ORIGINALABR Heart Failure

of Infants Following
ARTICLE and Short
Maternal Stature intoa Toxic
Exposure 43 year-old male
Products

Table 1. Initial laboratory Results

Auditory Brainstem Response Latencies of Infants and
CBC
Maternal ExposureBlood chem.
to Environmental Urinalysis
Toxic Products ABG
Reference Result Reference Result Color straw pH 7.408
Value Value
WBC
Charlotte5-10
M. Chiong,1,2 4.5 Enrique M. RBSOstrea, Jr.,3, 3.9-6.1
4 Erasmo Gonzalo 6.3 Transp 1,2 Esterlita
DV. Llanes, Clear T. Villanueva-Uy,
pCo2 49.14,5
RBC 4-6 HGBA1C 4.27-6.07 6.4 Sp Gravity 1.010 po2 70
HGB Alexis L. Reyes,
120-150 90
4,5 Teresa
BUN Luisa I. Gloria-Cruz
2.6-6.4 5.0and Maria Rina
1,2
pH T. Reyes-Quintos
8.0
1,2
HCo3 31.3
HCT 0.38-0.48 0.27 CREA 53-115 123 Sugar NEG o2 sat 93.6
MCV 80-100 Fl of Otorhinolaryngology,AlB
1Department 34-50 32 Protein NEG Fio2
College of Medicine and Philippine General Hospital, University of the Philippines Manila 21%
MCH 27-31 PG 2Philippine National Ear TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9
Institute, National Institutes of Health, University of the Philippines Manila
MCHC 320-360 G/l HDl 0.91-1.56 0.67 WBC 0-2
3Department of Pediatrics (Neonatal Medicine), School of Medicine, Wayne State University, Detroit, Michigan, USA
RDW 11.5-15.5% lDl 1.1-3.8 4.21 Cast
4Institute of Child Health and Development, National Institutes of Health, University of the Philippines Manila
PBS
PlT 200-400 Inc ToTAl CHol 4.2-5.2 5.25 Epith cell Rare
5Department of Pediatrics (Developmental Pediatrics), College of Medicine and Philippine General Hospital, University of theSlight poikilocytosis,
Philippines Manila
RETIC 0.005-0.015 AST 15-37 95 Bacteria occ’l acanthocytes, ovalocytes,
SEG 50-70% 48 AlT 30-65 91 Mucus th Rare slight toxic granulation,
lYMPH 20-44% 50 Alk po4 184 Crystals Rare slight anisocytosis
MoNo 2-9% 2 NA 140-148 136.9 Am urates
Eo 0-4% 0 K 3.6-5.2 3.35
BASo 0-2% 0 Cl 100-108 86
BlAST 0% 0 CA++ 2.12-2.52 2.37
P 2.27
MG++ 0.74-1 0.83

fat pad. Cardiac enzymes were not consistent with an acute

Table 2. Thyroid Function Tests
coronary event (Table 3), however, intravenous (IV) heparin
Introduction
Reference Value Result (overlapping with oral warfarin) was still given to cover for
In a tropical primarily agricultural country like the
Free T4 (0.8-2.0) 0.02 ng/dl
the presenceenvironmental
Philippines, of a possible toxic
lV thrombus as demonstrated
products such as pesticides
TSH (0.4-6.0) 24.75 Uiu/ml
by
and rheologic stasis
insecticides on cardiac
abound in mostultrasound.
homes given Medications
previous
were
reportsshifted to prevalence
of high IV diureticsofand inotropes;with
infestations oralpests
digoxin
suchwas
as
started. IV antibiotics
flies (97.7%), were given
roaches (89.8%) for possible(97.6%).
and mosquitoes pulmonary
1 Use

infection. The patient

of these products is later
deemedon showed
justifiedimprovement, and was
when the significant
eventually
prevalence weaned
of pests off
andfrom ventilatory
vector-borne support,
diseases extubated,
is considered,
whether in the farm or at home. The acute toxic effects of
Table
these 3. Cardiacseen
products Enzymes
in acute poisoning have already been
identified, and include effects on the central nervous system
Reference Range (mmoL) Result
manifesting as varied neurological symptoms and
Qualitative PoSITIVE
behavioral
Troponin I changes. Profound bilateral sensorineural
2

hearing
CK-MB loss has been associated
0-6.0 with peripheral neuropathy
1.14
inCK-ToTAl 21-232acute poisoning from
the extremities following 543 combined
mixture of 75% malathion and 15% metamidophos.3
The auditory pathway has also not been spared from
neurotoxin effects of other substances such as lead,4,5,6
cocaine,7 and methylmercury,8 as established with delayed
Figure 1. Electrocardiogram upon admission brainstem auditory evoked potentials. Combined exposure
to organophosphates and pyrethroid insecticides revealed
an associated high frequency hearing loss in 57% of exposed
transferred to the intensive care unit (ICU) for ventilatory Brazilian farm workers.9 Central auditory dysfunction
support and closer monitoring. on bedside cardiac ultrasound, assessed through pitch pattern sequence and duration
there was a finding of eccentric left ventricular hypertrophy,
pattern sequence showed 56% of exposed workers with
global hypokinesia with depressed overall systolic function
central hearing disorder and a relative risk of 7.58 for the
_______________
with concomitant spontaneous echo contrast on left ventricular
Corresponding author: Charlotte M. Chiong, MD group exposed to insecticides (95% CI 2.9-19.8) when
(lV) cavity suggestive of rheologic stasis, the ejection fraction
Philippine National Ear Institute compared to the non-exposed group.10
was 25%,
National with
Institutes moderate mitral regurgitation, moderate
of Health In the rural areas where numerous chemicals are
aortic regurgitation
University with
of the Philippines aortic sclerosis, severe tricuspid
Manila
released in the environment, it would be sensible to assess
regurgitation with
623 Pedro Gil Street, mildManila
Ermita, pulmonary hypertension, pulmonary
1000 Philippines
Telephone: +632 5548400 loc. 2072 the possibility
Figure that such on
2. Chest radiograph exposures
admissioncan also affect the
regurgitation, and minimal pericardial effusion or pericardial
Email: charlotte_chiong@yahoo.com auditory system. Constant use of these products results in

