Sarin-Nerve Agent

Contract No.
IOM-2794-04-001
The National Academies
HEALTH EFFECTS OF
PROJECT SHAD
CHEMICAL AGENT:
SARIN NERVE AGENT

[CAS # 107-44-8]
Prepared for the National Academies
by
The Center for Research Information, Inc.
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Revision 1
2004
ACKNOWLEDGEMENTS
Submitted to Dr. William Page, Program Officer, Advisory Panel for

the Study of Long-term Health Effects of Participation in Project SHAD
(Shipboard Hazard and Defense), Institute of Medicine, the National
Academies.
This report is subject to the copyright and reproduction arrangements defined in

Contract No. IOM-2794-04-001 of the National Academies.
This report and any supplements were prepared by the Center for Research
Information, Inc. which is solely responsible for its contents.
Although this draft is the definitive submission on its subject matter, the Center for
Research Information recognizes its ethical and contractual obligation to update,
revise, or otherwise supplement this report if new or necessary information on its
subject matter should arise, be requested, or be ascertained during the contract
period.
The Principal Investigator wishes to acknowledge and thank Matthew Hogan, Linda
Roberts, Lawrence Callahan, Kristine Sasala, Judith Lelchook and Emnet Tilahun
for research assistance, editorial content assistance, and project input.
Principal Investigator: Victor Miller

Text Draft & Editing: Victor Miller, Lawrence Callahan, & Matthew Hogan
Project Manager: Matthew Hogan
Administration: Linda Roberts
Contract No. IOM-2794-04-001

Health Effects of Sarin Nerve Agent
ii
SPECIAL NOTE ON PSYCHOGENIC SEQUELAE OF PERCEIVED

EXPOSURE TO BIOCHEMICAL WARFARE AGENTS
This report deals primarily with the biological health challenges engendered by the agent
that is the subject of the report. Nevertheless, this report also incorporates, by reference
and attachment, a supplement entitled "Psychogenic Effects of Perceived Exposure to
Biochemical Warfare Agents".
The supplement addresses and describes a growing body of health effects research and
interest centered upon the psychogenic sequelae of the stress experienced personally from
actual or perceived exposure to chemical and biological weaponry. Because awareness
of exposure to agents in Project SHAD logically includes the exposed person also
possessing a perception of exposure to biochemical warfare agents, the psychogenic
health consequences of perceived exposure may be regarded as additional health effects
arising from the exposure to Project SHAD agents. This reasoning may also apply to
simulants and tracers. Therefore, a general supplement has been created and submitted
under this contract to address possible psychogenic effects of perceived exposure to
biological and chemical weaponry.
Because such health effects are part of a recent and growing public concern, it is expected
that the supplement may be revised and expanded over the course of this contract to
reflect the actively evolving literature and interest in the issue.

iii
TABLE OF CONTENTS
I. EXECUTIVE SUMMARY.... 1
II. BACKGROUND DATA: CHEMISTRY & HISTORY..
Chemistry..
History of Development/Use as Weapon .
Study & Reports of Human Exposures
7
7
8
11
III. PATHOGENESIS & FORENSIC DIAGNOSTICS.... 14

Pathophysiology 14
Pharmacokinetics. 16
Forensic Assays & Environmental Detectors.
16
IV. HEALTH EFFECTS..
18
Overview 18
Acute Toxicity.. 19
Developmental & Reproductive Activity.. 19
Carcinogenicity 20
Genotoxicity. 20
Immunotoxicity 20
Otic Effects.. 21
Pulmonary Effects..
21
Cardiac Effects 21
Skeletal Muscle Effects..
21
Nervous System Effects.
22
Diagnosis of Fact & Extent of Intoxication.
22
V. PSYCHOGENIC EFFECTS..
25
VI. TREATMENT & PREVENTION
26
VII. SECONDARY SOURCE COMMENT..
28
VIII. BIBLIOGRAPHY WITH ABSTRACTS
29

iv
I. EXECUTIVE SUMMARY
In 1936 German chemist Gerhard Schrader discovered that an organophosphate
compound, ethyl dimethylphosphoramidocyanidate (later called Tabun), was a potent
insecticide. Dr. Schrader reported his discovery to German authorities, who then set up a
laboratory for Schrader to further pursue toxic nerve agents for military purposes. In
1938, Schrader along with some associates, synthesized 1-methylethyl
methylphosphonofluoridate. It was named sarin, after the chemists Schrader, Ambrose,
Rdiger and van der Linde, who were responsible for its synthesis.
Sarin is a chemical warfare nerve agent which is described by the chemical formula
C4H10FO2P, and is identified by Chemical Abstracts Service (CAS) Registry number 10744-8. Under normal conditions it is a colorless liquid, and odorless. It is miscible in both
polar and nonpolar solvents, and it hydrolyzes slowly in water at neutral or slightly acidic
pH. Sarin is significantly less stable to hydrolysis than VX. Sarins hydrolysis products
are considerably less toxic than the original agent.
The synthesis of sarins chemical class, the organophosphosphates, dates back to 1820.
Widespread poisoning by organophosphates was first seen in the United States in early
1930, when many people developed a strange paralytic illness traced to a Prohibition-era
alcohol substitute, called Jamaican Ginger or Jake, which had been adulterated with triortho-cresyl phosphate (TOCP). TOCP was the first chemical proven to show a delayed
type of neurotoxicity.
The use of chemical warfare agents is ancient but their most extensive use occurred
during World War I when chlorine and mustard gas inflicted over one-million casualties.
Nazi Germany later produced large amounts of the organophosphate agent tabun along
with far lesser amounts of sarin (1000 lb) throughout World War II but they were not
known to be used. In 1950, the US Armys Chemical Corp began the construction of
plants for the full-scale production of sarin but ceased in 1957 because stockpile
requirements were met.
The only confirmed military use of nerve agents in history was by Iraq, which used tabun
and sarin aerial bombs to repel Iranian troops. In the latter part of the war, Iraqs
extensive use of chemical warfare agents is believed to have brought an end to the
conflict. Reports claim that between 5,500 to 10,000 Iranian troops were killed by nerve
agents and mustard gas, and up to 100,000 soldiers were exposed. In March of 1988, Iraq
used a combination of chemical weapons, including mustard gas, tabun, sarin, VX and
possibly even cyanide to kill as many as 5,000 people in the Kurdish town of Halabja.
Iraq is believed to have produced between 790 to 810 tons of sarin which degraded or
were destroyed after the Gulf War.
The first known terrorist use of a nerve agent involved sarin and occurred in Matsumoto
City, Japan on the evening of June 27, 1994. About 12 liters of sarin were released using
a heater and a fan from the window of a delivery truck. The attack was undertaken to kill
four judges involved in a dispute with the Aum Shinrikyo cult. There were 471 victims of
sarin poisoning, 54 were hospitalized, and 253 treated at outpatient facilities. Seven died.
On March 20, 1995, Aum Shinrikyo launched an even bolder attack on the subway
system in Tokyo. At 8:00 AM, at the height of rush hour, sarin was released. Twelve
subway passengers were killed. About 980 persons suffered mild to moderate exposure,
and 500 persons were hospitalized. Over 5,000 people, many of whom were not actually
exposed, sought medical attention.
The largest experimental use of sarin on humans appears to have occurred at Porton
Down in the United Kingdom in the 1950s. The purpose of the studies was to obtain
precise information on the toxic properties of these agents. Certain experiments went
terribly wrong. One man died 45 minutes after 200 mg of sarin were dripped onto a
uniform patch on his forearm.
The US also ran a number of tests using sarin that may have resulted in human exposure.
The tests were part of Project 112 of the Deseret Test Center; Project SHAD (Shipboard
Hazard and Defense) was part of this program. The tests monitored the environmental
effects of sarin, the dispersal pattern of bomblets, shipboard detection of agents, and
protective measures. Several of the tests did involve exposure of personnel to nerve
agents and to potential biowarfare agents. The Department of Defense (DOD) has
identified about 5,000-6,000 persons who may have been exposed to one or several of
these agents.
Very little data on Soviet chemical weapons testing has emerged. Several reports
indicate that there was exposure of the population in Russia to nerve agents. One paper
had a short summary reporting 209 acute poisonings involving sarin, soman or VX in
Russian production facilities. Several long term health effects were described including
memory loss, asthenia, sleep disorders and cardiovascular effects.
The most widespread use of nerve agents occurred during and shortly after the Iran-Iraq
war but unfortunately there is very little accessible scientific literature addressing either
the short term or long term medical consequences of this use. Iraq used nerve agents and
mustard gas against its Kurdish population from April 1987 to October 1988, to quell
rebellion and punish the population. It is estimated that approximately 250,000 civilians
where exposed to these agents and over 5,000 were killed. Unfortunately, there also been
very little study of this population. The exposures to nerve agents in Japan remain the
most extensively studied sarin incidents.
The acute toxicity of sarin is believed to be rooted in its inhibition of
acetylcholinesterases (AChEs). The inhibition of AChE leads to a rise in the
concentration of acetylcholine and the hyperstimulation of both nicotinic and muscarinic
acetylcholine nerve receptors. Sarin has been shown to react with a number of other
receptors and enzymes as well. At very low concentrations (0.3-1.0 nM), sarin reacts with
muscarinic m2 receptors on presynaptic gamma-aminobutyric acid (GABA)-ergic
neurons. The reduction in the action-potential mediated release of GABA can account for
the occurrence of seizures in individuals exposed to sarin. Sarin also bind tightly to
muscarinic m2 receptors in the heart and may play a role in cardiotoxicity.
There have been several reports on the ability of sarin to inhibit the enzyme neurotoxic
esterase or neuropathy targeted esterase (NTE). The inhibition of NTE has been reported
to be responsible for the onset of organophosphate induced delayed neuropathy (OPIDN).
The pathway through which inhibition of NTE leads to OPIDN has not yet been
elucidated, although it is known neuropathy only occurs when over 70% of NTE activity
is inhibited following acute exposure and 50% following repeated exposures. It should be
noted that subclinical neuropathy was reported 30 days after sarin exposure in Japan and
a subsequent study also picked up electromyographic evidence of neuropathy six months
after exposure.
The acute effects of sarin are believed to be primarly due to (-)-isomer of sarin. The (+)isomer appears to be eliminated rapidly from body following administration. Animal
studies indicate that (-)-sarin is rapidly distributed throughout the body, within minutes,
but eliminated very slowly with a half-life of several hours. The primary metabolite of
sarin, isopropyl methylphosphonic acid, was found in large amounts in the serum and
urine of victims in Japan. The concentration of the metabolite and the amount of time
from exposure can be used to estimate the level of exposure. These studies indicated that
several of the survivors were exposed to supra-lethal levels of sarin.
There are currently no real time clinical tests for Sarin exposure but there have been a
number of forensic assays developed that can confirm exposure. Most of these tests
involve isolating RBC AChE and/or serum butyrylcholinesterase from blood and
releasing and detecting any organophosphates that are released. There has also been a
great deal of work on the environmental detection of sarin and other nerve agents. The
Department of Defense has developed several detectors to monitor air for the presence of
nerve agents. The mainstay of the Army chemical detection is the M8A1 alarm which
constantly samples the air for higher molecular weight molecules. The detector ionizes
gases and mass filters away the low molecular ions generated from air.
The health effects of sarin, are dependent on the route of administration, dose received,
and the speed at which treatment is given. Casualties can go from being fully
functioning to comatose with severe respiratory distress in a matter of seconds following
exposure. Aggressive, rapid therapy can substantially minimize adverse health effects
seen in patients exposed to nerve agents.
Acute effects seen at low concentrations include: miosis, ocular pain, blurred or dimmed
vision, tearing, rhinorrhea, broncospasm, slight dyspnea, respiratory secretions, salvation,
and diaphoreses. At intermediate concentrations, moderate dyspnea, nausea, vomiting,
diarrhea are seen. At high concentrations, convulsions, loss of consciousness, muscle
fasciculations, flaccid paralysis, copious secretions, apnea and death.
Toxic factors and exposure limits established by the US Dept. of Health and Human
Services (DHHS) include the vapor concentration per period of exposure during which
50% lethality is seen for humans (LCt50). That level is 100 mg/m3/min; the no death dose
equals 10 mg/m3/min; the no neuromuscular (NNM) effect dose equals 4 mg/m3/min. The
concentration which induces miosis in 50% of victims (ECt50 (miosis)) equals 2-4
mg/m3/min. The no observable effect level (NOEL) equals 0.5 mg/m3/min; the maximal
single concentration for 1 hour equals 0.001 mg/m3; the maximal single concentration for
8 hours equals 0.0003 mg/m3; the safety factor of 0.1 is used for the general population
and the limit levels are 0.0001 mg/m3 for 1 hour, 0.00003 mg/m3 for 8 hours and
0.000003 mg/m3 for 72 hours.
There has been no evidence in humans of reproductive or developmental toxicity. In
animals, there has been no evidence of sarin related adverse effects with respect to
reproductive performance, fetal toxicity, and teratogenesis. There is no evidence of
carcinogenicity in human. In chronic inhalation studies in mice, rats and dogs, sarin did
not appear to be carcinogenic. No significant pulmonary tumors were observed in strain
A mice after 3/19 and 3/20 animals after 52 weeks of exposure to 0.001 and 0.0001
mg/m3, respectively.
There is relatively little information available regarding the human genotoxicity of sarin.
In bioassays using bacteria and mammalian cell cultures with and without metabolic
activation sarin did not show any evidence of genotoxic or mutagenic activity. There was
no increase in mutations using the Ames test. But several studies of the victims of the
Tokyo subway attack indicate that the sister-chromatid exchange (SCE) of lymphocytes
was higher in persons exposed to sarin, and there was a positive correlation between the
extent of serum cholinesterase inhibition and the level of SCE. The SCE effect appeared
to last up to three years after exposure.
Miosis (pinpoint pupils) is characteristic of sarin exposure. It usually occurs within
seconds or minutes of exposure. It can last up to 9 weeks resulting in dim vision. Blurred
vision and eye pain can accompany sarin exposure. There is very little data on the effect
of sarin on hearing.
Rhinorrhea, typically intense, is often seen shortly after sarin exposure. Tightness in the
chest is a common symptom after exposure to small amounts of sarin and usually
dissipates within hours of exposure. As the amount of exposure increases, dyspnea and
pulmonary distress increase and often someone severely poisoned will go into respiratory
failure and die. No data indicate that respiratory effects persist long after exposure.
Several animal studies that indicate there is a potential for some immunotoxicity or
immunodulatory effects upon sarin exposure. Reductions of T-cell mediated immune
reaction, a substantial increase in NK cell and macrophage activity, and a substantial
decrease in CD4 T-cell activity have been seen in testing. A single exposure was
observed to have the same effect as multiple exposures.
Bradycardia is frequently seen following moderate or high level sarin exposure. There
have been reports of persistent arhythmias following exposure. In cases of severe
poisoning, cardiomyopathy may also be seen.
Neuromuscular effects are common as acetylchloline is a primary neurotransmitter at the

