnosis not considered ⁴. Symptoms typically occurs 4–10 hour following the exposure to metal-containing fumes and resolve by 1–2 days. Symptom recognition and occupational history taking are keys to making a diagnosis. However exposure to some metal fume, such as cadmium, can cause more serious illness, or even death.

Repetitive exposure to metal fumes has been correlated with the development of occupational asthma in welders ⁵. There has also been an association with a small reduction in lung function with chronic exposure ⁶. Episodes of metal fume fever, although self limiting, may be the first warning sign in individuals who have poor safety prevention practices at home or in the workplace and may ultimately predispose them to developing chronic respiratory disease. Theories of pathogenesis relate to release of cytokines causing pulmonary and systemic inflammatory reactions, and others suggest an allergic response ⁷.

In 2009, there were 554 calls regarding metal fume fever to poison centers in the United States ⁸. Of these, one-quarter were treated in a healthcare facility with minor to moderate symptoms in the majority of exposures.

Metal fume fever key points

• Metal fume fever is a diagnosed with exposure to metal fumes within the last 48 hours and ‘flu-like’ symptom development with resolution within 1–2 days.
• Metal fume fever is most likely to present on Monday due to loss of tolerance over the weekend in occupational welders.
• Medical profession and patient awareness are crucial to aid diagnosis and help prevent occurrences at home, school and the workplace.
• Repeated metal fume fever presentations may indicate poor workplace practices and ultimately lead to development of chronic respiratory disease.

Metal fume fever long term effects

Repetitive exposure to metal fumes has been correlated with the development of occupational asthma in welders ⁵. There has also been an association with a small reduction in lung function with chronic exposure ⁶.

Metal fume fever symptoms

The most common symptoms of metal fume fever were fever, chills, headache and myalgia.

Table 1. Symptoms relating to metal fume fever

Symptom	Number of cases (%)
Fever Chills Headache Myalgia Malaise Cough Nausea Abdominal discomfort Dyspnoea Paraesthesia tongue	51 (60) 25 (29) 23 (27) 19 (22) 14 (16) 11 (13) 11 (13) 8 (9) 8 (9) 1 (1)

Metal fume fever prevention

A careful workplace exposure assessment including measurement of ambient zinc and other metal (e.g., chrome, nickel, copper and manganese) fume concentrations or concentrations of fluorocarbon polymer decomposition products at different locations within the workplace should be performed.

Metal fume fever diagnosis

A clinical diagnosis based on a combination of symptoms, metal exposure, exposure time and resolution increases the likelihood of a diagnosis of metal fume fever. A differential diagnosis including occupational asthma needs to be kept in mind.

Chest radiographs are typically normal in cases of metal fume fever and polymer fume fever; however, mild vascular congestion may be demonstrated and severe cases may feature diffuse patchy infiltrates. Laboratory studies are typically not necessary but may demonstrate leukocytosis with leftward shift or an elevated erythrocyte sedimentation rate ⁹.

Metal fume fever treatment

The primary treatment for both metal fume fever and polymer fume fever is supportive and directed at symptom relief. Oral hydration, rest, and the use of antipyretics and anti-inflammatory medications (e.g., non-steroidal anti-inflammatory drugs and aspirin) are recommended ⁹. A careful workplace exposure assessment analysis conducted by an occupational medicine specialist or clinical toxicologist in concert with a qualified industrial hygienist should be performed.

Metal fume fever prognosis

Metal fume fever is typically a benign and self-limited disease entity that resolves over 12–48 hours following cessation of exposure.

Repetitive exposure to metal fumes has been correlated with the development of occupational asthma in welders ⁵. There has also been an association with a small reduction in lung function with chronic exposure ⁶.

References

1. Shannon M, Borron SW, Burns MJ. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. 4th edn, 2007, p. 1167.
2. Nemery B. Metal toxicity and the respiratory tract. Eur Respir J 1990;3:202–19.
3. Metal fume fever. A case review of calls made to the Victorian Poisons Information Centre. AUSTRAIIAN FAMILY PHYSICIAN Volume 41, No.3, March 2012 Pages 141-143 https://www.racgp.org.au/download/documents/AFP/2012/March/201203wong.pdf
4. Noel NE, Ruthman JC. Elevated serum zinc levels in metal fume fever. Am J Emerg Med 1988;6:609–10.
5. El-Zein M, Infante-Rivard C, Malo J-L, Gautrin D. Prevalence and association of welding related systemic and respiratory symptoms in welders. Occup Environ Med 2003;60:655–61.
6. Antonini JM, Lewis AB, Roberts JR, Whaley DA. Pulmonary effects of welding fumes: review of worker and experimental animal studies. Am J Ind Med 2003;43:350–60.
7. Gordan T, Fine JM. Metal fume fever. Occup Med 1993;8:505–17.
8. Bronstein AC, Spyker D, Heard SE, et al. 2009 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clin Toxicol 2010;48:979–1178.
9. Michael I. Greenberg & David Vearrier (2015) Metal fume fever and polymer fume fever, Clinical Toxicology, 53:4, 195-203, DOI: 10.3109/15563650.2015.1013548 https://doi.org/10.3109/15563650.2015.1013548