Vol. 46
VOL. 43 NO.
N0. 432009
2012 ACTA MEDICA
ACTA MEDICA PHILIPPINA
PHIlIPPINA 13
5
ABR of Infants Following Maternal Exposure to Toxic Products
CASE REPORT

sub-clinical exposureHeart of humans Failure albeit and in much Short lowerStatureNewborns in a 43ofyear-old male mothers underwent
identified pregnant
concentrations that are not enough to cause acute toxic OAE (Welch Allyn®Audiopath EOAE Screener 29230) and
Katerina
effects. ChronicT.sub-clinical
leyritana1effects , Ma. Czarlota
seem difficult M. Acelajado-Valdenor
to assess , Amado o. Tandoc
ABR (Interacoustics
1
III2 and
EP15) testing and Agnes D. Mejia
assessment of mental
1

considering the intricate measurement of use and development by developmental pediatricians at 6, 12 and 24
subsequent exposure. 1
Department of Medicine,
Despite this,College of Medicine
it is importantand Philippine
to General Hospital,
months using University
the GMDS of the Philippines
– locomotor, Manila personal-social,
determine the presence of such
2
Department
products of Pathology, College of Medicine,
in a community, University
hearing of thespeech,
and Philippines Manilaand eye coordination, and
hand
demonstrate exposure to such products, and identify performance tests.11 The presence of OAEs will show a
possible short- and long-term effects. This would help in ‘pass’ result, and the absence of OAEs will show a ‘refer’
regulating and possibly modifying behaviors regarding use result, suggesting normal and abnormal cochlear functions,
of such products especially in pregnant women who may respectively. ABR recorded with standard machine followed
unduly increase the risks to the fetus with their exposure. American National Standards Institute (ANSI) standards.
Previous studies Presentation
1,8 have ofshown the case that appropriate require regular of
Determination laxative use. There
the presence was also
of wave V aftera report of two
introducing
This is a of
assessment case of a 43-year-old
exposure maybe performedmale presenting through with short
analysis more
clicks syncopal episodes.intensities
sound at different He was brought(from 100 to decibels
another (dB)doctorto
stature
of various andbiological
heart failure.matrices,The patient
of which was admitted
maternal hairat was
the in
30 adB)
private
was hospital
performed. where the assessment
Evaluation of the was ABRstill a “heart
tracings to
medicine
found to be wardthe mostof the Philippine
robust General
for detecting Hospital
maternal (PGH)
exposure problem”. The patient
determine presence was again
of waves I, III, Vprescribed
and their unrecalled
inter-peak
for dyspnea. and
to pesticides Thismeconium
paper will found investigate
to be theseveral issues:
most sensitive medications
latencies (I-III, and I-V,again
III-V)was lost to follow-up.
in milliseconds This time,
were performed.
differentiating
for establishing congenital
exposure infrom infants.acquired
1,8 These hypothyroidism,
studies found however,
Infants were symptoms
classified were persistent.
as having normalHe hearing
later consulted
if wave at V
the
propoxurrelationship
to be the betweenmost common hypothyroidism
toxic product and foundthe in another
was present local at
hospital,
or below where
40 dBhe was admitted
suggesting and managed
possible normal
cardiomyopathies,
meconium in about and 23.8 %. the therapeutic options in patients as a case ofpathway,
auditory anemia and andbronchial
with hearing asthma. He ifwas
loss discharged
wave V was
withCorrelation
cardiomyopathy secondary to hypothyroidism.
of neuro-development determined through slightly improved after four days, only to
present at greater than 40 dB suggesting possible abnormal have recurrent heart
The patient had been born full
GMDS and hearing status by screening with OAE and ABR term to a then 31-year- failure symptoms, prompting admission
auditory pathway. The latencies of wave I, III, V were at PGH.
old Gravida
showed good4 correlation
Para 3 (G4P3), between the 4theth
ofpresence
9 siblings, of with
hearing an Upon admission
determined to determine the anypatient
delaywas in thein appearance
mild respiratory of the
apparently unremarkable delivery
loss and developmental delay. This study looks at the
11 at home facilitated by distress,
response, indicating possible insults in fever.
with stable vital signs and no note of the Pertinent
auditory
apossible
traditionaleffectsbirthofattendant.
pesticide He was noted
exposure on to thebeinfantile
normal physical
pathway.exam findings included short stature, thick lips, non-
at birth. The patient was allegedly
auditory system specifically looking at changes in ABR wave at par with age both pitting
The periorbital
samplesedema, weredry skin, a displaced
analyzed for commonly apical impulse,
used
physically and mentally until
latency measures in those with maternal and infanteight years old when he was crackles on both lung fields, and bilateral
pesticides: cyfluthrin, propoxur, chlorpyrifos, cypermethrin, non-pitting bipedal
said to have
exposures to stopped
environmentalgrowing toxic in products.
height. He was brought to edema. Therebioallethrin,
pretilachlor, was also a malathion,
3 cm x 3 cm reducible
diazinon, umbilical
transfluthrin,
a private doctor, whose diagnosis was undisclosed, and he hernia. However, there was no pallor, no
lindane and DDT. The pesticides measured included most of neck vein distention,
was given medications toMethods increase height, which the patient no