neuromuscular junction. Increased acetylcholine initially leads to stimulation, followed
by fatigue and muscle paralysis. In the Tokyo attack, asthenia or muscle weakness was
seen in most patients upon admission to the hospital. Following liquid exposure muscle
fasciculations at the site of exposure are often seen after excessive sweating. Long-term
shoulder stiffness may be a result of exposure. Myopathy has also been seen in rats in the
absence of treatment following a moderate dose of sarin.
Although inducing convulsions and the resultant neuropathology, sarin in the the
Japanese incidents was found not to have caused persistent neurological disorders in most
patients. One exception was a patient who suffered from akinetic mutism for at least two
years following exposure. Studies in rats have shown that there is wide variability in
neurotoxicity following repeated sublethal doses of sarin. There is a lack of tolerance
with repeated doses, and a cumulative effect on toxicity.
Headaches are a very common symptom of sarin exposure. Loss of memory can happen;
a case of amnesia is reported following exposure in Japan. Long term changes in
electroencephalograms (EEG) in workers following accidental sarin exposure have been
observed. Increases in REM sleep have been found.
The initial diagnosis of sarin exposure is based on signs, symptoms and historical factors.
The first step in the diagnosis is to confirm presence of both nicotinic and muscarinic
effects. A convenient mnemonic for the signs and symptoms of nerve agent poisoning is
dumbbels, which stands for Diaphoresis (and diarrhea); Urination; Miosis; Bradycardia;
Bronchospasm (and bronchorrhea); Emesis; Lacrimation (with rhinorrhea and
salivation); Seizures (as well as muscle fasciculation and weakness).
Symptoms depend on the site and extent of exposure. Following dermal contact
symptoms can be delayed 18 hours but symptoms from inhalation can occur within
seconds. Percutaneous absorption of liquid sarin also occurs readily and typically leads to
localized sweating, followed by muscular fasciculations and weakness. (Lee 2003,
National Research Council 1997). Useful markers of nerve agent exposure include serum
butyrylcholinesterase and red blood cell AChE activity. Significantly reduced levels of
these are indicative of nerve agent exposure. Analysis of patients from the Tokyo subway
event indicates that miosis may be a better indicator of potential systemic toxicity than
red blood cell (RBC) AChE levels.
Psychogenic effects were reported from the Japanese incidents. Post-traumatic stress
disorder (PTSD) was seen in a number of sarin victims. Several studies have shown
persistent decreases in serum cholinesterase activity in patients with PTSD that evolved
over six months with no correlation with the serum cholinesterase activity taken right
after exposure. Fatigue, asthenia, insomnia, blurred vision, general anxiety were the
common manifestations. A survey of general effects of perceived exposure to chemical
and biological warfare agents is contained in the supplement under this contract
"Psychogenic Effects of Perceived Exposure to Biochemical Warfare Agents."
There are essentially five components of treatment for sarin exposure. The first
component is prophylaxis. This is typically accomplished by the administration of
pyridostigmine, a carbamate that reacts reversibly with AchE protecting the enzyme from
inactivation. The second component of treatment is decontamination and evacuation.
The third component of treatment is the use of anticholinergic agents to block the effect
of increased acetylcholine at synapses. Atropine is commonly used for this purpose. The
fourth component is the use of oximes to regenerate AchE enzymes. The fifth
component of treatment is the use of anticonvulsants. Diazepam has been the mainstay
of anticonvulsant therapy for nerve agent poisoning. In addition to these treatments, there
has also been interest in using adenosine agonists such as N6-cyclopentyladenosine
(CPA) to attempt to decrease the amount of acetylcholine released at synapses. CPA has
shown promise in reducing the potential cardiovascular toxicity following sarin exposure.
Future study of sarin would benefit from greater availability and evaluation of sarinexposure and testing data from the Iran-Iraq war and the former Soviet Union.

II. BACKGROUND: CHEMISTRY & HISTORY

Chemistry
Project SHAD Agent name: Sarin
Formula: C4H10FO2P
Structure:
O
O P F
CAS Number: 107-44-8

Names:
Sarin
Phosphonofluoridic acid, methyl-, 1-methylethyl ester
Phosphonofluoridic acid, methyl-, isopropyl ester, (+-)T-144
T-2106
TL 1618
Trilone 46
IMPF
Isopropoxymethylphoshoryl fluoride
Isopropoxymethylphosphoryl fluoride
Isopropyl methanefluorophosphonate
(+-)-Isopropyl methylphosphonofluoridate
GB
o-Isopropyl methylphosphonofluoridate
Physical Properties (Winkenwerder 2002a)
Colorless liquid
Miscible in water
Odorless and stable when pure
Nonflammable
Molecular Weight 140.1
Vapor Density (Air = 1) = 4.86
Liquid Density (g/cc) = 1.0887 @ 25 C
Freezing/Melting Point = -56 C
Boiling Point = 158 C
Vapor Pressure (mm Hg) = 2.9 @ 25 C; 2.1 @ 20 C
Log Kow= 0.72
Decomposition Temp. = 150 C

Sarin is a chemical warfare nerve agent.
Sarin is miscible in both polar and nonpolar solvents. It hydrolyzes slowly in water at
neutral or slightly acidic pH and more rapidly under strong acid or alkaline conditions.
Sarin is significantly less stable to hydrolysis than VX, particularly at acidic pH. The
hydrolysis products are considerably less toxic than the original agent (HSDB 2004).
Sarin is metabolized by both paraoxonase (PON1) and butyrylcholinesterase (also known
as serum acetylcholine esterase). The P-F linkage is hydrolyzed, resulting in the
formation of a relatively non-toxic phosphonic acid (Costa et al. 1999, Raveh et al. 1993)
Sarin is also a racemic mixture of stereoisomers, the chiral center of the molecule is on
the phosphorus atom. The (-) isomer of sarin appears to react with acetylcholinestrase
(AchE) at a rate at least 3-4 orders of magnitude greater than the (+)-isomer. The (+)isomer is referred to as the non-toxic isomer but may convert to (-)-isomer in-vivo. It
should be noted that it has been difficult to obtain (+)-isomer in pure form (Benschop et
al. 2001, Spruit et al. 2000)
History of Development & Use as Weapon
The use of chemical warfare agents goes back to antiquity. Early documented uses of
chemical warfare agents include: the Chinese use of arsenical smoke circa 1000 BC; the
use of hellebore roots by Athenian soldiers to poison the drinking water of Kirrha in 600
BC; the use of sulfur dioxide and other noxious fumes by the Spartans against the
Athenians during the Peloponnesian Wars; and the use mandrake root-laced wine by the
Carthaginians to sedate Roman soldiers in 200 BC. The most extensive use occurred
during World War I when the chlorine and mustard gas attacks resulted in over onemillion casualties (Eckert 1991, Landersman 2003, Smart 1997).
The synthesis of organophosphosphates dates back to 1820, when Jean Louis Lassaigne
reacted phosphoric acid with alcohols (Furtado et al. 2003). The first reported toxicity
involving organophosphates happened in France, when creosote oil was used to treat
tuberculosis and several of the patients developed neuromuscular spasms. The US
experienced widespread poisoning involving organophosphates in the early 1930s, when
many in the Midwest and South developed a strange paralytic illness that eventually
resulted in spastic gaits. Dr. Maurice Smith of the National Institutes of Health (NIH)
traced the disease to an alcohol substitute called Jamaican Ginger, or Jake, that had been
adulterated with tri-ortho-cresyl phosphate (TOCP). (TOCP was also the first chemical
proven to exhibit a delayed-type of neurotoxicity.)
Approximately 20,000-50,000 people were poisoned in the Jamaican Ginger incident.
Some recovered from the syndrome but for many the damage was permanent. The
characteristic gait was referred to as Jake leg and inspired a number of popular songs
(Smith 1930, Parascandola 1995, Morgan 1978, Ecobichon 2001, Baum 2003).
In 1936, Gerhard Schrader, a German chemist working for I.G. Farben, discovered that
an organophosphate compound named ethyl dimethylphosphoramidocyanidate (later
called Tabun) was a potent insecticide. During the course of their experiments, both Dr.
Schrader and an assistant were exposed to Tabun and suffered untoward effects,
including miosis and shortness of breath. As required by German law, Dr. Schrader
reported his discovery to German authorities who requested a demonstration. They then
set up laboratory for Schrader to further pursue toxic nerve agents for military purposes
(Smart 1997; Mitretek 2004).
In 1938, Schrader along with associates synthesized 1-methylethyl
methylphosphonofluoridate. The compound was named sarin after the chemists Schrader,
Ambrose, Rdiger and van der Linde who were responsible for its synthesis. Sarin was
significantly more toxic than Tabun. Although Germany produced large amounts Tabun
(12,000 tons) and smaller amounts of Sarin (1000 lb) during World War II, neither of the
agents appears to have used during the war (Smart 1997; Mitretek 2004).
After World War II, the US Armys Chemical Corp began the construction of plants for
the full-scale production of sarin. The Army developed a five-step process for synthesis
that was spread across two plants. The first two steps were performed at a plant at
Muscle Shoals, Alabama; the final steps were completed at Rocky Mountain Arsenal,
Colorado. Plant construction was completed and production began in 1953. In 1957, the
Army ceased production because stockpile requirements were met and the Army decided
to move forward with VX production. The Army also developed a number of munitions
to deliver sarin, including cluster bombs, large bombs, 105 mm and 155 mm artillery
shells, and rockets with warheads capable of delivery over very long distances (Smart
1997).
Although the US Army has never used nerve agents in war, there have been both
accidental and intentional releases that have resulted in the exposure of the environment,
soldiers, and civilians. Operation Chase involved the disposal of the M55 rocket system
after the thin aluminum heads of the rockets which contained the sarin began to leak. In
1967, the Army decided to dispose of the leaking munitions by encasing them inside
concrete within ships, and then the sinking the ships. The dumping of sarin filled rockets
into the sea raised serious concerns among the public. Another well-known incident
occurred in Okinawa on July 8, 1969 when an accident occurred during the cleaning of
sarin or VX filled shells. Twenty-three soldiers and one civilian were exposed. Although
there were no fatalities, this event created an international incident when Japan demanded
that chemical weapons be removed from the island (Smart 1997).
In the late 1960s, it was also revealed that there had been open air testing of nerve agents
both at Edgewood and in Hawaii during 1966-67. These incidents, along with an incident
in Britain which involved the release of VX, turned the public against chemical weapons.
In 1969, President Nixon renounced the first strike use of chemical weapons and curtailed
research on chemical agents (Smart 1997).

