Chemical Weapons in the Iran-Iraq War (1980–1988). 5. Accumulated Experience in the Treatment of Lesions Caused by Sulfur Mustard

Sulfur mustard was widely used during the Iran-Iraq war (1980–1988) and in other conflicts in the Middle East. Due to its availability, it can be used by terrorist organizations on the territory of the Russian Federation. Iran is the only country, against which mustard gas was used in modern warfare. The aim of this work is to analyze and summarize the experience of treating of sulfur mustard exposure, accumulated by Iranian specialists during the Iran-Iraq war (1980–1988). The UN official documents and materials, declassified CIA documents, articles of Iranian authors as well as other open sources have been used during its preparation. The Iraqi army used mustard gas in two aggregate states: liquid and dry. Dry mustard gas was a novelty of that war. It was a powdered silica steeped in mustard gas, with a particle size of less than 5 μm. The first signs and symptoms of poisoning could appear after 15 minutes, while acute poisoning effects of exposure to mustard gas vapour or liquid were typically delayed for several hours. The reasons for the severe mustard lesions of the servicemen were the lack of personal protective equipment, untimely evacuation from the mustard gas contamination zone, and the absence of mobile reserves of clean water and degassing installations in battle formations. Iranian experts consider 0.5% sodium hypochlorite solution to be the most effective decontaminant. The only safe antidote is sodium thiosulfate, administered within 60 minutes after exposure to mustard gas. During the evacuation of victims and their treatment in hospitals it is necessary, in severe cases, to insert an intravenous catheter, carry out a tracheotomy with the installation of a tracheotomy tube, and use bronchoscopy as early as possible to flush the bronchi. The treatment of skin and eye lesions should be conservative. In case of a corneal perforation, if its diameter is more than 2 mm – keratoplasty, if it is less – cyanoacrylate glue. Treatment of respiratory lesions aims to relieve symptoms and reduce the severity of complications. For this, bronchodilators, antitussives, mucolytics and, if necessary, antibiotics are used. The use of corticosteroids should be limited to the treatment of those patients with bronchospasm, who can not be treated by bronchodilators. The Iranians also consider gene therapy and treatment with mesenchymal stem cells to be the promising method used in the treatment of lung lesions.

1. Karami Ali. Long Legacy // CBRNe WORLD. 2012. August. P. 30–40.

2. Hashemian А., Khoshnood K., Desai M.M. et al. Anxiety, depression, and posttraumatic stress in Iranian survivors of chemical warfare // JAMA. 2006. V. 296. № 5. P. 560–566.

3. Supotnitskiy M.V., Shilo N.I., Kovtun V.A. Chemical Weapons in the Iran-Iraq War (1980– 1988). 1. Iraq Preparing for Chemical War // Journal of NBC Protection Corps. 2019. V. 3. № 1. P. 40–64. https://doi.org/10.35825/2587-5728-2019-3-1-40-64 (in Russian).

4. Supotnitskiy M.V., Shilo N.I., Kovtun V.A. Chemical Weapons in the Iran-Iraq War (1980–1988). 2. Combat Use of Chemical Weapons // Journal of NBC Protection Corps. 2019. V. 3. № 2. P. 150–174. https://doi.org/10.35825/2587-5728-2019-3-2-150-174 (in Russian).

5. Supotnitskiy M.V., Shilo N.I., Kovtun V.A. Chemical Weapons in the Iran-Iraq War (1980–1988). 3. Medical Consequences of Chemical Warfare // Journal of NBC Protection Corps. 2019. V. 3. № 3. P. 255–289. https://doi.org/10.35825/2587-5728-2019-3-3-255-289 (in Russian).

6. Supotnitskiy M.V., Shilo N.I., Kovtun V.A. Chemical Weapons in the Iran-Iraq War (1980–1988). 4. The Destruction of Iraqi Chemical Weapons // Journal of NBC Protection Corps. 2020. V. 4. № 2. P. 131–159. https://doi.org/10.35825/2587-5728-2020-4-2-131-159 (in Russian).