the apparent
major congenital
ingredients malformations,
of differentno cardiac murmurs
preparations of
tookAllfor only one month with no
pregnant women consulting at the Bulacan improvement. Through the and no clubbing. There was also no note
insecticides and pesticides. In the Philippines, there are of an anterior neck
17
years,
Provincialthe patient
Hospital was apparently
from April 2002 well,toalthough
Februarystill 2003of short
were mass.
various preparations such as sprays, vaporizer, mats,
stature, with thick lips, coarse facial
identified and recruited to participate in the study. Study features and dry skin. laboratory
mosquito coils,workup
moth bag showed
and oilcardiomegaly
spray. Maternal with pulmonary
and infant
He was notably slow in ambulation.
participants who did not consent and who failed to submit He was said to have congestion,
exposures to several pesticides and metabolitesaorta
thoracic dextroscoliosis, and atheromatous by
were
bronchial asthma at age 15 years,
for follow-up were excluded. The study was approved by and since then he had been chest radiograph, and left ventricular hypertrophy
correlated with auditory brainstem response latencies to by 12-lead
taking
the Humansalbutamol tablets occasionally
Investigation Committees for boutsWayne
at both of dyspnea
State electrocardiogram
determine possible(12-l ECG) (Figures 1 and 2), normocytic
associations.
occurring one to two times annually.
University and the University of the Philippines Manila. normochromic anemia (Hgb 90 mg/dl), dyslipidemia, and
The patient’s symptoms
Informed consent was obtained for collection of started in 2001 when he was pre-renal azotemia (serum creatinine
Results 123 mmol). Electrolytes
reported to have sudden loss of consciousness.
demographic information, blood and hair samples from the During this on admission
There were 686 newbornshyponatremia,
showed slight (365 males (53.2%) hypokalemia,
and 321
time, the patient did not have
mothers and their infants, meconium samples from any symptoms of heart failure; and hypochloremia (serum Na 136,
females (46.8%)) with data on maternal and infant K 3.35, Cl 86). Blood gases
exposure
no prior seizures, cyanotic episodes,
newborns, and newborn hearing screening and diagnosis chest pain, headache, or revealed partially compensated metabolic
to pesticides and auditory brainstem responses. Mean age alkalosis with mild
of
blurring of vision. He regained consciousness
using OAE with ABR testing. Maternal blood and hair shortly after and hypoxemia. The patient was noted to be
babies on the day of testing is 2 months (±2.63), with 72.7 % hypothyroid based
was
samplesbroughtwere to acollected
private physician, whose assessment
upon recruitment was a
and delivery, on elevated
tested serum thyroid-stimulating
at 2 months. At 3 months, 78.57% hormoneof all (TSH) and
the babies
“heart problem”. He was prescribed unrecalled medications markedly decreased serum free thyroxine (FT4). The exact
while infant cord blood samples were obtained at birth, could undergo ABR testing and 100% were tested by 12
taken values are shown in Tables 1 and 2.
infant forhairaand fewmeconium
months and sampleseventually discontinued
were obtained when
later in the months of age (Table 1). Fifteen infants were noted to have
the syncopal episode did not recur. Upon admission to the wards, the patient was managed
nursery. To ensure sample adequacy for analysis, collection significant hearing loss, with 47% bilateral and only the right
In the next four years, the patient would develop as having congestive heart failure from cardiomyopathy
of samples were pursued in homes of the study participants. or left ear abnormal in 53% (Table 2). As shown in Table 3,
intermittent, progressive exertional dyspnea and bipedal secondary to acquired hypothyroidism. oral loop diuretics,
Hair was taken from the nape or base of the scalp with the the subjects had no differences in latency measures between
edema. later on this would be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta-
size of a pencil eraser in diameter. Meconium was collected the left and right sides for all the stimulation intensities
body weakness, anorexia, and constipation, severe enough to blockers, statins, and levothyroxine were started. Electrolyte
from diapers during the first 2 days of life. Methods of utilized except for delay in IPL I-III on the left at 80 db
correction was instituted. The sections of Endocrinology
collection and preparation of specimens and measurement of stimulation, and wave III and IPL I-III significantly delayed
and Cardiovascular Diseases were co-managing the patient
pesticides
Corresponding in author:
various Ma. specimens have been extensively
Czarlota Acelajado-Valdenor, M.D. in the left after 40 db stimulation. At 60 db, no differences
Department of together with the General Medicine service.
described inMedicine
previous articles related to the study. 1,8 were noted between the right and left ears. It was considered
Philippine General Hospital He soon developed respiratory failure, upon which the
Pesticides were measured in micrograms/deciliter. important to look at latency measures separately for the
Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial
Telephone: +632 554-8488 right and left to detect evidence of right and left differences
pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