Nerve agents were also tested in Panama, particularly between 1964-1968, when the US
Army test fired chemical munitions both in the Canal Zone and on San Jose Island. It is
not known if there was any human exposure during these tests (Lindsay-Poland 1998).
Although the Army Chemical Corp was not eliminated during the 1970s, its activities
were diminished. Research nevertheless continued on binary weapons, which are
weapons in which two less toxic and more stable chemicals mix upon firing to form a
nerve agent. (Munitions containing phosphonic difluoride in one canister and
isopropanol and isopropylamine in the other formed sarin upon firing.) The Army
Chemical Corp was rejuvenated during the 1980s, in response to a perceived gap in
chemical warfare agents between the US and the former Soviet Union (Smart 1997).
During the 1980s, the only confirmed military use of nerve agents occurred when Iraq
used tabun and sarin-filled aerial bombs to repel Iranian troops in the Iran-Iraq war.
(Iraqs chemical weapons program dates back to 1971, when a small facility was built at
Rashid.) Iraq continued to produce tabun, VX, and sarin throughout the 1980s. Iraqs
extensive use of chemical warfare agents is believed to have brought an end to the
conflict. Reports claim that between 5500 to 10,000 Iranian troops were killed by nerve
agents and mustard gas, and that up to 100,000 soldiers were exposed (Peterson 2002,
Federation of American Scientists 1990).
Iraq was also the only government to use nerve agents to quell civilian uprisings. In
March of 1988, Iraq used a combination of chemical weapons, including mustard gas,
tabun, sarin, VX and possibly even cyanide to kill as many as 5000 people in the Kurdish
town of Halabja. Iraq is believed to have ultimately produced between 790 to 810 tons of
sarin. The sarin was of low quality and purity, however, and could only be stored for
limited periods of time. During 1992-1994, UN weapons inspectors destroyed 70 tons of
sarin in Iraq (Federation of American Scientists 2004; Council on Foreign Relations
2004). A recent reminder of the Iraq Chemical Weapons program was the discovery of a
binary weapon that designed produced sarin in an improvised explosive device near
Baghdad. The shell was believed to be a remnant from a test firing from the earlier
period that had failed to explode (Ritter 2004).
The first known terrorist use of a nerve agent involved sarin and occurred in Matsumoto
City, Japan on the evening of June 27, 1994. During this attack, about 12 liters of sarin
were released using a heater and a fan from the window of a delivery truck. The attack
was undertaken to kill four judges involved in a dispute with the Aum Shinrikyo cult.
This attempt resulted in 471 victims of sarin poisoning. Fifty-four were hospitalized, 253
were treated at outpatient facilities and 7 died. All of the judges survived (Nakajima
1998; Organisation for the Prohibition of Chemical Weapons (OPCW) 2004).
On March 20, 1995, Aum Shinrikyo launched an even bolder attack, this time on the
subway system in Tokyo. In this attack 5 two-person teams, consisting of a subway rider
and getaway driver, worked together. The target station was Kasumigaseki, near a large
number of government buildings and the headquarters of the Tokyo police. Each of the
subway riders executing the attack carried several double layered plastic bags containing
10
approximately 20 ounces of sarin. At 8:00 AM, at the height of rush hour, each subway
rider pierced the plastic bag and exited the train. Twelve subway passengers were killed
in these attacks, 980 persons suffered mild to moderate exposure, and 500 persons were
hospitalized. Over 5000 people nonetheless sought medical attention; many of these had
not even been exposed (Organisation for the Prohibition of Chemical Weapons (OPCW)
2004).
The US and 161 other countries have joined the Chemical Weapons Convention (CWC),
in which they pledged not to develop or stockpile chemical weapons. The CWC created
the Organisation for the Prohibition of Chemical Weapons (OPCW) which is responsible
for implementing the convention. The countries that are signatories have pledged to
destroy the existing stockpiles of chemical weapons by the year 2007. As of April 2004,
roughly 12% of the world stockpile has been destroyed. In the year 2000, there were
over 15,000 tons of sarin declared by several countries (Bismuth et al. 2004, CWC
2004A, CWC 2004B).
Study & Reports of Human Exposure
Although nerve agents were invented in Nazi Germany, the extent and type of human
testing during that period have not been directly reported (Augsberger 2000). The largest
experimental use of sarin on humans appears to have occurred at Porton Down in the
United Kingdom in the 1950s. An inquest into the death of Ronald Maddison revealed
that as many as 3000 to 20,000 volunteers may have been exposed to sarin and other
nerve agents between 1947 and 1989 (Barnett 2003, Edwards 2000).
The purpose of the studies was to obtain precise information on the toxic properties of
nerve agents. Most of the volunteers were not told they were participating in studies on
nerve agents but many were told the studies were to develop a cure for the common cold.
In 1953, scientists at Porton Down were trying to determine the precise lethal dose of
sarin. These particular studies involved 396 soldiers, who had various amounts of sarin
dripped onto patches on their uniforms in a sealed gas chamber. The experiments went
terribly wrong resulting in the death of one volunteer and at least the hospitalization of
several others for extended periods of time. In the case of the fatality, 200 mg of sarin
had been dripped onto a uniform patch on Mr. Maddisons forearm and 45 minutes later
he was dead. The coroners report was never released, but there is currently an inquest
into the nerve agent experiments at Porton Down (Barnett 2003, Edwards 2000).
The US also ran a number of tests using sarin that may have resulted in human exposure.
The tests were part of Project 112 of the Deseret Test Center; Project SHAD was part of
this program. The tests monitored the environmental effects of sarin, the dispersal
pattern of bomblets, shipboard detection of agents, and protective measures. Several of
the tests did involve exposure of personnel to nerve agents and potential biowarfare
agents. The Department of Defense (DOD) has identified about 5000-6000 persons who
may have been exposed to one or several of these agents. Many aspects of these tests are
11
still classified, although the DOD did report that there were no acute illnesses reported
during testing. At least 246 of these soldiers were exposed to sarin (Veterans
Administration 2004, DeploymentLink 2003, Spencer et al. 2000). DOD has recently
acknowledged that some civilians may have also been exposed during testing although
there appears to be no health records of that exposure (Mientka 2002).
Sarin was introduced to the Soviet arsenal as early as 1946. Unfortunately, very little
data on the Soviet chemical weapons testing have emerged. Several reports indicate that
exposure to nerve agents of elements of the Russian population took place. Much of the
information was not collected or has not been revealed. Russia declared a stockpile of
over 11,000 tons of sarin on hand in the 1990s (Fedorov 1994).
One paper that has emerged gives a short summary of 209 acute poisonings involving
sarin, soman or VX in Russian production facilities. Several long term health were
described including memory loss, asthenia, sleep disorders and cardiovascular effects
(Yanno et al. 1997)
The use of nerve agents during and shortly after the Iran-Iraq war produced very little
accessible scientific literature addressing either the short term or long term medical
consequences of the use. Nevertheless, a recent paper analyzed the work of an Iranian
physician who treated a number of victims of nerve agent poisoning. In these papers,
Iranian physicians emphasized the importance of evacuation, decontamination and
aggressive early therapy in treating victims (Newmark 2004).
Iraq also used nerve agents and mustard gas against its Kurdish population from April
1987 to October 1988, to quell rebellion and punish the population. It is estimated that
approximately 250,000 civilians where exposed to these agents and over 5,000 were
killed. Unfortunately, there also been very little humanitarian aid or study of this
population for either environmental or long-term health effects (Gosden 2002).
In contrast to the widespread exposures in Iraq and Iran that were poorly studied,
exposures to nerve agents in Japan have been extensively studied. The two terrorist
incidents in Japan perpetuated by the Aum Shinrikyo resulted in sarin exposure for
several thousand people. (Seto 2001; Okudera et al. 1997; Morita et al. 1995).
Approximately 5,500 passengers were exposed, 9 passengers and two station officers
were killed. The two station officers died from touching the plastic bags. In addition to
passengers and station workers, 135 of 1384 emergency workers and 23% of the hospital
workers at St. Lukes, the hospital that received over 600 victims, displayed signs or
symptoms of secondary exposure. None of the emergency or hospital workers died. If
Aum Shinrikyo would have used a more concentrated solution the result may have been
much worse (Okumura et al. 2000, Okumura et al.1998a, Okumura et al. 1998b,
Yokohama et al. 1998).
In addition to intentional releases, there have been a number of accidental releases of
sarin that resulted in human exposure. The largest exposure may have occurred after the
Gulf War in Iraq when US soldiers destroyed munitions in Pit and Bunker 73 in
12
Khamisiyah Iraq. Bunker 73 was destroyed on March 4, 1991 and the Pit was destroyed
on March 10, 1991. Reports indicated as much 8 tons of sarin/cyclosarin were present in
approximately 1250 rockets that were destroyed in the Pit and in the additional munitions
destroyed in the Bunker. Recently revised CIA/DOD estimates indicate that a worst case
is that 321 kg of sarin/cyclosarin were released from the Pit demolition and that 51 kg
were released from the destruction of Bunker 73. It is unlikely that any US ground were
exposed following the demolition of Bunker 73 but it is likely that US ground forces
were exposed to low levels of nerve agents following the demolition of the Pit. DOD has
identified as many 100,000 troops who may have been in hazard areas and possibly
exposed to low levels of nerve agents (Winkenwerder 2002b).
In 1979, Duffy reported on long-term effects of production workers, who were exposed
to sarin. In his studies he identified 77 workers who were exposed to either low or
moderate amounts of sarin at least once (Duffy et al. 1979). On July 14, 2002, four
workers at Army's Chemical Depot in Tooele, Utah, were exposed to sarin during
disposal operations. One of the workers suffered serious complications (Zacharias 2002).

13
III. PATHOGENESIS & FORESNIC DIAGNOSTICS

Pathophysiology
The acute toxicity of sarin is believed to be predominantly due to the inhibition of
acetylcholinesterases (AChEs). The inhibition of AChE leads to a rise in the
concentration of acetylcholine and to the hyperstimulation of both nicotinic and
muscarinic acetylcholine nerve receptors. AChE is responsible for the hydrolysis of
acetylcholine to produce acetic acid and choline. The hydroxyl group on a serine residue
in the active site of the enzyme helps cleave the choline ester but is also phosphorylated
by sarin. Once phosphorylated the reactivation of the enzyme is very slow and the
enzyme-inhibitor complex can undergo a process called aging in which the enzyme is
essentially irreversibly inactivated. The half-life of the aging process is about 5 hours.
Once an enzyme has undergone aging it can no longer be reactivated by oximes such as
pradiloxime chloride.(Spencer et al. 2000; Tripathi et al. 1989; Sidell et al. 1992).
In addition to AChEs, sarin has been shown to react with a number of other receptors
and enzymes. Sarin reacts with muscarinic receptors in animal studies. At very low
concentrations (0.3-1.0 nM), sarin reacts with muscarinic m2 receptors on presynaptic
gamma-aminobutyric acid (GABA)-ergic neurons. This binding significantly reduced the
postsynaptic current in GABA-ergic neurons. The reduction in the action-potential
mediated release of GABA can account for the occurrence of seizures in individuals
exposed to sarin (Chebabo et al. 1999).
Sarin has also been shown to bind tightly to muscarinic m2 receptors in the heart which
may play a role in cardiotoxicity (Silveira et al. 1990). Sarin, unlike VX, appears to have
no effect on the binding of alpha-cobrotoxin to nicotinic acetylcholine receptors (Chi et
al. 1995). Single fiber electromyography studies in man have indicated that there is a
down-regulation or desensitization of acetylcholine receptors at the neuromuscular
junction following exposure to low levels of sarin. The down-regulation of acetylcholine
receptors is believed to be responsible for an intermediate syndrome of neuropathy in
which paralysis occurs 24 to 96 hours after exposure. The syndrome usually dissipates, if
it is not fatal, 14-18 days after exposure (Baker et al. 1996; Senanayake et al. 1987).
There have been several reports on the ability of sarin to inhibit the enzyme neurotoxic
esterase or neuropathy targeted esterase (NTE). NTE is a 150 kd intregral membrane
protein whose function has not been fully elucidated but recent studies indicate that NTE
is a lysophospholipase essential for embryonic blood vessel development and survival,
and whose inhibition leads to neuronal loss (Akassoglou et al. 2004, Moser et al. 2004,
Quistad 2003).
The inhibition of NTE has been reported to be responsible for the onset of
organophosphate induced delayed neuropathy (OPIDN). OPIDN was responsible for the
Jamaican Ginger episode described above, and usually has a time of onset of at least two
weeks following exposure. (There may also be age dependence in OPIDN in some
species. In chickens, OPIDN is only seen in older chickens and not in chicks.) The
14
pathway through which inhibition of NTE leads to OPIDN has not yet been elucidated,
although it is known that neuropathy only occurs when over 70% of NTE activity is
inhibited following acute exposure and 50% following repeated exposures (Ehrich et al.
2001).
OPIDN is usually not seen in acute sarin exposures at concentrations below the LD50 in
chickens and other animals (Bucci et al. 1992, Spencer et al. 2000). Other studies have
reported symptoms suggestive of OPIDN in mice exposed following repeated inhalation
of sublethal doses of sarin (Husain et al. 1993). OPIDN has also not been observed in
humans following severe, mild or moderate nerve agent exposures, but OPIDN
theoretically could occur, particularly when prophylaxis is administered (Sidell 1997,
Spencer et al. 2000).
Recent animal studies have shown no effect of pyridostigmine bromide on NTE
inhibition either alone or in combination with sarin (Wilson et al. 2002). It should also be
noted that subclinical neuropathy was reported 30 days after sarin exposure in Japan and
a subsequent study also picked up electromyographic evidence of neuropathy six months
after exposure (Morita et al. 1995, Murata et al. 1997)
Although all humans are susceptible to sarin toxicity there have been several papers that
indicate polymorphisms may play a role in the development of neurotoxicity, particularly
during low levels of exposure. The high-density-lipoprotein-associated enzyme
paraoxonase hydrolyzes sarin and other organophosphates into essentially non-toxic
products. There are two major polymorphic forms of the enzyme, the Arg192 and
Gln192 isoforms. Although the Arg192 isoform hydrolyzes paraoxon more rapidly, it
displays lower activity towards sarin. The dominance of the Arg192 isoform among the
Japanese has been postulated to play a role in the toxicity seen in the Japanese incidents
(Yamasaki 1997).
Butyrylcholinesterase levels have also been shown to correlate with protection from
sarin toxicity (Raveh et al. 1993). Butyrylcholinesterase is also polymorphic. Although
no studies have yet correlated butyrylcholinesterase polymorphism with toxicity, the
activity of the enzyme should affect sarin toxicity (Maekawa et al. 1997).
The effect of sarin on a variety of receptors and AChE has also been studied in
combination with heat and pyridostigmine bromide in attempts to mimic conditions
during the Gulf War. The study with pyridostigmine showed that treatment with low
levels of sarin caused an upregulation of m2 muscarinic receptors in various areas of the
central nervous system (Abou-Donia et al. 2002). The study involving heat-stressed rats
and low levels of sarin showed a reduction of m1 muscarinic receptors both in the
presence and absence of heat and an increase in m3 receptors only in the presence of
heat. The study also showed a reduction of AChE in the hippocampus with sarin and
heat stress (Henderson 2002).
Another study showed modulation of nicotinic and the m2 muscarinic acetylcholine
receptors following sarin exposure. An initial decrease was observed 1-3 hours postContract No. IOM-2794-04-001
15
exposure followed by increases in both receptors at 6-20 hours. The effect on nicotinic
receptors was more pronounced (Khan et al. 2000). The long-term effects of receptor
modulation may be associated with memory and cognitive disorders.
Exposure to high levels of sarin causes seizures which, if untreated, can lead to
substantial neuropathy. A three-phase model of nerve agent induced seizures and
neuropathy has been proposed. The initial phase is a cholinergic phase that lasts from the
time of exposure to approximately 5 minutes after the onset of seizures. The second
phase is a progressively mixed phase involving acetylcholine and excitory amino acids
such as glutamate. This phase lasts from five minutes to forty minutes after the onset of
seizures. The final phase is a noncholinergic phase where extended stimulation of
neurons with excitory amino acid combined with hypoxia/anoxia/ischemia leads to
prolonged elevation interneuronal free Ca++ and resultant neurotoxicity (McDonough et
al. 1997).
Exposure to high levels of organophosphates has been long known to impair the immune
system (Street et al. 1975). Recently several groups have shown that subclinical
exposures of sarin in rats and mice can impair both T cell responses and the bactericidal
activity of macrophages. Sarin does not appear to act through the hypothalamuspituitary-adrenal axis but through action on the autonomic nervous system. The
suppression of immune function has been reported to last up to twelve months following
exposure (Kassa et al. 2004, Kassa et al. 2000, Kalra et al. 2002).
Pharmacokinetics
The acute effects of sarin are believed to be primarly due to (-)-isomer of sarin. The (+)isomer appears to be eliminated rapidly from body following administration. Animal
studies indicate that (-)-sarin is rapidly distributed throughout the body, within minutes,
but eliminated very slowly with a half-life of several hours (Spruit et al. 2000).
The primary metabolite of sarin is isopropyl methylphosphonic acid which was found in
large amounts in the serum and urine of victims in Japan. The concentration of the
metabolite and the amount of time from exposure can be used to estimate the level of
exposure. These studies indicated that several of the survivors were exposed to supralethal levels of sarin (Noort et al. 1998, Minami et al. 1997).
Forensic Assays & Environmental Detectors
Although there are currently no real-time clinical tests for Sarin exposure, there have
been a number of forensic assays developed that can confirm exposure. Most of these
tests involve isolating RBC AChE and/or serum butyrylcholinesterase from blood and
releasing and detecting any organophosphates that are released. One technique involves
solubilizing sarin-bound AChE from tissues or blood, trypsinizing the proteins and
releasing bound organophosphate with alkaline phosphatase. The organophosphate
undergoes trimethylsilyl derivatization and is identified using gas chromatography (GC)
(Nagao et al. 2003, Matsuda et al. 1998). Another method uses the fluoride ion to
16
reactivate butyrylcholinesterase and/or AChE and then quantitates by GC the arin