7. Franke S. Lehrbuch der Militärchemie. Band 1. Deutscher Militärverlag. Berlin, 1967.

8. Haines D.D., Fox S.C. Acute and long-term impact of chemical weapons: Lessons from the Iran-Iraq war // Forensic Sci. Rev. 2014. V. 26. P. 98–114.

9. Impact and implication of chemical weapons use in the Iran-Iraq war. Director Central Intelligence. Interagency Intelligence Memorandum. NI IIM 88-10004C. Top Secret. April 1988. Approved for release 08.10.2010.

10. Javed Ali. Chemical Weapons and the Iran-Iraq War: A Case Study in Noncompliance // The Nonproliferation Review/Spring. 2001. P. 43–58.

11. Kehe K., Thiermann F., Balszuweit F. et al. Acute effects of sulfur mustard injury Munich experiences // Toxicology. 2009. V. 263. P. 3–8. doi:10.1016/j.tox.2009.04.060

12. Darchini-Maragheh E., Balali-Mood M. Delayed Complications and Long-term Management of Sulfur Mustard Poisoning: Recent Advances by Iranian Researchers (Part І of ІІ)// Iran. J. Med. Sci. 2018. V. 43, № 2. P. 103–124.

13. Razavi S.M., Karbakhsh M., Salamati P. Preventive measures against the mustard gas: a review // Medical Journal of the Islamic Republic of Iran. 2013. Vol. 27, № 2. Р. 83–90. https://doi.org/10.22088/cjim.10.3.241

14. Eghtedardoost M., Mohammad Z.H., Askari N. et al. The delayed effect of mustard gas on housekeeping gene expression in lung biopsy of chemical injuries // Biochemistry and Biophysics Reports. 2017. Vol. 11. P. 27–32.

15. Rajavi Z., Safi S., Javadi M.A. et al. Clinical Practice Guidelines for Prevention, Diagnosis and Management of Early and Delayed-onset Ocular Injuries Due to Mustard Gas Exposure // J. Ophthalmic. Vis. Res. 2017. V. 12, № 1. P. 65–80. https://doi.org/10.4103/jovr.jovr_253_16

16. Hefazi M., Maleki M., Mahmoudi M., Tabatabaee A., Balali-Mood M. Delayed complications of sulfur mustard poisoning in the skin and the immune system of Iranian veterans 16–20 years after exposure // Int. J. Dermatol. 2006. V. 45. P. 1025–1031.

17. Foroutan S.A. Medical notes on chemical warfare, part II // Kowsar. Med. J. 1997. V. 1. P. 159–177. [in Persian].

18. Balali-Mood M., Hefazi M. Comparison of Early and Late Toxic Effects of Sulfur Mustard in Iranian Veterans // Basic & Clinical Pharmacology & Toxicology. 2006. V. 99. P. 273–282

19. Etemad L., Moshiri M., Balali-Mood M. Advances in treatment of acute sulfur mustard poisoning–a critical review // Critical reviews in toxicology. 2019. V. 49, № 3. P. 191–214. https://doi.org/10.1080/10408444.2019.1579779

20. Chilcott R.P. Toxicity of sulphur mustard // Toxicol. Appl. Pharmacol. 2005. V. 204. P. 99–100. https://doi.org/10.1016/j.taap.2004.09.016

21. Balali-Mood M., Hefazi M. The pharmacology, toxicology, and medical treatment of sulphur mustard poisoning // Fundam Clin Pharmacol. 2005. V. 19. P. 297–315. https://doi.org/10.1111/j.1472-8206.2005.00325.x

22. Graham J.S, Schoneboom B.A. Historical perspective on effects and treatment of sulfur mustard injuries // Chem. Biol. Interact. 2013. V. 206. P. 512–522. https://doi.org/10.1016/j.cbi.2013.06.013