12 ACTA MEDICA
6 ACTA MEDICA PHILIPPINA
PHIlIPPINA Vol.46
VOL. 43NO.
N0. 43 2009
2012
 Heart Failure
ABR of Infants Following and Short
Maternal Stature intoa Toxic
Exposure 43 year-old male
Products

Table
and if1.present
Initial laboratory
report these Results
separately for comparison to Table 3. Overall mean auditory brainstem response
those with notable hearing loss. As detailed in Table 4, there latencies, right and left ears.
CBC Blood chem. Urinalysis ABG
were nine pesticides with positive exposures measured in
Reference Reference 80Result Color straw pH 7.408
meconium, the best matrix forResult infant exposure with levels of dB
Value Value Parameters Right Left p
propoxur,
WBC diazinon,
5-10
malathion,
4.5
bioallethrin,
RBS pretilachlor,
3.9-6.1 6.3 Transp Clear pCo2 49.1
Absolute Wave
DDT,
RBC cyfluthrin,4-6 cypermethrin, and DDE. HGBA1C The highest4.27-6.07 6.4
Latencies Sp Gravity 1.010 po2 70
HGB
frequency of 120-150
exposure was noted 90 BUN
for propoxur 2.6-6.4
at 21.2 % I 5.0 pH 1.50 (±0.30)8.0 HCo3
1.49 (±0.29) 31.3
0.19
HCT
(165/777) 0.38-0.48
of the 0.27
infants. For maternal CREA
hair which is the53-115
best III123 Sugar 4.23 (±0.33)
NEG o2(±0.35)
4.23 sat 93.6
0.67
MCV 80-100 Fl AlB 34-50 V 32 Protein 6.47 (±0.40)
NEG 6.47Fio2
(±0.41) 21%
0.65
matrix for maternal exposure, there were ten pesticides with
MCH 27-31 PG TAG 0.34-1.7 0.82 RBC 0-1 Temp 36.9
positive exposure including lead, HDl mercury, arsenic, Interpeak Wave
MCHC 320-360 G/l 0.91-1.56 0.67
Latencies
WBC 0-2
cadmium,
RDW propoxur,
11.5-15.5% malathion, chlorpyrifos,lDl bioallethrin,
1.1-3.8 4.21 Cast 2.73 (±0.30) PBS
I-III 2.76 (±0.30) 0.04
PlT
pretilachlor, 200-400
and DDT. However, Inc ToTAlofCHol
evidence 4.2-5.2
exposure to 5.25
III-V Epith cell2.25 (±0.25)
Rare Slight
2.24 poikilocytosis,
(±0.25) 0.64
RETIC
only six pesticides such as arsenic, lead, AST
0.005-0.015 cadmium, mercury,15-37 95
I-V Bacteria 4.98 (±0.41)
occ’l acanthocytes,
4.99 (±0.41) ovalocytes,
0.14
SEG 50-70% 48 AlT 30-65 91 Mucus th Rare slight toxic granulation,
propoxur
lYMPH
and chlorpyrifos were noted inAlk infant
po4
hair. 60184
dB Crystals Rare
20-44% 50 slight anisocytosis
Table 5 2-9%
MoNo shows the ABR 2 wave latency
NA measures in
140-148 Parameters
136.9 Am uratesRight Left P
infants
Eo with hearing loss defined as ABRK wave V thresholds
3.6-5.2 Absolute
3.35 Wave
0-4% 0
Latencies
BASo than 0-2%
greater 40 dB compared 0 with those Cl without hearing100-108 86
I 2.21 (±0.43) 2.19 (±0.43) 0.08
BlAST
loss ( <40 dB 0% 0
ABR wave V threshold). CA++
This serves as a 2.12-2.52
good 2.37
III 4.80 (±0.48) 4.80 (±0.48) 0.31
P 2.27
reference for the next table that examines MG++effects on 0.74-1
ABR V
0.83
6.92 (±0.47) 6.92 (±0.49) 0.98
latencies following infant exposure to propoxur. Interpeak Wave
The differences in latencies (Wave I, III, V) and Latencies
I-III 2.58 (±0.37) 2.61 (±0.36) 0.49
interpeak latencies (IPLs I-III, I-V, III-V) in auditory
III-V
fat pad. Cardiac enzymes2.13 (±0.28) 2.10 (±0.24)with an
were not consistent 0.36acute
brainstem responses
Table 2. Thyroid between
Function Testsinfants exposed (with positive I-V 4.70 (±0.51) 4.69 (±0.50) 0.60
pesticide exposure, maternal hair and meconium) and coronary event (Table 3), however, intravenous (IV) heparin
Reference Value Result (overlapping
40 dB with oral warfarin) was still given to cover for
infants
Free T4
unexposed (with negative pesticide
(0.8-2.0)
exposure,
0.02 ng/dl Parameters Right Left P
maternal hair and meconium) the presence of a possible lV thrombus as demonstrated
TSH (0.4-6.0) to propoxur are
24.75 shown in
Uiu/ml Absolute Wave
Table 6. With propoxur exposure (as detected in meconium byLatencies
rheologic stasis on cardiac ultrasound. Medications
among infants), ABR testing at 80 db showed significant were
I shifted to IV diuretics and inotropes;
2.93 (±0.42) oral digoxin
2.84 (±0.48) 0.42 was

differences in the latency of wave III and IPL I-III on the started.
III IV antibiotics 5.38
were given for5.42
(±0.41) possible
(±0.45) pulmonary
0.002
V 7.53 (±0.49) 7.53 (±0.61) 0.42
right , wave III, V and IPL I-III both on the left ears. No infection. The patient later on showed improvement, and was
eventually weaned off from ventilatory support, extubated,
Interpeak Wave
major differences were seen at 60 dB and 40 dB. Latencies
I-III 2.41 (±0.36) 2.54 (±0.35) 0.00
Table
III-V 3. Cardiac Enzymes
2.14 (±0.28) 2.13 (±0.32) 0.70
Table 1. Distribution of newborns’ age when ABR was I-V 4.48 (±0.46) 4.60 (±0.47) 0.12
performed (N=686). Reference Range (mmoL)
Result
Qualitative PoSITIVE
Table 4. Frequency distribution of infants with positive
Age in months Frequency % Troponin I
maternal
CK-MB and infant environmental
0-6.0 exposure1.14to various
1-3 539 78.57
4-6 50 7.29 pesticides.
CK-ToTAl 21-232 543
7-9 89 12.97
10-12 8 1.17 Matrix
Total 686 100.00 Maternal Hair(%) Infant Hair(%) Meconium (%)
Mean 2.41 months ± 2.63 Pesticides
Range 11 months, 1-12 Lead 25.8 9.9 0
Figure 1. Electrocardiogram
50th percentile at 1 month upon admission Cadmium 0.2 9.9 0
Mercury 24.7 9.9 0
Arsenic 7.5 17.7 0
Table 2. Laterality of newborns with Wave V threshold ≤40 Malathion 0.9 0 0.3
transferred
dB (with hearingto theloss)
intensive
(n=15).care unit (ICU) for ventilatory Chlorpyrifos 0.1 0.1 0
support and closer monitoring. on bedside cardiac ultrasound, Bioallethrin 9.0 0 0.3
there Laterality
was a finding of eccentric left ventricular
Frequency % hypertrophy, Pretilachlor 0.1 0 0.8
globalBilateral
hypokinesia with depressed7 overall 46.66
systolic function DDT 0.2 0 0.5
Propoxur 9.9 0.3 21.2
with concomitant
Unilateral spontaneous echo contrast on left ventricular Diazinon 0 0 0.1
(lV) cavityRight 4
suggestive of rheologic stasis, the26.67
ejection fraction Cyfluthrin 0 0 0.8
Left 4 26.67
was 25%,
Total with moderate 15mitral regurgitation, 100.00 moderate
Cypermethrin 0 0 1.5
DDE 0 0 0.2
aortic regurgitation with aortic sclerosis, severe tricuspid
regurgitation with mild pulmonary hypertension, pulmonary
regurgitation, and minimal pericardial effusion or pericardial Figure 2. Chest radiograph on admission