produced. (Degenhardt et al. 2004, Jakubowski et al. 2004, Polhuijs et al. 1997).
(Diagnostic methods based upon history and observations of signs and symptoms are
treated at the end of the following section on Health Effects.)
There has also been a great deal of work on the environmental detection of sarin and
other nerve agents. The Department of Defense has developed several detectors to
monitor air for the presence of nerve agents. The mainstay of the Army chemical
detection is the M8A1 alarm which constantly samples the air for higher molecular
weight molecules. The detector ionizes gases and mass filters away the low molecular
ions generated from air. This is a low specificity detector and a number of other
compounds can interfere (Augerson 2000, Rostker 1997). There have also been a
number of other detectors developed to detect nerve agents, the NRL-SAWRHINO which
uses sensors and gas chromatography has the ability to distinguish between interfering
gases and nerve agents (McGill et al. 2000).

17
IV. HEALTH EFFECTS

Overview
The health effects of sarin, like most nerve agents, are dependent upon the route of
administration, the dose received, and the speed at which treatment is given. Casualties
can go from being fully functioning to comatose with severe respiratory distress in a
matter of seconds following exposure. Aggressive, rapid therapy can substantially
minimize adverse health effects seen in patients exposed to nerve agents (Newmark
2004). The overall experience from Iran-Iraq war, and the two Japanese attacks is that
most patients who are exposed to nerve agents physically recover relatively quickly if
they survive initial exposure (Newmark 2004, Ohbu et al. 1997, Murata et al. 1997).
Acute Toxicity
Acute effects seen at low concentrations include: miosis (pinpoint pupils), ocular pain,
blurred or dimmed vision, tearing, rhinorrhea, broncospasm, slight dyspnea, respiratory
secretions, salvation, and diaphoreses. At intermediate concentrations moderate dyspnea,
nausea, vomiting, diarrhea are seen. At high concentrations convulsions, loss of
consciousness, muscle fasciculations, flaccid paralysis, copious secretions, apnea and
death.(Lee 2003). The LD50 of sarin in variety of species is listed below:
ROUTE OF EXPOSURE
Oral
Oral
Dermal
Dermal
Dermal
Dermal
Intravenous
Intravenous
Intravenous
Intravenous
Subcutaneous
Intramuscular
Intramuscular
Intramuscular
Intraperitoneal
SPECIES
Human
Rat
Human
Pig
Rat
Mouse
Human
Monkey
Pig
Rat
Rat
Human
Monkey
Rat
Rat
LD50 (g/kg)
71-285
550-1060
1429-28,000
115,900
2500
1080
14
20
15
39-45
103-108
30
22
108-170
218-250
Table derived from National Research Council (US) 1999.

The acute emergency guideline levels (AEGLs) are threshold exposure limits for the
general public for mild effects, serious adverse effects and lethality. For sarin the levels
are expressed air concentrations applicable to exposure periods ranging from 10 min to 8
18
hours. The data in the table below is derived largely from rat exposure data (Hartmann
2002).
AEGL LEVEL
1 (nondisabling; mild)
2 (disabling)
2 (disabling)
2 (disabling)
2 (disabling)
2 (disabling)
3 (lethal)
3 (lethal)
3 (lethal)
3 (lethal)
3 (lethal)
TIME (HOURS)
0.167
0.5
1
4
8
0.167
0.5
1
4
8
0.167
0.5
1
4
8
CONCENTRATION (mg/m3)
0.0069
0.004
0.0028
0.0014
0.001
0.087
0.05
0.035
0.017
0.013
0.38
0.19
0.13
0.07
0.051
Other toxic factors and exposure limits established by the US Dept. of Health and Human
Services (DHHS) include: the vapor concentration X time of exposure -- in which 50%
lethality is seen for humans (LCt50) at 100 mg/m3/min. The no death dose equals 10
mg/m3/min; the no neuromuscular (NNM) effect dose equals 4 mg/m3/min; the
concentration which induces miosis in 50% of victims (ECt50 (miosis)) equals 2-4
mg/m3/min. The no observable effect level (NOEL) equals 0.5 mg/m3/min; the maximal
single concentration for 1 hour equals 0.001 mg/m3; the maximal single concentration for
8 hours equals 0.0003 mg/m3; the safety factor of 0.1 is used for the general population
and the limit levels are 0.0001 mg/m3 for 1 hour, 0.00003 mg/m3 for 8 hours and
0.000003 mg/m3 for 72 hours (Moore 1998).
Developmental and Reproductive Toxicity
There has been no evidence in humans of reproductive or developmental toxicity. There
is no evidence of developmental toxicity in rats dosed up to 380g/kg/d or in rabbits
dosed 15g/kg/d and who were exposed over several days of gestation that produced
maternal toxicity (Laborde et al. 1996). In other studies rats were exposed for 1 week to
1 year and then mated with either exposed or unexposed rats. There was no evidence of
sarin related adverse effects with respect to reproductive performance, fetal toxicity, and
teratogenesis (National Research Council (US) 1999).
Carcinogenicity
There is no evidence of carcinogenicity in humans. In chronic inhalation studies in mice,
rats and dogs, sarin did not appear to be carcinogenic. Pulmonary tumors were observed
19
in strain A mice after 3/19 and 3/20 animals after 52 weeks of exposure to 0.001 and
0.0001 mg/m3, respectively, while controls showed no tumors. The results were not
considered significant, however, since strain A mice are very susceptible to tumors and
rates at six months were 5/19, 6/18, and 9/29 for mice dosed at 0.001 and 0.0001 mg/m3
and controls, respectively (National Research Council (US) 1999, Munro et al. 1994).
Genotoxicity
There is little information available regarding the human genotoxicity of sarin. In
bioassays using bacteria and mammalian cell cultures with and without metabolic
activation sarin did not show any evidence of genotoxic or mutagenic activity. There was
no increase in mutations using the Ames test. There was also no increase in mutations
when mouse L5718 cells were tested at concentrations of 200g/mL (National Research
Council (US) 1999). There was also no evidence of sister chromatid exchanges (SCE) in
Chinese hamster ovary cells at concentrations up to 1.4 mM (Nasr et al. 1988). Several
studies of the victims of the Tokyo subway attack, however, indicated that the SCE of
lymphocytes was higher in persons exposed to sarin. These also revealed a positive
correlation between the extent of serum cholinesterase inhibition and the level of SCE.
These studies indicate that sarin exposure may lead to SCE and the effect appeared to last
up to three years after exposure. One paper indicates that the synthetic by-products
diisopropylmethylphosphonate (DIMP) or diethylmethylphosphonate (DEMP) may be
responsible for the increase in SCE (Li et al. 2004, Li et al. 2000, Minami et al. 1998).
Immunotoxicity
Although there is no direct evidence of human immunotoxicity, there are several animal
studies that indicate there is a potential of some immunotoxicity or immunomodulatory
effects upon sarin exposure. Experiments in rats has indicated that exposure at 0.75 LD50
significantly reduced T-cell mediated immune reaction. The reduced activity was
attributed to be due the inhibition of a variety of esterases (Zabrodskii et al. 2003).
Another study involving BALB/c mice dosed at subclinical levels showed a substantial
increase in NK cell and macrophage activity, and a substantial decrease in CD4 T-cell
activity. The studies also showed that a single exposure has the same effect as multiple
exposures. Studies in rats have also shown a decrease in T-cell activity (Kassa et al.
2004a, Kassa et al. 2004b, Kalra et al. 2002). Other studies have shown significant
reductions in NK cell, cytotoxic T-cell activity by the DIMP and DEMP by-products.
The sarin by-products presumably work through the inhibition of granzyme function (Li
et al. 2000, Li et al. 2002).
Eye and Visual Effects
Miosis, as noted above, is characteristic of sarin exposure and often the first sign. It
usually occurs within seconds or minutes of exposure and can last up to 9 weeks. Dim
vision, which consists of a reduction of light entering the eye, is often the result of
miosis. Blurred vision and eye pain can also accompany sarin exposure. Intraocular
pressure and color do not appear to be affected by sarin (Sidell 1997, Rengstorff 1985).
20
Otic Effects
There is very little data on the effect of sarin on hearing. Animal studies indicate that
sarin cause increased acoustic startle in rats. The effect was not seen in rats also treated
with pyridostigmine bromide (Scremin et al. 2003).
Pulmonary Effects
Rhinorrhea is typically seen shortly after sarin exposure. The rhinorrhea can be quite
intense and has been described as much worse from that seen with any cold or hay fever.
These secretions make it difficult to attempt artificial respiration if needed. Respiratory
effects are also very common and occur rapidly after exposure. The effects are caused by
chemical irritation; and the effect of acetylcholine on nicotinic, muscarinic, and central
nervous neurons. Tightness in the chest is a common symptom after exposure to small
amounts of sarin and usually dissipates within hours of exposure. As the amount of
exposure increases dyspnea and pulmonary distress increase and often someone severely
poisoned will go into respiratory failure and die. There is not any data that indicates
respiratory effects persist long after exposure (Sidell 1997, Niven et al. 2004).
Cardiac Effects
Bradycardia is frequently seen following moderate or high level sarin exposure.
Bradycardia may be caused from stimulation of the atrial-ventricular node through the
vagus nerve (Sidell 1997). Although bradycardia is frequently resolved following
treatment, there have been reports of persistent arrhythmias following exposure. In cases
of severe poisoning cardiomyopathy may also be seen (Okudera 2002). Studies in rats
have shown cardiomyopathy following high doses of sarin (Singer et al. 1987). Other rat
studies have revealed that acute dosages of sarin induce QT prolongation and cardiac
lesions (Abraham et al. 2001). Electocardiograms showed that decreases in the graphic
R-R interval variability (CVRR) as well as the C-CLF, C-CHF taken six months after
exposure correlated with serum AChE levels (Murata et al. 1997).
Skeletal Muscle Effects
Neuromuscular effects have been studied since nerve agents were discovered.
Acetylchloline is a primary neurotransmitter at the neuromuscular junction. Increased
acetylcholine initially leads to stimulation, followed by fatigue and paralysis of muscle
fibers, muscle and muscle groups (Sidell 1997). In the Tokyo attack, asthenia or muscle
weakness was seen in most patients upon admission to the hospital (Murata et al 1997).
Following liquid exposure, muscle fasciculations at the site of exposure are often seen
following excessive sweating (Lee 2003). Long-term shoulder stiffness has also been
associated with sarin exposure although it is not clear the incidence is greater than a
control population (Nakajima 1999). Myopathy has also been seen in rats in the absence
of treatment following a moderate dose of sarin (Gupta et al. 1992).
21
Nervous System Effects