23. Callaway S., Pearce K.A. Protection against systemic poisoning by mustard gas, di(2-chloroethyl) sulphide, by sodium thiosulphate and thiocit in the albino rat // Br. J. Pharmacol. Chemother. 1958. V. 13(4). P. 395–398. https://doi.org/10.1111/j.1476-5381.1958.tb00227.x

24. Hatiboglu I., Mihich E., Moore GE, Nichol CA. Use of sodium thiosulfate as a neutralizing agent during regional administration of nitrogen mustard: an experimental study // Ann Surg. 1962. V. 156. P. 994. https://doi.org/10.1097/00000658-196212000-00022

25. Poursaleh Z, Harandi AA, Vahedi E, Ghanei M. Treatment for sulfur mustard lung injuries; new therapeutic approaches from acute to chronic phase // Daru. 2012. V. 20(1). P. 27. https://doi.org/10.1186/2008-2231-20-27

26. Dorr R.T., Soble M., Alberts D.S. Efficacy of sodium thiosulfate as a local antidote to mechlorethamine skin toxicity in the mouse // Cancer Chemother Pharmacol. 1988. V. 22. P. 299–302. https://doi.org/10.1007/BF00254235.

27. Graham J.S., Chilcott R.P., Rice P. et al. Wound healing of cutaneous sulfur mustard injuries: strategies for the development of improved therapies // J. Burns. Wounds. 2005. V. 4. e1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1501116/

28. Ghorani-Azam A., Balali-Mood M. Clinical pharmacology and toxicology of mustard compounds / In: Balali-Mood M., Abdollahi M., editors. Basic and clinical toxicology of mustard compounds. New York (NY): Springer, 2015. P. 63–101.

29. Gu T.Y. Mechanism and treatment of sulfur mustard-induced cutaneous injury // Chin. J. Traumatol. 2014. V. 17. P. 345–350. https://doi.org/10.3760/cma.j.issn.1008-1275.2014.06.010

30. Baradaran-Rafii A., Eslani M., Tseng S.C. Sulfur mustard-induced ocular surface disorders // Ocul Surf. 2011. V. 9. P. 163–178. https://doi.org/10.1016/S1542-0124(11)70026-X

31. Trufanov S.V. The use of cyanoacrylate glue in the surgical treatment of corneal perforation (clinical case) // Bulletin of Ophthalmology. 2020. V. 136 (5), P. 232–236. https://doi.org/10.17116/oftalma2020136052232 (in Russian).

32. Freitag L., Firusian N., Stamatis G., Greschuchna D. The role of bronchoscopy in pulmonary complications due to mustard gas inhalation // Chest. 1991. V. 100. P. 1436–1441.

33. Krumbhaar E.B., Krumbhaar H.D. The blood and bone marrow in yellow cross gas (mustard gas) poisoning. Changes produced in the bone marrow of fatal cases // J. Med. Res. 1919. V. 40(3). P. 497–508.

34. Tabarestani M., Balau-Mood M., Farhoodi M. Hematological findings of sulphur mustard poisoning in Iranian combatants // Med. J. Islamic Republic Iran (MJIRI). 1990. V. 4. P. 185–190.

35. Arabipoura I., Amani J., Ali S. et al. The study of genes and signal transduction pathways involved in mustard lung injury: A gene therapy approach // Gene. 2019. V. 714. P. 143968. https://doi.org/10.1016/j.gene.2019.143968

36. Wu D-D., Song J., Bartel S. et al. The potential for targeted rewriting of epigenetic marks in COPD as a new therapeutic approach // Pharmacology and Therapeutics. 2018. V. 183. P. 1–14. https://doi.org/10.1016/j.pharmthera.2017.08.007

37. Nejad-Moghaddam A., Tahmasbpour T., Sohrabiyan M. et al. Stem cells therapy: a review on approaches that can be used for treatment of respiratory failures in sulfur mustard-injured patients // Immunopharmacology and Immunotoxicology. 2018. V. 40. № 5. Р. 359–367. https://doi.org/10.1080/08923973.2018.1510961