Vol. 46
VOL. 43 NO.
N0. 432009
2012 ACTA MEDICA
ACTA MEDICA PHILIPPINA
PHIlIPPINA 13
7
ABR of Infants Following Maternal Exposure to Toxic Products
CASE REPORT

Table 5. Comparison Heart Failure

of latencies andparameters
of ABR Short Stature Table in a 43 year-old
6. Comparison male
of absolute wave latencies and interpeak
between infants with hearing loss (Wave V threshold > 40 wave latencies between infants with and without meconium
Katerina
dB) and withoutT.hearing
leyritana , Ma. Czarlota
loss 1(Wave M. ≤Acelajado-Valdenor
V Threshold 40 dB). , Amado
exposure
1
o. Tandocpesticide
to environmental III2 and propoxur.
Agnes D. Mejia1

80 dB 1
Department
Right of Medicine, College ofLeft
Medicine and Philippine General
80 dB Hospital, University of the Philippines Manila
(> 40 dB) (≤ 40 dB) 2Department
p (> 40 of
dB)Pathology, College ofpMedicine,Latencies
(≤ 40 dB) University of the Philippines
Right Manila Left
Parameters (n=11) (n=677) (n=11) (n=677) Exposed Unexposed p Exposed Unexposed p
Absolute Wave I 1.50±.27 1.51±.31 .75 1.48±.27 1.49±.30 .75
Latencies III 4.16±.31 4.25±.33 .006 4.18±.35 4.25±.34 .03
I 1.79 (±0.52) 1.50 (±0.29) .00 2.02 (±0.53) 1.48 (±0.27) .00 V 6.43±.40 6.49±.40 .13 6.42±.44 6.49±.40 .08
III 4.38 (±0.50) 4.22 (±0.32) .02 4.48 (±0.60) 4.23 (±0.34) .00
V 6.53 (±0.60) 6.47 (±0.40) .10 6.67(±0.71) 6.47 (±0.40) .00 Interpeak Wave
Interpeak Wave Presentation of the case require
Latencies regular laxative use. There was also a report of two
This is a case of a 43-year-old male presenting with short
Latencies more
I-III syncopal 2.66±.30episodes.
2.75±.30 He was .002 brought
2.70±.31 to 2.77±.30
another doctor .02

stature
I-III and2.58(±0.31)
heart failure. The patient
2.73 (±0.30) .54 was admitted
2.46 (±0.22) 2.76 (±0.30) at the
.18 inIII-V
a private2.27±.24
hospital2.24±.25
where the.24 assessment
2.25±.27 was still a “heart
2.24±.25 .86
III-V 2.15 (±0.24) 2.25 (±0.25) .91 2.20 (±0.22) 2.24 (±0.25) .85 I-V 4.93±.43 4.99±.41 .19 4.94±.44 5.00±.40 .11
medicine ward of the Philippine General Hospital (PGH) problem”. The patient was again prescribed unrecalled
I-V 4.74 (±0.49) 4.66 (±0.35) .27 4.98 (±0.41) 5.00 (±0.40) .23
for dyspnea. This paper will investigate several issues: medications and again was lost to follow-up. This time,
60 dB
differentiating congenital from acquired hypothyroidism, however, symptoms were persistent. He later consulted at
60 dB Right Left Right Left
the relationship(> 40 dB)
between
(≤ 40 dB) p
hypothyroidism
(> 40 dB)
and pthe
(≤ 40 dB)
another local hospital,
Exposed
where hep wasExposed
Unexposed
admittedUnexposed
and managed p
cardiomyopathies,
Parameters (n=6) and the
(n=677) therapeutic(n=11) options (n=677) patients
in asI a case of2.17±.40
anemia and bronchial
2.22±.45 .35 asthma. He
2.17±.35 was discharged
2.19±.46 .69
with cardiomyopathy
Absolute Wave secondary to hypothyroidism. slightly
III improved
4.79±.36 after four days,
4.86±.39 .58 only to have4.80±.49
4.78±.49 recurrent heart.63
The patient had been born full term to a then 31-year-
Latencies failure
V symptoms,
6.93±.45 prompting
6.92±.48 admission
.77 at PGH.
6.94±.49 6.92±.50 .66
old
I Gravida 4 (±0.37)
2.23 Para 32.21 (G4P3),
(±0.44) the .50 42.56of 9 siblings,
th (±0.54)
with .27
2.18 (±0.43) an Upon admission the patient was in mild respiratory
apparently
III unremarkable
4.89 (±0.46) 4.80 (±0.38)delivery at (±0.63)
.33 5.06 home 4.80 facilitated
(±0.48) by
.08 distress,
IPL with stable vital signs and no note of fever. Pertinent
a Vtraditional 6.91birth
(±0.69) attendant.
6.47 (±0.40) He .06 was noted 6.91
7.09 (±0.86) to (±0.49)
be normal .00 physical
I-III
exam findings
2.60±.38
included.71short2.60±.36
2.58±.36
stature,2.62±.36
thick lips, non-
.66
III-V 2.15±.23 2.12±.29 .29 2.13±.26 2.10±.24 .12
atInterpeak
birth. Wave
The patient was allegedly at par with age both pitting periorbital edema, dry skin, a displaced apical impulse,
Latencies I-V 4.74±.49 4.70±.52 .49 4.70±.47 4.69±.5 .86
physically and mentally until eight years old when he was crackles on both lung fields, and bilateral non-pitting bipedal
I-III 2.61(±0.34) 2.58 (±0.37) .73 2.44 (±0.20) 2.61 (±0.36) .06
said
III-V
to have2.02stopped growing in height.
(±0.29) 2.13 (±0.28) .61
He was brought.12to
2.03 (±0.33) 2.10 (±0.24)
edema.
40 dB
There was also a 3 cm x 3 cm reducible umbilical
a I-V
private doctor, whose
4.50 (±0.50) diagnosis
4.70 (±0.51) .94 was undisclosed,
4.51 (±0.45) 4.70 (±0.50)and .78he hernia. However, Right there was no pallor, no neckLeft vein distention,
was given medications to increase height, which the patient no apparent congenital
Exposed malformations,
Unexposed p no
Exposed cardiac murmurs
Unexposed p
took
40 dBfor only one month Right with no improvement. Left Through the and
I no clubbing.
2.90±.4 There was
22.93±.43 also.68 no note of
2.93±.47 an anterior
2.81±.49 neck
.11
years, the patient
(> 40 dB)was (≤ apparently
40 dB) p well,
(> 40although
dB) still
(≤ 40 dB) of short
p mass.
III 5.39±.4 15.38±.42 .70 5.46±.43 5.41±.46 .27
stature,
Parameterswith(n=11)
thick lips, coarse facial(n=11)
(n=677) features (n=677)
and dry skin. V laboratory workup
7.54±.4 showed cardiomegaly
97.52±.50 .67 7.58±.56 with pulmonary
7.52±.64 .32