There exists a good deal of data on the neurotoxicity of sarin in humans. The role of
sarin in inducing convulsions and the resultant neuropathology was described above
(McDonough et al. 1997). Reports from the Japanese sarin terrorist incidents reveal that
most patients who were exposed and survived have not suffered from persistent
neurological disorders. There have been exceptions, however. One is a patient from
Matsumoto who suffered from akinetic mutism for at least two years following exposure.
Studies in rats have shown that there is wide variability in neurotoxicity following
repeated sublethal doses of sarin. These studies showed that there is a lack of tolerance
with repeated doses and a cumulative effect on toxicity (Fernado et al. 1985).
Although the mechanism of action has not been described, headaches are a very common
symptom of sarin exposure (Ohbu et al. 1997, Murata et al.). Loss of memory is also
common and there has even been one case of amnesia following exposure (Hatta et al.
1996, Hood 1997). Long term changes in electroencephalograms (EEG) in workers
following accidental sarin exposure have been observed. The study revealed increases in
beta and delta activity, and a slowing in theta activity. The study also showed increased
REM sleep. These findings have been somewhat controversial and it is not known if
abnormal EEG is actually characteristic any clinically relevant syndromes. (Duffy et al.
1979; National Research Council (US) 1999).
Discussion regarding possible psychogenic effects of sarin exposure is treated in the full
section on Psychogenic Effects.
Diagnosis of Fact & Extent of Intoxication
The initial diagnosis of sarin exposure is based on signs, symptoms and historical factors.
The first step in the diagnosis is to confirm presence of both nicotinic and muscarinic
effects. A convenient mnemonic for the signs and symptoms of nerve agent poisoning is
dumbbels, which stands for the following:
Diaphoresis, diarrhea
Urination
Miosis
Bradycardia
Bronchospasm and bronchorrhea
Emesis
Lacrimation, rhinorrhea, and salivation
Seizures, muscle fasciculation, weakness
(PIER 2004)
Symptoms depend on the site and extent of exposure. Following dermal contact
symptoms can be delayed for up to18 hours, symptoms from inhalation can occur within
seconds of exposure. Miosis is commonly the first symptom seen following vapor
exposure due to the relatively low threshold value of 0.5 mg-min/m3 and to the volatility
22
of sarin. Sarin is more volatile that any of the other nerve agents so there is usually
always vapor exposure whenever sarin is released. Percutaneous absorption of liquid
sarin also occurs readily and typically leads to localized sweating, followed by muscular
fasciculations and weakness (Lee 2003, National Research Council 1997). Useful
markers of nerve agent exposure include serum butyrylcholinesterase and red blood cell
(RBC) AChE activity. Both of these enzymes react with sarin; significantly reduced
levels are indicative of nerve agent exposure, although it does not absolutely correlate
with toxicity (Suziki et al. 1997). Analysis of patients from the Tokyo subway event
however indicated that miosis could be a better indicator of potential systemic toxicity
than red blood cell AChE levels (Nozaki et al. 1997). In addition to the effects on AChE
levels, high levels sarin exposure has been shown to reduce serum triglycerides,
potassium and chloride and to cause increases in serum creatine phosphokinase (CPK),
leukocytes and ketones in urine (Morita et al. 1995, Minami et al. 1998).
In many countries other than the US, the Peradeniya Organophosphorous Poisoning
(POP) scale is used to assess the extent of organophosphate poisoning. The values in the
scale are described below:
PARAMETER
Miosis
Fasciculation
Respiration
Bradycardia
Level of Consciousness
Convulsions
FINDING
Pupil size > 2mm
Pupil size ~ 2mm
Pupils Pinpoint
None
Present not generalized or continuous
Generalized and continuous
Respiration Rate (RR) =20 min -1
RR > 20 min -1
RR > 20 min 1 with central cyanosis
Heart rate (HR)> 60 min 1
HR 41-60
HR < 41
Conscious and rational
Impaired, responds to verbal commands
Impaired, no response to verbal commands
Absent
Present
SCORE
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
0
1
The total possible score is 11; the higher the score, the worse the patient prognosis.
Death has not been seen in patients who have a score of three or less (Wiener et al. 2004).

23

24
V. PSYCHOGENIC EFFECTS
Because of the nature of nerve agents and the terror they create, psychogenic effects are
very common following their use or perceived use. In the Iran-Iraq war, soldiers would
frequently inject themselves with atropine and insist they had been exposed to nerve
agents, when all evidence indicated that they had not been exposed (Newmark 2004a). In
the Tokyo attacks, over 5000 persons reported to hospitals to be treated while, by the best
estimate, only about 1000 people were actually exposed (WHO 2001). Because of the
high prevalence of psychogenic effects and the need for immediate treatment upon actual
exposure, it is important to be able to distinguish between psychogenic events and actual
exposure.
Post-traumatic stress disorder (PTSD) was seen in a number of sarin victims in Japan.
Several studies have shown persistent decreases in serum cholinesterase activity in
patients with PTSD. The studies also showed no correlation in serum cholinesterase
activity taken right after exposure and the development of PTSD six months later
(Tochigi et al. 2002, Nakajimi et al. 1999, Murata et al. 1997).
Typical symptoms seen in PTSD include fatigue, asthenia, insomnia, blurred vision,
general anxiety. MRI studies have shown a negatively correlation with the gray-matter
volume in the left anterior cingulate cortex (ACC). The ACC is believed to be involved
in attention, emotional regulation and conditioned fear -- all factors recognized in the
development of PTSD (Yamasue et al. 2003).
A survey study of volunteer participants in the 1955-1975 Edgewood military testing of
antichoinesterase agents found that those who had undergone the testing subsequently
experienced greater sleep disturbance than those who had undergone no chemical tests.
Further, volunteers who reported exposure to civilian or military chemical agents
independent of participation in the Edgewood program reported a number of adverse
neurological and psychological effects, beyond that reported by those who experienced
only experimental exposure. Self-reported experiences of exposure which are subject to
recall bias appear to have induced greater psychological health effects consequences than
actual experimental agent exposure (Page 2003).
A survey of general effects of perceived exposure to chemical and biological warfare
agents is contained in the supplement under this contract "Psychogenic Effects of
Perceived Exposure to Biochemical Warfare Agents."

25
VI. TREATMENT & PREVENTION

There are essentially five components of treatment for sarin exposure. The first
component is prophylaxis. This is typically accomplished by the administration of
pyridostigmine, a carbamate that reacts reversibly with AchE protecting the enzyme from
inactivation. Studies have shown, however, that physostigmine is more effective than
pyridostigmine in reducing the toxicity of sarin. A phosphotriesterase enzyme has been
shown more effective than any of the carbamates (Tuovinen et al. 1999). Human
butrylcholinestrase has also been shown to be effective in reducing toxicity by essentially
acting as a dead-end target and inactivating enzyme for nerve agents (Raveh et al. 1993).
The second component of treatment is decontamination and evacuation. Evacuation and
extensive decontamination not only protects the victim from further exposure but also
protects health care workers who may come in contact with the victim. Decontamination
consists of removing all clothes and extensively washing the patient, particularly the
patient's hair. It is important to provide health care in an area that is free from nerve
agents (CDC 2004)
The third component of treatment is the use of anticholinergic agents to block the effect
of increased acetylcholine at synapses. Atropine is commonly used for this purpose. It
demonstrates nanomolar inhibition activity against all three subtypes of muscarinic
receptors. One paper has postulated that selective inhibition of m2 and m3 receptors may
be more effective in the treatment of sarin exposure (Trovero 1998). There are currently
no agents routinely used to block the acetylcholine activity at nicotinic receptors.
The fourth component is the use of oximes to regenerate AchE enzymes. There have
been a number of oximes that are capable of regenerating AchE enzyme. Obidoxime and
pralidoxime are the only oximes that have been approved for this use. Pralidoxime is the
agent of choice in the US military, while obidoxime is used in Europe and other part of
the world (Newmark 2004a, Newmark 2004b, Kassa 2002). Oximes, to be effective,
have to be used prior to aging; the half-life of aging of sarin on the AchE enzyme is 5
hours (CDC 2004).
The fifth component of treatment is the use of anticonvulsants. Diazepam has been the
mainstay of anticonvulsant therapy for nerve agent poisoning. Although diazepam is
generally thought to act through gamma-aminobutyric acid A (GABAA) receptors, its
effects on nerve agent poisoning may work through other mechanisms. Diazepam should
only be given for high dose exposure when a patient is having seizures. In hospital
setting it should always be administered IV because availability by IM is usually low
(Marrs 2003, Tuovinen 2004).
In addition to the treatments mentioned above there has also been interest in using
adenosine agonists such as N6-cyclopentyladenosine (CPA) to attempt to decrease the
amount of acetylcholine released at synapses. CPA has shown promise in reducing the
potential cardiovascular toxicity following sarin exposure (Joosin et al. 2004).
26
The Iranians have the most extensive experience in treating nerve gas exposure.
Unfortunately, there is very little published work on the strategies used and the lessons
learned during the Iran-Iraq war. A recent paper chronicles the work of Syed Abbas
Foroutan, an Iranian physician primarily responsible for treatment strategies throughout
the war. The Iranian army, like the US military, realized that forward treatment is
essential for survival and reducing morbidity. To accomplish this, the Iranian military
distributed to all soldiers three autoinjecters containing 2 mg of atropine. Atropine is an
anticholinergic agent that has rapid IM uptake and dispersion and binds to muscarinic
cholinergic receptors. Rapid treatment can restore the normal function of muscarinic
receptors. Foroutan, unlike the US military and NATO, relied primarly on atropine to
treat most of the victims. His failure to use oximes was partly due to the lack of
availability and also to his belief that rapid atropinization was essential for treatment
(Newmark 2004a).
Foroutan used extensive amounts of atropine, sometimes up to 200 mg. He used the ease
of breathing and the drying of respiratory secretions as the standard to which treatment
doses should be titrated. Like NATO, he thought that miosis should not be used as an
endpoint to determine if enough atropine has been used. As mentioned above, Foroutan
disagreed with NATO guidelines on the rate of atropinization. Frontline Iranian soldiers
did not have either oximes or diazepam autoinjecters to provide treatment at the site of
exposure. Foroutan used obidoxime instead of pralidoxime based on the mistaken notion
that obidoxime had a longer half-life. Oximes regenerate AchE but must be used prior to
sarin undergoing aging. The lack of oximes at the frontline may have undermined the
effectiveness of this therapy. Foroutan also used diazepam, not only to control seizures
but also but also as a muscle relaxant. The Iranians did not appear to use any
prophylactic agents to minimize the effect of sarin exposure (Newmark 2004a).

27
VII. SECONDARY SOURCE COMMENT

The literature on sarin is huge. About 700 references can be found in PubMed alone
on a search for sarin. A Scirus search returns over 1700 journal references.
Despite the great amount of literature, perhaps the most notable gap on sarin is the
relative absence of data (a fact alluded to throughout this report) from sarin exposures
in the Iran-Iraq war and the former Soviet Union.

