Raisa Masood, MD
Resident Physician
SUNY Upstate
Syracuse, New York, United States
Ymi Ton, MD, MS
Resident Physician
NewYork-Presbyterian
New York, California, United States
Akinpelumi Beckley, MD
Assistant Professor of Rehabilitation and Regenerative Medicine at CUMC
Columbia University Medical Center Department of Rehabilitation and Regenerative Medicine
New York, New York, United States
Peripheral neuropathy due to chlorine and other unmixed chemicals
Case Description:
A 70-year-old female presented with fourteen-month history of headaches, right sided weakness, distal paresthesias, gait instability, and speech difficulties after swimming in a pool with a high concentration of chlorine. Previous workup included CT spine showing cervical spinal stenosis and C5-6 ventral cord impingement, MRI showing T2 signal posterior to splenium, and electrodiagnostic studies demonstrating axonal peripheral neuropathy. Exam demonstrated decreased sensation in the palmar hands, and symmetric weakness with finger abduction, finger flexion, thumb abduction, and throughout the lower extremities. Reflex testing revealed 3+ in biceps, triceps, brachioradialis, and patellar tendons. She demonstrated reciprocal gait pattern with reduced speed and right foot slap. She was recommended for physical and occupational therapy for neuromuscular reeducation, gait training, and ADL training which provided some improvement with ambulation and pain. She was to continue multi-disciplinary care with neurorehabilitation, peripheral neuropathy, and neurology specialists for further diagnostic testing and symptom management.
Discussions:
This case describes a unique and underrecognized clinical presentation of peripheral neuropathy due to chlorine and other toxins. Potential mechanisms to explain the symptoms of chlorine-induced peripheral neuropathy are related to chlorine’s oxidant potential.3 Potential pharmacological treatments involve antioxidants and anti-inflammatory agents to alleviate oxidative products and inflammation.4 Physical and occupational therapy is also important to address functional deficits as recent studies show that it results in a significant improvement in balance, proprioception, and a short-term modest improvement in pain.5,6
Conclusions:
Pool shock peripheral neuropathy can lead to debilitating neuromuscular symptoms and functional deficits and appears to have a prolonged recovery course. Supportive management with therapy to address functional deficits and decrease pain should be implemented as part of a multi-disciplinary team approach of monitoring the natural progression of this disease and managing its symptoms to provide the best outcomes for these patients.