He was Wave
Absolute notably slow in ambulation. He was said to have congestion, thoracic dextroscoliosis, and atheromatous aorta by
bronchial
Latencies
asthma at age 15 years, and since then he had been chest
IPL
radiograph, and left ventricular hypertrophy by 12-lead
I 2.87 (±0.14) 2.93 (±0.42) .35 2.81 (±0.36) 2.84 (±0.49) .77 I-III 2.41±.39 2.41±.35 .99 2.49±.39 2.56±.34 .25
taking salbutamol tablets occasionally for bouts of dyspnea electrocardiogram (12-l ECG) (Figures 1 and 2), normocytic
III 5.33 (±0.47) 5.38 (±0.41) .45 5.33 (±0.40) 5.42 (±0.45) .78 III-V 2.16±.22 2.14±.30 .47 2.11±.23 2.13±.35 .37
occurring one to two times annually. normochromic anemia (Hgb 90 mg/dl), dyslipidemia, and
V 7.44 (±0.70) 7.53 (±0.49) .03 7.57 (±0.73) 7.53 (±0.61) .34 I-V 4.52±.52 4.47±.44 .49 4.59±.48 4.60±.47 .90
The patient’s symptoms started in 2001 when he was
Interpeak Wave
pre-renal azotemia (serum creatinine 123 mmol). Electrolytes
reported
Latencies to have sudden loss of consciousness. During this on admission showed slight hyponatremia, hypokalemia,
time, Table
and 7. Association
hypochloremia of propoxur
(serum Na 136, Kexposure
3.35, Cl 86). with
Bloodstatus
gases of
I-III the patient did not
2.73(±0.42) 2.40 have
(±0.35) any.94 symptoms
2.56 (±0.01) of heart
2.54 (±0.35)failure;
.06
no prior seizures,
III-V cyanotic
2.11 (±0.51) episodes,
2.14 (±0.28) .11 chest
2.09 pain,2.13
(±0.33) headache,
(±0.32) or
.47
hearing (ABR
revealed threshold).
partially compensated metabolic alkalosis with mild
blurring
I-V of vision. He regained
4.76 (±0.52) 4.48 (±0.46) consciousness
.95 4.70 (±0.49) shortly after and
4.59 (±0.47) .81 hypoxemia. The patient was noted to be hypothyroid based
Presence of wave V at
was brought to a private physician, whose assessment was a on elevated serum thyroid-stimulating hormone (TSH) and
Propoxur >40dB <40dB Total
“heart problem”.
There He was prescribed
were differences unrecalled medications
found sporadically in different markedly decreased (+) 2
serum free thyroxine
141
(FT4).143The exact
taken for a few months and
waves and pesticides. In some cases, exposureeventually discontinued when
to certain values are shown (-) in 14Tables 1 and 2. 411 525
the syncopal episode did not recur.
pesticides was found in 1 or 2 infants only, yet effects could Upon admission
Total 16 to the wards, the 652 patient was 668managed
In thepronounced
be more next fourasyears, the patient
in diazinon, found in wouldmeconium develop of asRiskhaving
exposed
congestive =2/143 (1.4%)
heart failure from cardiomyopathy
Riskunexposed =14/525 (2.7%)
intermittent, progressive exertional
only one infant with abnormal ABR wave V threshold dyspnea and bipedal secondary
Relative risk to acquired hypothyroidism.
=0.52 (0.12-2/30) P=0.0565oral loop diuretics,
edema.
greater thanlater80 ondb this would beofaccompanied
suggestive severe to profoundby generalized
hearing angiotensin-converting
1St Infant: Wave V at 80dB at the enzyme (ACE) inhibitors, beta-
right (1.6ug/L)
body weakness,
impairment. anorexia, and constipation, severe enough to blockers,
2nd Infant: statins, and both
Wave at 100dB levothyroxine
ears (0.32ug/L)were started. Electrolyte

Correlating exposures to pesticides and hearing loss correction was instituted. The sections of Endocrinology
(Tables 7-9), 2author:
infantsMa.
hadCzarlota
exposure to propoxur, with a 1.4% and
1.34%. Cardiovascular
Remarkably, Diseases this infant were hadco-managing
propoxur exposurethe patient as
Corresponding Acelajado-Valdenor, M.D.
risk of hearing
Department loss, lower compared to the 2.7% risk of
of Medicine together with the General Medicine
well. One infant had pretilachlor exposure and a mild service.
Philippine General
hearing loss Hospital
in infants without exposure. On the other hand, He soon
unilateral developed
hearing respiratory
loss with a 6.25% failure, upon which
risk compared to the
the
Taft Avenue,
1 infant Manila,to
exposed 1000 Philippines had hearing loss, with a
cypermethrin considerations were
unexposed group with 1.99%. acute pulmonary congestion, nosocomial
Telephone: +632 554-8488 pneumonia, to rule out an acute coronary event. He was later
6.25% czarlota@yahoo.com
Email: risk, higher compared to the unexposed group of

12 ACTA MEDICA
8 ACTA MEDICA PHILIPPINA
PHIlIPPINA Vol.46
VOL. 43NO.
N0. 43 2009
2012
 Heart Failure
ABR of Infants Following and Short
Maternal Stature intoa Toxic
Exposure 43 year-old male
Products

