1. Toxic Oil Syndrome: A new disease Toxic Oil Syndrome: A new disease A 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)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? What is its origin? How can we prevent it? How can we prevent it?

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

5. Descriptive Epidemiology First Case 1 st 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 Epidemic Curve for TOS May 1 June 10 August 1 October 15 1981, weeks 0-9 40-49 >80 20-29 60-69 Males Females

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 disease70.0 Sclerodermiform changes21.3 Neuropathy32.0 Pulmonary Hypertension 8.2 Liver disease 7.2 Sicca Syndrome35.0 Eosinophilia 78.0 Myalgias 80.0

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

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

11. Case Control Studies Made at the Beginnig of the TOS Outbreak after the Official Anouncement of the Cause LocationCasesControlsOR (CI) or “p” value Pozuelo42/4832/9621 (7.7-64.8) Chozas (León) 19/1915/19Inf. (p=0.05) Cerezo (Seg)13/1325/44Inf (p=0.002) San Cristobal10/108/19Inf (p=0.002) Bocigas (Soria) 11/1122/33Inf (p=0.03) Arconada (Pal) 18/189/21Inf (p=0.001) Colmenar (Mad) 16/206/209.3 (1.8-52.7) Madrid52/58615/1,72515.6 (6.7-44.8) Madrid (nuns)23/350/56Inf (p=4x10 -13 ) Madrid (nuns)42/430/70Inf (p=2.3x10 -31 )

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

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

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

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

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

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

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 toxicology are being performed