28
VIII. BIBLIOGRAPHY WITH ABSTRACTS

{Unless otherwise noted, the abstracts for the following references are
rendered verbatim as provided by the original publication or as made
available in a standard print or electronic catalogue or database.
Errors, omissions, or other defects of style or substance are strictly
those of the original source. This bibliography contains supplemental
material on the subject in addition to references that are specifically
cited in the text above.}
Abou-Donia et al. 2002. Sensorimotor deficit and cholinergic changes following
coexposure with pyridostigmine bromide and sarin in rats. Toxicol Sci. 66(1):148-58.
A myriad of neurological symptoms including muscle and joint pain, ataxia, chronic
fatigue, headache, and difficulty in concentration have been reported by Persian Gulf War
(PGW) veterans. A large number of these veterans were prophylactically treated with
pyridostigmine bromide (PB) and possibly exposed to sarin. In the present study we
investigated the effects of PB and sarin, alone and in combination, on sensorimotor
performance and the central cholinergic system of rats. Male Sprague-Dawley rats were
treated with PB (1.3 mg/kg, 15 daily doses, oral) and sarin (50, 75, 90, and 100
microg/kg, single im dose on day 15), alone and in combination. The animals were
evaluated for postural reflexes, limb placing, orienting to vibrissae touch, incline plane
performance, beam-walk time, and forepaw grip time 7 and 15 days following treatment
with sarin. Treatment with either PB or sarin alone resulted in significant sensorimotor
impairments. Coexposure to sarin and PB resulted in significant sensorimotor deficits that
worsened over time. By 15 days following sarin treatment, plasma butyrylcholinesterase
(BChE) activity returned to normal levels in the animals treated with sarin alone, whereas
in the animals exposed to PB or PB plus sarin, there was an increase in the enzyme
activity. Cortical acetylcholinesterase (AChE) activity remained inhibited in the animals
treated with sarin alone and in combination with PB. Muscarinic acetylcholine receptor
(m2 mAChR) ligand binding with [(3)H]AFDX-384 in cortex and brain stem showed
significant increases (approximately 120-130% of control) following coexposure to PB
and sarin at higher doses. To evaluate the potential of PB for augmentation or inhibition
of the toxicity induced by acute sarin exposure, the animals were exposed to either 10 or
100 microg/kg sarin (single im injection) with or without pretreatment with PB, and
sacrificed 3 h after treatment with sarin. Pretreatment with PB offered slight protection in
the plasma as well as brain regional enzyme activities. Pretreatment with PB did not have
any effect on sarin-inhibited brain regional AChE activity following treatment with 100
microg/kg sarin. These results show that prophylactic treatment with PB offers some
degree of protection in peripheral cholinesterase. Furthermore, these results show that
treatment with either sarin or PB alone resulted in sensorimotor impairments, while
coexposure to high doses of sarin with PB caused an exacerbated deficit.
Abraham et al. 2001. QTc prolongation and cardiac lesions following acute
organophosphate poisoning in rats. Proc West Pharmacol Soc. 44:185-6.
29
Sarin and soman induced the following similar effects: prolongation of QT interval
duration, cardiac lesions and immediate and statistically significant decrease in body
weight. However, animals exposed to soman remained underweight and suffered delayed
death. Thus, as sarin produced both cardiac lesions and QT prolongation, without
exhibiting late death, it is unlikely that the late death observed in soman-poisoned rats are
attributable to QT prolongation and the occurrence of life-threatening arrhythmias. It is
postulated that low body weight may precipitate late mortality in soman-exposed rats. It
is well documented that QT prolongation in the rat is explained in terms of blockade of
the Ito potassium channels and the Na+/Ca+2 exchanger. Soman and sarin may exert
their effect on QT interval duration through non-specific action on these sites. As druginduced QT prolongation in man is mediated by blockade of Ikr potassium channels, the
data presented in this study may not predict late death in humans in cases of
organophosphate intoxication.
Akassoglou et al. 2004, Brain-specific deletion of neuropathy target
esterase/swisscheese results in neurodegeneration. Proc Natl Acad Sci USA.
101(14):5075-80.
Neuropathy target esterase (NTE) is a neuronal membrane protein originally identified
for its property to be modified by organo-phosphates (OPs), which in humans cause
neuropathy characterized by axonal degeneration. Drosophila mutants for the homolog
gene of NTE, swisscheese (sws), indicated a possible involvement of sws in the
regulation of axon-glial cell interaction during glial wrapping. However, the role of
NTE/sws in mammalian brain pathophysiology remains unknown. To investigate NTE
function in vivo, we used the cre/loxP site-specific recombination strategy to generate
mice with a specific deletion of NTE in neuronal tissues. Here we show that loss of NTE
leads to prominent neuronal pathology in the hippocampus and thalamus and also defects
in the cerebellum. Absence of NTE resulted in disruption of the endoplasmic reticulum,
vacuolation of nerve cell bodies, and abnormal reticular aggregates. Thus, these results
identify a physiological role for NTE in the nervous system and indicate that a loss-offunction mechanism may contribute to neurodegenerative diseases characterized by
vacuolation and neuronal loss.
Augerson 2000. Nerve agents. Chapter 5 In A Review of the Scientific Literature as it
Pertains to Gulf War Illnesses Volume 5: Chemical and Biological Warfare Agents. Rand
Corporation. Available at:
http://www.rand.org/publications/MR/MR1018.5/MR1018.5.chap5.html
Baker et al. 1996. Single fibre electromyographic changes in man after organophosphate
exposure. Hum Exp Toxicol. 15(5):369-75.
1. Neuromuscular (NM) changes resulting from organophosphate exposure are known to
be complex. After severe acute poisoning recovery from initial depolarisation paralysis
may be followed in a limited number of cases by onset of a non-depolarisation paralysis
(the Intermediate Syndrome). It is not clear whether this block arises subclinically in all
cases of poisoning as a sequel to the initial depolarisation. 2. Single fibre
electromyography (SFEMG) is a sensitive clinical neurophysiological technique allowing
detection of subclinical changes at the neuromuscular junction. In the study reported it
30
has been used to examine changes in NM transmission in the forearm of fit volunteers
exposed to a low level of sarin (isopropyl methyl phosphonofluoridate). 3. Small changes
in SFEMG were seen at three hours and three days after an exposure sufficient to cause a
reduction in red cell acetyl cholinesterase to 60% of normal. The SFEMG changes were
not accompanied by any clinical neuromuscular symptoms or signs and returned to
normal 2 years after exposure. 4. The results indicate that there are reversible subclinical
changes compatible with the development of non-depolarising NM block without frank
clinical expression. In the small population examined there were individual variations in
response which may reflect differences in safety margin at the neuromuscular junction.
Barnett 2003. Final agony of RAF volunteer killed by sarin - in Britain. The Observer
September 28, 2003. Available at:
http://observer.guardian.co.uk/uk_news/story/0,6903,1051293,00.html
Baum 2003. Jake leg: How the blues diagnosed a medical condition. The New Yorker
September 15, 2003:50-57. Available at:
http://www.knoxandbaum.com/sitebuildercontent/sitebuilderfiles/jakeleg.pdf.
Benschop et al. 2001. Toxicokinetics of Nerve Agents. In Chemical Warfare Agents:
Toxicity at Low Levels (SM Somani, JA Romano Jr. Eds) Chapter 2, CRC Press Boca
Raton Fl.
Bismuth et al. 2004. Chemical weapons: documented use and compounds on the
horizon. Toxicol Lett. 149(1-3):11-8.
Man's inhumanity to man is expressed through a plethora of tools of modern warfare and
terror. The use of chemical and biological weapons with the goals of assault,
demoralisation and lethality has been documented in recent history, both on the
battlefield and in urban terror against civilians. A general review of a few of the currently
employed chemical weapons and biological toxins, along with a look at potential
chemical weapons and tools of counter-terrorism, follows. While these weapons are
fearsome elements, the dangers should be viewed in the context of the widespread
availability and efficacy of conventional weapons.
Bucci et al. 1992. Toxicity Studies on Agents GB and GD (Phase II): Delayed
Neuropathy Study of Sarin, Type II, in SPF White Leghorn Chickens. National Center for
Toxicological Research Final Report; AD-A257183.
Burchfiel et al. 1982. Organophosphate neurotoxicity: chronic effects of sarin on the
electroencephalogram of monkey and man. Neurobehav Toxicol Teratol. 4(6):767-78.
The neurotoxic effects of the organophosphate sarin (107448), on the
electroencephalograms (EEGs) on monkeys and humans were investigated. In the animal
study, electrodes were permanently implanted in rhesus-monkeys for chronic EEG
recording. Animals received intravenous injections of either a single large dose of 5
micrograms per kilogram (microg/kg) sarin or multiple small doses (ten injections) of
1microg/kg sarin intramuscularly at 1 week intervals. In both cases EEG recordings were
taken 24 hours after administration. One year after exposure three additional recordings
31
were performed with animals awake in light, awake in darkness, and in drowsy states.
The human study consisted of 77 industrial workers with a documented history of at least
one exposure to sarin. Each subject had two EEG recording sessions. EEG data was
obtained either under clinical laboratory or all night sleep conditions. Five recording
states were used for spectral EEG analysis: eyes open, eyes closed, drowsy,
hyperventilation, and post hyperventilation. In monkeys, there was a persistent increase
in beta activity in the temporal lobe EEG of animals treated with large and small doses of
sarin. The beta increase was present at 24 hours after drug administration and persisted 1
year later for most animals. At 24 hours post drug, significant changes in other frequency
bands were observed, but EEG alterations disappeared within a few days or weeks. In the
human study, the major differences in spectral analysis of EEGs were increases in beta
activity in the sarin exposed population. For sleep EEG records, the exposed population
had significantly increased rapid eye movement sleep. Univariate and multivariate
spectral analyses resulted in significant differences between comparisons and exposed
groups. The authors conclude that in both humans and primates the major long term
effect of sarin on EEGs is an enhancement of higher frequency (beta) activity.
CDC 2004. NIOSH Emergency Response Card:Sarin. Available at:
http://www.bt.cdc.gov/agent/sarin/erc107-44-8.asp.
Chebabo et al. 1999. The organophosphate sarin, at low concentrations, inhibits the
evoked release of GABA in rat hippocampal slices. Neurotoxicology. 20(6):871-82.
In the present study, the whole-cell mode of the patch-clamp technique was applied to
neurons of the CA1 pyramidal layer of rat hippocampal slices to investigate the effects of
the organophosphate (OP) sarin on field stimulation-evoked and on tetrodotoxin (TTX)insensitive postsynaptic currents (PSCs) mediated by activation of type A gammaaminobutyric acid (GABA) receptors or AMPA-type glutamate receptors. At 0.3-1 nM,
sarin reduced the amplitude of GABA-mediated PSCs and had no effect on the amplitude
of glutamatergic PSCs evoked by field stimulation of neurons synaptically connected to
the neuron under study. The effect of sarin on evoked GABAergic PSCs was unrelated to
cholinesterase inhibition, was partially reversed upon washing of the neurons with sarinfree external solution, and was mediated by a direct interaction of the OP with muscarinic
acetylcholine receptors present on presynaptic GABAergic neurons. Sarin had no effect
on the amplitude or kinetics of GABA- or glutamate-mediated miniature postsynaptic
currents (MPSCs) recorded in the presence of the Na+-channel blocker TTX (300 nM),
indicating that the OP does not interact with GABA(A) or glutamate receptors. Further,
sarin did not alter the frequency of GABAergic or glutamatergic MPSCs, a finding that
led to the conclusion that this OP does not affect the TTX-insensitive release of
neurotransmitters. A selective reduction by sarin of the action potential-dependent release
of GABA in the hippocampus can account for the occurrence of seizures in intoxicated
subjects.
Chi et al. 1995. Action of organophosphate anticholinesterases on the three
conformational states of nicotinic receptor. Adv Exp Med Biol. 363:65-73.
Organophosphate and other ligands were examined for binding on the membrane-bond
nicotinic receptor at three conformational states. Soman (pinacolyl
32
methylphosphonofluoridate), sarin (isopropyl methylphosphonofluoridate, tabun (ethyl

N-dimethylphosphoramidocyanidate) and phencyclidine did not show any effect on the
binding of [25I]alpha-cobrotoxin to the nicotinic receptor. However, VX, O-ethyl-S-(2diisopropylaminoethyl) methylphosphonothiolate, at concentrations higher than 10
umol/L exhibited profound inhibition on the equilibrium binding rates in a concentrationdependent manner. Agonist nicotine and antagonist d-tubocurarine also showed
significant inhibitions.
Costa et al. 1999. The role of paraoxonase (PON1) in the detoxication of
organophosphates and its human polymorphism. Chem Biol Interact. 119-120:429-38.
In human populations, serum paraoxonase (PON1) exhibits a substrate dependent
polymorphism. The Arg192 isoform hydrolyzes paraoxon rapidly but diazoxon, soman
and especially sarin slowly. On the other hand, the Gln192 isoform hydrolyzes paraoxon
slowly, but diazoxon, soman and sarin more rapidly than the Arg192 isoform. Our
experiments with a mouse model system have convincingly shown that PON1 plays a
major role in the detoxication of organophosphate (OP) compounds processed through
the P450/PON1 pathway. Recent studies have also shown that PON1 plays an important
role in the metabolism of oxidized lipid compounds. Currently, there is an effort
underway to identify genes and polymorphisms that play an important role in
'environmental susceptibility'. The PON1 polymorphism has been cited as a prime
example of such a genetic polymorphism. The advent of the polymerase chain reaction
(PCR) for DNA amplification with improvements, modifications and automation has
provided a very convenient way to do individual genotyping. It is tempting to set up large
scale PCR analyses of populations to determine individuals at risk for environmental
exposures affected by the PON1 polymorphism. In fact, a number of such studies have
already been carried out in examining the relationship of the PON1 polymorphism to
vascular disease. We advocate the use of a high throughput two-dimensional enzyme
assay that provides both PON1 genotype and phenotype (PON1 status). The high level of
variation of gene expression within each genetic class in humans, together with our
animal model studies indicate that it is very important to determine PON status as
opposed to PON1 genotype alone. Experiments in rats and mice have shown that
injection of PON1 purified from rabbit serum by the i.v., i.p. or i.m. route, significantly
increases PON1 activities in rodents' plasma. Under these conditions, the acute toxicity
(assessed by the degree of acetylcholinesterase inhibition) of paraoxon and chlorpyrifos
oxon is significantly decreased, compared to control animals. Protection is maximal when
PON1 is administered before the OPs, but still occurs when PON1 is utilized as a postexposure treatment. Furthermore, protection by PON1 is also provided toward the parent
compound chlorpyrifos. Pon1-knockout mice display a much greater sensitivity to
chlorpyrifos oxon toxicity than wild mice. However, the acute toxicity of guthion, which
is not a substrate for PON1, does not differ between knockout and wild mice. These
observations underline the importance of considering both genetic variability of enzyme
isoform as well as enzyme level (PON1 status) and the developmental time course of
appearance of PON1 in developing risk assessment models.
CWC 2004A. Background of Chemical Disarmament.
33
In the time between April 1997 and the present day, the OPCW has grown into a major
international organisation in the field of arms control and disarmament. It has grown
faster than any other global disarmament regime in history, from the original 87 States
Parties to 162 as of 27 April 2004. The CWC commits States Parties to destroy all
stockpiles of chemical weapons by 2007. So far, the OPCW has overseen the destruction
of nearly 12 percent of the world's stockpile.
The OPCW has a full-time staff of around 500 international civil servants and an
approved budget for 2004 of 73,153.390 million euros a year. As of October 2000, the
OPCW and the UN entered into a formal agreement for the exchange of information,
resources, and personnel. The CWC regime now covers 95 percent of the world's
population, 92 percent of the world's landmass, and 98 per cent of its chemical industry.
Never before in history have the countries of the world been so close to the destruction of
an entire category of weapons of mass destruction. It is only with the complete
commitment of all its States Parties to the cause of multilateral disarmament that the
OPCW will be able to complete its task and its fundamental goal: a chemical weaponsfree world.
Available at: http://www.opcw.org/html/intro/chemdisarm_frameset.html
CWC 2004B. Convention on the Prohibition of the Development, Production,
Stockpiling and Use of Chemical Weapons and on Their Destruction. Available at:
http://www.opcw.org/docs/cwc_eng.pdf
Council on Foreign Relations 2004. Terrorism: Questions & Answers: Sarin. Available
at: http://cfrterrorism.org/weapons/sarin.html
Degenhardt et al. 2004. Improvements of the fluoride reactivation method for the
verification of nerve agent exposure. J Anal Toxicol. 28(5):364-71.
One of the most appropriate biomarkers for the verification of organophosphorus nerve
agent exposure is the conjugate of the nerve agent to butyrylcholinesterase (BuChE). The
phosphyl moiety of the nerve agent can be released from the BuChE enzyme by
incubation with fluoride ions, after which the resulting organophosphonofluoridate can be
analyzed with gas chromatography-mass spectrometry (GC-MS). This paper describes
recent improvements of the fluoride-induced reactivation in human plasma or serum
samples by enhancing the sample preparation with new solid-phase extraction cartridges
and the MS analysis with large volume injections. Analysis is performed with thermal
desorption GC with either mass selective detection with ammonia chemical ionization or
high-resolution MS with electron impact ionization. The organophosphorus chemical
warfare agents analyzed in this study are O-ethyl S-2-diisopropylaminoethyl
methylphosphonothiolate, ethyl methylphosphonofluoridate, isopropyl
methylphosphonofluoridate (sarin, GB), O-ethyl N,N-dimethylphosphoramidocyanidate,
ethyl N,N-dimethylphosphoramidofluoridate, and cyclohexyl methylphosphonfluoridate.
Detection limits of approximately 10 pg/mL plasma were achieved for all analytes, which
corresponds to 0.09% inhibition with GB on a sample with normal BuChE levels.
DeploymentLink 2003. Project 112 Tests Available at:
http://deploymentlink.osd.mil/current_issues/shad/shad_chart/shad_chart_8_3.shtml
34
Contains a table of all the tests involved in Project 112 with links to fact sheets on the
tests.
Duffy et al. 1979. Long-term effects of an organophosphate upon the human
electroencephalogram. Toxicol. Appl. Pharmacol. 47(1):161-176.
The brain electrical activity of workers exposed to the organophosphate compound (OP),
sarin, was compared to that of control subjects. Exposed workers had a history of one or
more documented accidental exposures to toxic levels of sarin. However, no exposed
subject had exposure within 1 year of his examination. The comparison included standard
clinical electroencephalograms (EEGs), computer-derived EEG spectral analysis, and
standard overnight sleep EEGs. It was not possible to diagnose subjects individually by
expert visual inspection of their EEGs. However, statistically significant between-group
differences for both the visually inspected and computer-derived data were reported by
both univariate and multivariate statistical methods. Different EEG changes revealed by
visual inspection and computer-derived spectral analysis appear to reflect the differing
sensitivities of these two analytic techniques. Statistically significant group differences
included increased beta activity, increased delta and theta slowing, decreased alpha
activity, and increased amounts of rapid eye movement sleep in the exposed population.
It is suggested the the above findings represent an unexpected persistence of known
short-term OP actions. It is also suggested that these results, when taken along with the
reported long-term behavioral effects of OP exposure, provide parallel evidence that OP
exposure can produce long-term changes in brain function.
Ecobichon DJ, 2001. Toxic Effects of Pesticides. In Casarett and Doulls Toxicology:
The Basic Science of Poisons (MO Amdur, J Doull, CD Klaassen, Eds.), Chapter 22.
McGraw-Hill, New York, NY.
Edwards 2000. Poison Gas. New Scientist. (November 8, 2000). [Available at
http://www.newscientist.com/news/news.jsp?id=ns9999150]
Ehrich et al. 2001. Organophosphate-Induced Delayed Neuropathy. In Handbook of
Neurotoxicology (EJ Massaro Ed.), Chapter 2. Humana Press, Totowa NJ.
Fedorov 1994. Chemical Weapons in Russia: History, Ecology, Politics. Center of
Ecological Policy of Russia Available at:
http://www.fas.org/nuke/guide/russia/cbw/jptac008_l94001.htm
Federation of American Scientists 1990. Iraq's Chemical Warfare Program: More SelfReliant, More Deadly. Available at:
http://www.fas.org/irp/gulf/cia/960702/73909_01.htm
Federation of American Scientists 2004. Chemical Weapons Programs: History.
Available at: http://www.fas.org/nuke/guide/iraq/cw/program.htm