Table
Table 1.
8.Initial laboratory
Association Results
of cypermethrin exposure with status Table 12. Griffith’s Mental Development Scale of Infant 3.
of hearing (ABR threshold). Infant 3 – positive exposure to pretilachlor with mild
CBC Blood chem. Urinalysis ABG
unilateral hearing loss
Reference Presence Result
of wave V at Reference Result Color straw pH 7.408
Cypermethrinexp Value >40dB <40dB Value
Total Scores SQ %tile SQ %tile
WBC 5-10
(+) 1 4.5 15 RBS 163.9-6.1 6.3 Transp
6 mo
Clear
6 mo
pCo2
12 mo
49.1
12 mo
RBC 4-6(-) 9 643 HGBA1C 4.27-6.07
652 6.4 Sp Gravity 1.010 po2 70
Hearing/Language 100 50 86 19
HGB
Total 120-150 10 90 658 BUN 2.6-6.4
668 5.0
Performance
pH106
8.0
65
HCo3
76 7
31.3
HCT
Riskexposed 0.38-0.48=1/16 (6.25%)0.27 CREA 53-115 123 Quotient Sugar
General 103.8 (average)NEG o2 sat
90 (average) 93.6
MCV
Riskunexposed 80-100 Fl=9/643 (1.34%) AlB 34-50 32 Protein NEG Fio2 21%
MCH risk 27-31 PG
Relative =4.53 (0.61-33.64) TAG
P=0.1019 0.34-1.7 0.82 RBC 0-1 Temp 36.9
1MCHC 320-360 G/l
st Infant: Wave V at 80dB at the right (2.82ug/L)
HDl 0.91-1.56 0.67 WBC Discussion
0-2
RDW 11.5-15.5% lDl 1.1-3.8 While measures
4.21 Cast of central auditory effects PBS among
PlT 200-400 Inc ToTAl CHol 4.2-5.2 5.25
workers exposedEpith
tocell Rare
organophosphates have been reported,
Slight poikilocytosis,
Table 9. Association of pretilachlor exposure with status of
RETIC 0.005-0.015 AST 15-37 this95study looksBacteria
at early auditoryocc’l effects in newborns
acanthocytes, with
ovalocytes,
hearing
SEG (ABR50-70%
threshold). 48 AlT 30-65 91 Mucus th Rare
maternal exposure to environmental slight toxic granulation,
products. Propoxur,
lYMPH 20-44% 50 Alk po4 184 Crystals Rare slight anisocytosis
MoNo 2-9% 2 of wave V atNA
Presence 140-148 cypermethrin
136.9 and pretilachlor exposure
Am urates may contribute to
Eo
Pretilachlor 0-4% >40dB 0 <40dBK Total 3.6-5.2 increased
3.35 risk of hearing loss given possible effects on the
BASo
(+) 0-2% 1 0 15 Cl 16 100-108 86 or newborns. Three (3/668, 0.45%) with positive
fetus
BlAST
(-) 0% 13 0 639 CA++ 652 2.12-2.52 2.37
644 P
exposure to environmental toxins had wave V thresholds
Total 14 668 2.27
Riskexposed =1/16 (6.25%) MG++ 0.74-1 >400.83
dB, 2 of which at ≥80 dB, and 1/668 (0.15%) with multiple
Riskunexposed =13/652 (1.99%) exposures had wave V threshold ≥80 dB.
Relative risk =3.13 (0.44-22.30) P=0.0723
The risk of hearing loss with exposure to identified
3rd Infant: Wave V at 50dB at the left (0.48ug/L)
substances appears clinically significant whether these are
fat pad.changes
subtle Cardiac found
enzymes in were
ABR notwave consistent
latencieswith
or an acute
wave V
TableHowever,
2. Thyroidthere
Function
wereTests
no significant differences noted
coronary event (Table 3), however, intravenous
threshold elevations. The GMDS scores show good (IV) heparin
between the exposed and unexposed
Reference Value groups Result
with regard to (overlapping
GMDS-hearing
Free T4 and speech
(0.8-2.0)subscale and general
0.02 ng/dlquotient correlation atwithleastoral warfarin)
among waswith
infants still given
hearing to cover for
loss and
the presence of a possible
documented exposures to toxins. lV thrombus as demonstrated
TSH
scores. (0.4-6.0) 24.75 Uiu/ml
by rheologic stasisdespite
In this cohort, on cardiac ultrasound.
the rarity Medications
of the condition, there
Scrutinizing the 3 infants with exposures and hearing were shifted to IV diuretics and inotropes; oral digoxin was
loss, there were low scores in GMDS scoring noted. In infant seems to be an association between exposure to propoxur,
started. IV antibiotics were given for possible
cypermethrin, and pretilachlor and hearing loss. It is pulmonary
1 with 2 exposures at unilateral moderate hearing loss, infection. The patient later on showed improvement, and was
performance scores were low, although the general quotient important to delineate the effects of these exposures and
eventually weaned off from ventilatory support, extubated,
scores were average at 6 and 12 months (Table 10). Infant 2 eliminate other causes for the hearing loss. Further analysis
had propoxur exposure and bilateral profound hearing loss, using multivariate regression may be employed to include
Table 3. Cardiac
all possible Enzymes
variables that may contribute to hearing loss, so
with below average scores (Table 11). Infant 3 had
pretilachlor exposure and unilateral mild hearing loss, that individual effects may Range
Reference be quantified.
(mmoL) Result
showing modest scores in hearing and speech performance This study,
Qualitative along with published studies on OAE and
PoSITIVE
with average general quotient scores (Table 12). ABRs from
Troponin I our center encouraged us to push for legislation
toCK-MB
institute newborn hearing 0-6.0 screening so that1.14 even in far-
CK-ToTAl
Table 10. Griffith’s Mental Development Scale of Infant 1. flung areas these babies 21-232
can benefit from early 543 identification
Infant 1 – positive exposure for propoxur and cypermethrin and intervention for prevention of deleterious effects on
with moderate hearing loss neuro-development which include speech and hearing. The
present study would be helpful in educating people in the
Scores SQ %tile SQ %tile community on the proper use of commonly available
Figure 1. Electrocardiogram
6 mo upon
6 mo admission
12 mo 12 mo pesticides, in addition to motivating health regulatory
Hearing/Language 109 71 98 45 bodies to further investigate effects, institute regulations in
Performance 62 1 90 27
pesticide use, and conduct regular monitoring of burden of
transferred to the 90.4
General Quotient intensive
(average)care unit (ICU) for ventilatory
93.4 (average)
exposures.
support and closer monitoring. on bedside cardiac ultrasound,
Tablewas
there 11. Griffith’s
a findingMental Development
of eccentric Scale ofhypertrophy,
left ventricular Infant 2.
Conclusion
global
Infant 2hypokinesia withexposure
– positive for depressedto overall
propoxur systolic
with function
bilateral
Maternal exposure to some pesticides may contribute to
with concomitant
profound hearingspontaneous
loss echo contrast on left ventricular
(lV) cavity suggestive of rheologic stasis, the ejection fraction an increased risk for hearing loss among infants in an
was 25%, with moderate
Scores SQ mitral
%tile regurgitation,
SQ moderate
%tile agricultural community. Further monitoring of infants may
6 mo 6 mo 12 mo
aortic regurgitation with aortic sclerosis, severe tricuspid
12 mo be helpful to assess if these effects are reversible or
Hearing/Language 42.3 0.5 68.6 2 permanent.
regurgitation
Performance with mild
53.84 pulmonary
0.5 hypertension,
90.1 pulmonary
27
regurgitation,
General Quotientand minimal
47.6 (belowpericardial
average) effusion or pericardial
75.6 (below average) Figure 2. Chest radiograph on admission

Vol. 46
VOL. 43 NO.
N0. 432009
2012 ACTA MEDICA
ACTA MEDICA PHILIPPINA
PHIlIPPINA 13
9
ABR of Infants Following Maternal Exposure to Toxic Products
CASE REPORT

__________________ Heart Failure and Short Stature in a 43 year-old male

Acknowledgments
Katerina T. leyritana1, Ma. Czarlota M. Acelajado-Valdenor1, Amado o. Tandoc III2 and Agnes D. Mejia1
We would like to acknowledge the assistance of the following in
bringing the babies for hearing screening: Essie Ann Ramos, Abner
1
Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila
Hornedo, Patrocinio Mateo, Philip Cruz, Lilibeth Avendano,
2
Department of Pathology, College of Medicine, University of the Philippines Manila
Rubilyn Obando, Maribel Santiago, Roberta Briones, Rozza
Villavicencio and Cecilia Santiago.

This paper was supported by a grant from the National Institute

of Communication and Hearing Disorders (NICHD)
IR01HD03942800IA US EPA RFA2001 (STAR-HI) No. R829395-01-0.

Presentation of the case require regular laxative use. There was also a report of two
___________
This is a case of a 43-year-old male presenting with short more syncopal episodes. He was brought to another doctor
stature
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was Murata
7.
given medications to increase height, which the patient
K, Weihe P, Renzoni A, et al. Delayed evoked potentials in
no apparent congenital malformations, no cardiac murmurs
tookchildren
for only one month with nofrom
exposed to methylmercury improvement. Through
seafood. Neurotoxicol the
Teratol. and no clubbing. There was also no note of an anterior neck
years, the21(4):343-8.
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8. Ostrea
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Jr, Bielawski
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bronchial
9. Teixeiraasthma at age
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taking salbutamol
system tablets
in rural workers. Cadoccasionally for 19:218.
Inf Prev Acid. 1998; bouts of dyspnea electrocardiogram (12-l ECG) (Figures 1 and 2), normocytic
10. Teixeira CF, Giraldo Da Silva Augusto L, Morata TC. Occupational
occurring one to two times annually. normochromic anemia (Hgb 90 mg/dl), dyslipidemia, and
exposure to insecticides and their effects on the auditory system. Noise
The patient’s symptoms started in 2001 when he was
Health. 2002; 4(14):31-9. pre-renal azotemia (serum creatinine 123 mmol). Electrolytes
reported
11. ChiongtoCM, have sudden
Ostrea EM Jr,loss of A,
Reyes consciousness.
Llanes EG, Uy During
ME, Chan this
A. on admission showed slight hyponatremia, hypokalemia,
time,Correlation
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no prior seizures, cyanotic episodes, chest pain, headache, or revealed partially compensated metabolic alkalosis with mild
8.
blurring of vision. He regained consciousness shortly after and hypoxemia. The patient was noted to be hypothyroid based
was brought to a private physician, whose assessment was a on elevated serum thyroid-stimulating hormone (TSH) and
“heart problem”. He was prescribed unrecalled medications markedly decreased serum free thyroxine (FT4). The exact
taken for a few months and eventually discontinued when values are shown in Tables 1 and 2.
the syncopal episode did not recur. Upon admission to the wards, the patient was managed
In the next four years, the patient would develop as having congestive heart failure from cardiomyopathy
intermittent, progressive exertional dyspnea and bipedal secondary to acquired hypothyroidism. oral loop diuretics,
edema. later on this would be accompanied by generalized angiotensin-converting enzyme (ACE) inhibitors, beta-
body weakness, anorexia, and constipation, severe enough to blockers, statins, and levothyroxine were started. Electrolyte
correction was instituted. The sections of Endocrinology
and Cardiovascular Diseases were co-managing the patient
Corresponding author: Ma. Czarlota Acelajado-Valdenor, M.D.
Department of Medicine together with the General Medicine service.
Philippine General Hospital He soon developed respiratory failure, upon which the
Taft Avenue, Manila, 1000 Philippines considerations were acute pulmonary congestion, nosocomial
Telephone: +632 554-8488 pneumonia, to rule out an acute coronary event. He was later
Email: czarlota@yahoo.com

12 ACTA MEDICA
10 ACTA MEDICA PHILIPPINA
PHIlIPPINA Vol.46
VOL. 43NO.
N0. 43 2009
2012