35
Fernando et al. 1985. Variability of neurotoxicity of and lack of tolerance to the

anticholinesterases soman and sarin in the rat. Res Commun Chem Pathol Pharmacol.
48(3):415-30.
The neurotoxicity and lethality of Soman and Sarin, after single and repeated treatment at
50-60% of their LD50 doses in rats were investigated. Single treatment with Soman (100
micrograms/kg) and Sarin (120 micrograms/kg) produced severe tremors, convulsions
and hypothermia, in some rats only, while the others did not show toxicity, i.e. an all or
none effect. Soman and Sarin (100-120 micrograms/kg) caused, respectively, 89-93%
and 26-48% inhibition of AChE at 6 hr and 56-68% and 17-39% inhibition at 24 h after
single injections. Repeated treatment with Soman (90 micrograms/kg) and Sarin (100
micrograms/kg) at 4 day intervals caused variable incidences of neurotoxicity and
increasing mortalities, and after ten injections the survival rates were 31 and 54%, and
AChE inhibition was 86 and 75%, respectively. It is suggested, that the variable
neurotoxicity of and the low tolerance to of these compounds are partly related to
peripheral dispositional mechanisms. Furthermore, the profile of toxicity of these
anticholinesterase agents should be differentiated from, but not generalized with, that of
the other anticholinesterase organophosphates.
Furtado et al. 2003. Toxicity, Organophosphate. E-medicine. Available at:
http://www.emedicine.com/med/topic1677.htm.
Gosden et al. 2002. Lesson of Iraq's Mass Murder. Washington Post, June 2, 2002 B-07.
Available at: http://www.deconsolutions.com/pdf_Files/Post06022002.pdf
Hartmann 2002. Evaluation of risk assessment guideline levels for the chemical warfare
agents mustard, GB, and VX. Regul Toxicol Pharmacol. 35(3):347-56.
The U.S. Army has estimated acute lethality guideline levels for inhalation of the
chemical warfare agents mustard, GB, and VX. These levels are expressed as dosages
measured in milligram-minutes per cubic meter (mg-min/m(3)). The National Advisory
Council has also proposed acute emergency guideline levels (AEGLs) for the agents. The
AEGLs are threshold exposure limits for the general public for mild effects, serious
adverse effects, and lethality. They are expressed as air concentrations (in units of
mg/m(3)) and are applicable to emergency exposure periods ranging from 10 min to 8 h.
The report discusses strengths and deficiencies in the levels, important parameters (i.e.,
exposure time, breathing rate) that need to be explicitly addressed in deriving the
guideline levels, and possible impacts that could result from using AEGLs instead of
guideline dosages in future assessments. Copyright 2002 Elsevier Science (USA)
Hatta et al. 1996.. Amnesia from sarin poisoning. Lancet 347(9011):1343.
Henderson et al. 2002. Response of rats to low levels of sarin. Toxicol Appl Pharmacol.
184(2):67-76.
The purpose of this study was to determine whether exposure to levels of sarin causing
no overt clinical signs would cause more subtle, adverse health effects that persisted after
the exposure ended. Inhalation exposures of male Fischer 344 rats to 0, 0.2, or 0.4
mg/m(3) of sarin for 1 h/day for 1, 5, or 10 days under normal (25 degrees C) and heatContract No. IOM-2794-04-001
36
stressed (32 degrees C) conditions were completed and observations were made at 1 day
and 1 month after the exposures. The sarin exposures had no observed effects on body
weight, respiration rate, and minute volume during exposure nor in body temperature and
activity during the 30-day recovery period. There was no evidence of cellular changes in
brain determined by routine histopathology nor of any increase in apoptosis. Brain
mRNA for interleukin (IL)-1beta, tumor necrosis factor-alpha, and IL-6 was increased in
a dose-dependent manner. Autoradiographic studies demonstrated that M1 cholinergic
receptor site densities were unchanged at 1 day after repeated exposures with or without
heat stress. At 30 days, there was a decrease in M1 receptors in the olfactory tubercle
(with and without heat), and, with heat stress, M1 sites also decreased in a dosedependent manner in the frontal cortex, anterior olfactory nucleus, and hippocampus. M3
receptor sites were not affected by sarin exposure alone. In the presence of heat stress,
there was an upregulation in binding site densities in the frontal cortex, olfactory
tubercle, anterior nucleus, and striatum immediately after exposure, and these effects
persisted at 30 days. Although red blood cell acetylcholinesterase (AChE) was not greatly
inhibited by the 1-day exposure, there were 30 and 60% inhibitions after repeated
exposures at the low and high doses, respectively. Histochemical staining for AChE
demonstrated that sarin exposure alone reduced AChE in the cerebral cortex, striatum,
and olfactory bulb. Sarin exposure under heat stress reduced AChE staining in the
hippocampus, an area important for memory function. Thus, repeated exposures under
heat-stress conditions, to levels of sarin that would not be noticed clinically, resulted in
delayed development of brain alterations in cholinergic receptor subtypes that may be
associated with memory loss and cognitive dysfunction.
Hood 1997. The Tokyo attacks in retrospect: sarin leads to memory loss. Environ Health
Perspect. 2001 Nov;109(11):A542..
Husain et al. 1993. Delayed neurotoxic effect of sarin in mice after repeated inhalation
exposure. J Appl Toxicol. 13(2):143-5.
Delayed neurotoxicity of sarin in mice after repeated inhalation exposure has been
studied. Female mice exposed to atmospheric sarin (5 mg m-3 for 20 min) daily for 10
days developed muscular weakness of the limbs and slight ataxia on the 14th day after
the start of the exposure. These changes were accompanied by significant inhibition of
neurotoxic esterase (NTE) activity in the brain, spinal cord and platelets. Histopathology
of the spinal cord of exposed animals showed focal axonal degeneration. These changes
were comparatively less than in animals treated with the neurotoxic organophosphate,
mipafox. Results from this study indicate that sarin may induce delayed neurotoxic
effects in mice following repeated inhalation exposure.
Jakubowski et al. 2004. Quantitation of fluoride ion released sarin in red blood cell
samples by gas chromatography-chemical ionization mass spectrometry using isotope
dilution and large-volume injection. J Anal Toxicol. 28(5):357-63.
A new method for measuring fluoride ion released isopropyl methylphosphonofluoridate
(sarin, GB) in the red blood cell fraction was developed that utilizes an autoinjector, a
large-volume injector port (LVI), positive ion ammonia chemical ionization detection in
the SIM mode, and a deuterated stable isotope internal standard. This method was applied
37
to red blood cell (RBC) and plasma ethyl acetate extracts from spiked human and animal
whole blood samples and from whole blood of minipigs, guinea pigs, and rats exposed by
whole-body sarin inhalation. Evidence of nerve agent exposure was detected in plasma
and red blood cells at low levels of exposure. The linear method range of quantitation
was 10-1000 pg on-column with a detection limit of approximately 2-pg on-column. In
the course of method development, several conditions were optimized for the LVI,
including type of injector insert, injection volume, initial temperature, pressure, and flow
rate. RBC fractions had advantages over the plasma with respect to assessing nerve agent
exposure using the fluoride ion method especially in samples with low serum
butyrylcholinesterase activity.
Joosin et al. 2004. Cardiovascular effects of the adenosine A1 receptor agonist N6cyclopentyladenosine (CPA) decisive for its therapeutic efficacy in sarin poisoning. Arch
Toxicol. 78(1):34-9.
Mortality and occurrence of cholinergic symptoms upon sarin intoxication (144 micro
g/kg s.c., approximately 2 x LD50) in rats is completely prevented by treatment with the
adenosine A1 receptor agonist N6-cyclopentyladenosine (CPA, 2 mg/kg i.m.).
Previously, we have shown that CPA treatment altered the distribution of sarin into the
brain, presumably through its cardiovascular side effects. Therefore, the objective of the
present study was to evaluate the contribution of the cardiodepressant effects of CPA to
its therapeutic efficacy against sarin intoxication. Intramuscular treatment of rats with 0.5
and 2.0 mg/kg CPA 1 min after sarin poisoning attenuated most cholinergic symptoms
and prevented mortality, which seemed to be directly associated with an immediate
strong and long-lasting bradycardia and hypotension caused by CPA. Treatment with
lower doses of CPA (0.1 and 0.05 mg/kg i.m.) caused similar levels of bradycardia and
hypotension, albeit a few minutes later than at the higher doses of CPA. Upon sarin
intoxication, this was correlated with increased incidence of cholinergic symptoms and
decreased survival rates. Pretreatment with the peripheral adenosine A1 receptor
antagonist 8- p-sulphophenyltheophylline (8-PST, 20 mg/kg i.p.) counteracted the
cardiodepressant effects of 0.05 mg/kg CPA almost completely, thereby nearly abolishing
its therapeutic efficacy against sarin poisoning. In conclusion, the present results strongly
indicate that bradycardia and hypotension induced by the peripheral adenosine A1
receptor play a prominent role in the therapeutic efficacy of CPA in cases of sarin
poisoning.
Kalra et al. 2002. Subclinical doses of the nerve gas sarin impair T cell responses
through the autonomic nervous system. Toxicol Appl Pharmacol. 184(2):82-7.
The nerve gas sarin is a potent cholinergic agent, and exposure to high doses may cause
neurotoxicity and death. Subclinical exposures to sarin have been postulated to contribute
to the Gulf War syndrome; however, the biological effects of subclinical exposure are
largely unknown. In this communication, evidence shows that subclinical doses (0.2 and
0.4 mg/m(3)) of sarin administered by inhalation to F344 rats for 1 h/day for 5 or 10 days
inhibited the anti-sheep red blood cell antibody-forming cell response of spleen cells
without affecting the distribution of lymphocyte subpopulations in the spleen. Moreover,
sarin suppressed T cell responses, including the concanavalin A (Con A) and the antialphabeta-T cell receptor (TCR) antibody-induced T cell proliferation and the rise in the
38
intracellular calcium following TCR ligation. These concentrations of sarin altered

regional but not total brain acetylcholinesterase activity. Interestingly, serum
corticosterone levels of the sarin-treated animals were dramatically lower than the control
animals, indicating that sarin-induced immunosuppression did not result from the
activation of the hypothalamus-pituitary-adrenal (HPA) axis. Pretreatment of animals
with the ganglionic blocker chlorisondamine abrogated the inhibitory effects of sarin on
spleen cell proliferation in response to Con A and anti-TCR antibodies. These results
suggest that the effects of sarin on T cell responsiveness are mediated via the autonomic
nervous system and are independent of the HPA axis.
Kassa et al. 2000. Long-term alteration of immune functions following low level
exposure to sarin in rats. Acta Medica (Hradec Kralove). 43(3):91-4.
1. Long term alteration of immune functions caused by low doses of nerve agent sarin
were studied in rats exposed to sarin by inhalation. The alteration of immune functions by
sarin was monitored by using two methods (the evaluation of in vitro spontaneous as well
as stimulated proliferation of spleen cells and in vitro bactericidal activity of peritoneal
macrophages) at 3, 6 and 12 months following sarin exposure. 2. The results indicate that
not only symptomatic but also asymptomatic dose of sarin is able to alter some immune
functions at six and twelve months following exposure to sarin. 3. Thus, not only
organophosphorus insecticides but also nerve agents such as sarin can be potentially
immunotoxic even at very low doses that do not cause clinically manifested intoxication
following the inhalation exposure. The ability of sarin at low doses to alter immune
functions seems to be really long term (up to 12 months following the exposure).
Kassa et al. 2004a. The alteration of immune reactions in inbred BALB/c mice
following low-level sarin inhalation exposure. Inhal Toxicol. 16(8):509-15.
To study the influence of low-level sarin inhalation exposure on immune functions,
inbred BALB/c mice were exposed to low concentrations of sarin for 60 min in the
inhalation chamber. The evaluation of immune functions was carried out using
phenotyping of CD3 (T lymphocytes), CD4 (helper T lymphocytes), CD8 (cytotoxic T
lymphocytes), and CD19 cells (B lymphocytes) in the lungs, blood, and spleen,
lymphoproliferation of spleen cells stimulated in vitro by various mitogens (concanavalin
A, lipopolysaccharides), phagocyte activity of peritoneal and alveolar macrophages,
production of N-oxides by peritoneal macrophages, and the measurement of the natural
killer cell activity at 1 wk following sarin exposure. The results were compared to the
values obtained from control mice exposed to pure air instead of sarin. The results
indicate that low doses of sarin are able to alter the reaction of immune system at one
week following exposure to sarin. While the numbers of CD3 cells in the lungs, blood,
and spleen were slightly decreased, an increase in CD19 cells was observed, especially in
the lungs and blood. The reduced proportion of T lymphocytes is caused by decay of
CD4-positive T cells. Lymphoproliferation was significantly decreased regardless of the
mitogen and sarin concentration used. The production of N-oxides by peritoneal
macrophages was stimulated after exposure to the highest dose of sarin, whereas their
ability to phagocytize the microbes was increased after exposure to the lowest dose of
sarin. The natural killer cell activity was significantly higher in the case of inhalation
39
exposure of mice to the highest level of sarin. Thus, not only organophosphorus
insecticides but also nerve agents such as sarin are able to alter immune functions even at
a dose that does not cause clinically manifested disruption of cholinergic nervous system
in the case of inhalation exposure. Nevertheless, the alteration of immune functions
following the inhalation exposure to a symptomatic concentration of sarin seems to be
more pronounced.
Kassa et al. 2004b. The influence of single or repeated low-level sarin exposure on
immune functions of inbred BALB/c mice. Basic Clin Pharmacol Toxicol. 94(3):139-43.
To study the influence of single or repeated low-level sarin inhalation exposure on
immune functions, inbred BALB/c mice were exposed to low clinically asymptomatic
concentrations of sarin for 60 min. in the inhalation chamber. The evaluation of immune
functions was carried out using phenotyping of CD3 (T-lymphocytes), CD4 (helper Tlymphocytes), CD8 (cytotoxic T-lymphocytes) and CD19 (B-lymphocytes) in the lungs,
blood and spleen, lymphoproliferation of spleen cells stimulated in vitro by various
mitogens (concanavalin A, lipopolysaccharides), phagocyte activity of peritoneal and
alveolar macrophages, production of N-oxides by peritoneal macrophages and the
measurement of the natural killer cell activity at one week after sarin exposure. The
results were compared to the values obtained from control mice exposed to pure air
instead of sarin. The results indicate that an asymptomatic dose of sarin is able to alter the
reaction of the immune system at one week after exposure to sarin. While the number of
CD3 cells in lung was significantly decreased, a slight increase in CD19 cells was
observed especially in the lungs after a single sarin inhalation exposure.
Lymphoproliferation was significantly decreased regardless of the mitogen and sarin
concentration used and the number of low-level sarin exposures. The ability of peritoneal
and alveolar macrophages to phagocyte the microbes was also decreased regardless of the
number of low-level sarin exposures. The production of N-oxides by peritoneal
macrophages was decreased following a single low-level sarin exposure but increased
following repeated low-level sarin inhalation exposure. Nevertheless, the changes in the
production of N-oxides that reflects a bactericidal activity of peritoneal macrophages was
not significant. The natural killer cell activity was significantly higher in the case of
inhalation exposure of mice to low concentration of sarin regardless of the number of
exposures. Thus, not only organophosphorous insecticides but also nerve agents such as
sarin are able to alter immune functions following a single inhalation exposure even at a
dose that does not cause clinically manifested intoxication. Generally, the repeated
exposure to low concentrations of sarin does not increase the alteration of immune
functions compared to the single low-level sarin exposure with the exception of
phagocyte activity of alveolar macrophages and natural killer cell activity.
Kassa 2002. Review of oximes in the antidotal treatment of poisoning by
organophosphorus nerve agents. J Toxicol Clin Toxicol. 40(6):803-16.
The cholinesterase-inhibiting organophosphorus compounds referred to as nerve agents
(soman, sarin, tabun, GF agent, and VX) are particularly toxic and are considered to be
among the most dangerous chemical warfare agents. Included in antidotal medical
countermeasures are oximes to reactivate the inhibited cholinesterase. Much experimental
work has been done to better understand the properties of the oxime antidotal candidates
40
including the currently available pralidoxime and obidoxime, the H oximes HI-6 and
Hlo-7, and methoxime. There is no single, broad-spectrum oxime suitablefor the antidotal
treatment of poisoning with all organophosphorus agents. If more than one oxime is
available, the choice depends primarily on the identity of the responsible
organophosphorus compound. The H oximes appear to be very promising antidotes
against nerve agents because they are able to protect experimental animals from toxic
effects and improve survival of animals poisoned with supralethal doses. They appear
more effective against nerve agent poisoning than the currently used oximes pralidoxime
and obidoxime, especially in the case of soman poisoning. On the other hand,
pralidoxime and especially obidoxime seem sufficiently effective to treat poisonings with
organophosphorus insecticides that have relatively less toxicity than nerve agents.
Khan et al. 2000. Acute sarin exposure causes differential regulation of choline
acetyltransferase, acetylcholinesterase, and acetylcholine receptors in the central nervous
system of the rat. Toxicol Sci. 57(1):112-20.
Acute neurotoxic effects of sarin (O:-isopropylmethylphosphonoflouridate) in male
Sprague-Dawley rats were studied. The animals were treated with intramuscular (im)
injections of either 1 x LD(50) (100 microg/kg), and sacrificed at 0. 5, 1, 3, 6, 15, or 20 h
after treatment, or with im injections of either 0.01, 0.1, 0.5, or 1 x LD(50) and
sacrificed 15 h after treatment. Plasma butyrylcholinesterase (BChE) and brain regional
acetylcholinesterase (AChE) were inhibited (45-55%) by 30 min after the LD(50) dose.
BChE in the plasma and AChE in cortex, brainstem, midbrain, and cerebellum remained
inhibited for up to 20 h following a single LD(50) treatment. No inhibition in plasma
BChE activity was observed 20 h after treatment with doses lower than the LD(50)
dose. Midbrain and brainstem seem to be most responsive to sarin treatment at lower
doses, as these regions exhibited inhibition (approximately 49% and 10%, respectively) in
AChE activity following 0.1 x LD(50) treatment, after 20 h. Choline acetyltransferase
(ChAT) activity was increased in cortex, brainstem, and midbrain 6 h after LD(50)
treatment, and the elevated enzyme activity persisted up to 20 h after treatment.
Cortex ChAT activity was significantly increased following a 0.1 x LD(50) dose, whereas
brainstem and midbrain did not show any effect at lower doses. Treatment with an
LD(50) dose caused a biphasic response in cortical nicotinic acetylcholine receptor
(nAChR) and muscarinic acetylcholine receptor (m2-mAChR) ligand binding, using
[(3)H]cytisine and [(3)H]AFDX-384 as ligands for nAChR and mAChR, respectively.
Decreases at 1 and 3 h and consistent increases at 6, 15, and 20 h in nAChR and m2mAChR were observed following a single LD(50) dose. The increase in nAChR ligand
binding densities was much more pronounced than in mAChR. These results suggest
that a single exposure of sarin, ranging from 0.1 to 1 x LD(50), modulates the
cholinergic pathways differently and thereby causes dysregulation in excitatory
neurotransmission.
Laborde et al. 1996. Developmental toxicity of sarin in rats and rabbits. JToxicol
Environ Health. 47(3):249-65.
Sarin (Agent GB, isopropyl methylphosphonofluoridate) is an organophosphate
cholinesterase inhibitor. Sarin (Type I or Type II) was administered by gavage to CD rats
on d 6-15 of gestation at dose levels of 0, 100, 240, or 380 micrograms/kg/d and to New
41
Zealand White (NZW) rabbits on d 6-19 of gestation at dose levels of 0, 5, 10, or 15

micrograms/kg/d. Females were weighed on gestational days (GD) 0, 6-16 for rats and 620 for rabbits, and immediately prior to termination (GD 20 for rats and GD 29 for
rabbits). All animals were monitored daily for clinical signs of toxicity throughout dosing
and until sacrifice. At necropsy, gravid uteri were weighed and examined for the number
and status of implants (live, resorbed, or dead). Individual fetal body weight,
malformations, and variations (external, visceral, and skeletal) were recorded. Rat and
rabbit dams in the high-dose groups exhibited significant signs of maternal toxicity and
increased maternal mortality. Examination of gravid uteri revealed no statistical
differences among treatment groups in the incidence of resorptions or of dead or
malformed fetuses, or in average body weight of live fetuses per litter. These results show
no evidence or developmental toxicity in the CD rat or NZW rabbit following exposure to
either Type I or Type II sarin during embryonic differentiation and major organogenesis,
even at a dose that produced maternal toxicity.
Lee 2003. Clinical manifestations of sarin nerve gas exposure. JAMA. 290(5):659-62.
Li et al. 2000. The by-products generated during sarin synthesis in the Tokyo sarin
disaster induced inhibition of natural killer and cytotoxic T lymphocyte activity.
Toxicology. 146(2-3):209-20.
More than 5000 passengers on Tokyo subway trains were injured by the nerve gas, sarin
and its by-products. Analysis of phosphor-carrying metabolites of sarin and its byproducts in urine samples from the victims suggested that they were exposed not only to
sarin, but also by-products generated during sarin synthesis, i.e. diisopropyl
methylphosphonate (DIMP) and diethyl methylphosphonate (DEMP). We suspected
genetic after-effects due to sarin by-products, thus, we checked the frequency of sister
chromatid exchange (SCE) and found that SCE was significantly higher in the victims
than in a control group, and that DIMP and DEMP significantly induced human
lymphocyte SCE in vitro. In the present study, to explore whether DIMP and DEMP,
which induced a high frequency of SCE of lymphocytes, also affected the lymphocyte
functions, we examined the effect of DIMP and DEMP on splenic natural killer (NK) and
splenic cytotoxic T lymphocyte (CTL) activity in mice, and NK activity of human
lymphocytes in vitro. We found that DIMP and DEMP significantly inhibited NK and
CTL activity in a dose-dependent manner. The inhibition induced by DIMP was stronger
than that by DEMP. The effect of DIMP and DEMP on the splenic NK activity of mice
was stronger than on the splenic CTL activity, and the human lymphocytes is more
sensitive to DIMP and DEMP than the splenocytes of mice.
Li et al. 2002. Organophosphorus pesticides markedly inhibit the activities of natural
killer, cytotoxic T lymphocyte and lymphokine-activated killer: a proposed inhibiting
mechanism via granzyme inhibition. Toxicology. 172(3):181-90.
We have previously found that diisopropyl methylphosphonate, an organophosphorus byproduct generated during sarin synthesis in the Tokyo sarin disaster, significantly
inhibited natural killer (NK) and cytotoxic T lymphocyte (CTL) activities. In the present
study, to investigate whether organophosphorus pesticides (OPs) also affect NK and CTL
activities, we firstly examined the effect of five OPs on human NK activity, and then the
42
effect of Dimethyl 2,2-dichlorovinyl phosphate (DDVP), an OP on murine splenic NK,

CTL and lymphokine-activated killer (LAK), and human LAK activities in vitro. To
explore the underlying mechanism of decreased NK activity, we also investigated the
effect of 4-(2-aminoethyl) benzenesulfonyl fluoride-HCl (p-ABSF), an inhibitor of serine
proteases on NK, LAK and CTL activities, and the effect of DDVP on the activity of
granzymes (serine proteases). We found that OPs significantly decreased human NK
activity in a dose-dependent manner, but the degree of decrease in NK activity differed
among the OPs investigated, and that DDVP significantly decreased NK, LAK and CTL
activities in a dose-dependent manner, but the degree of decrease in these activities
differed. p-ABSF showed a similar inhibitory pattern to DDVP, and had an additive
inhibitory effect with DDVP on NK, LAK and CTL activities. We also found that DDVP
significantly inhibited granzyme activity in a dose-dependent manner. These findings
indicate that OPs significantly decrease NK, LAK and CTL activities in vitro via
granzyme inhibition.
Li et al. 2004. Elevated frequency of sister chromatid exchanges of lymphocytes in
sarin-exposed victims of the Tokyo sarin disaster 3 years after the event. Toxicology.
201(1-3):209-17.
We previously reported that the frequency of sister chromatid exchanges (SCEs) among
victims of the Tokyo subway sarin disaster was significantly higher than that of controls
2-3 months after the disaster. It has been reported that the victims were also exposed to
the by-products generated during sarin synthesis, i.e., diisopropyl methylphosphonate
(DIMP), diethyl methylphosphonate (DEMP) and N,N-diethylaniline (DEA) during the
disaster and we previously found that DIMP, DEMP and DEA induced a significant SCE
increase in human lymphocytes in vitro. To monitor the genetic aftereffects of the sarin
exposure, SCEs of peripheral blood lymphocytes were measured in fire fighters and
police officers involved in the disaster 3 years after the event. We found that the
frequency of SCEs was still significantly higher in the exposed subjects than the controls,
suggesting a risk of the genetic aftereffects of the sarin exposure. We further found a
significant positive correlation between the frequency of SCEs and the inhibition of
serum cholinesterase activity in the exposed subjects, suggesting that the elevated
frequency of SCEs is related to the sarin exposure. On the other hand, there was no
significant difference in natural killer activity between the exposed and the controls.
Lindsay-Poland 1998. Toxic Aftertaste: The United States tested mustard gas on its
own troops in Panamaand left a mess behind. Progressive, December 1998. Available
at: http://www.progressive.org/lindsaypoland1298.htm
Maekawa et al. 1997. Genetic mutations of butyrylcholine esterase identified from
phenotypic abnormalities in Japan. Clin Chem. 43(6 Pt 1):924-9.
We have identified 12 kinds of genetic mutations of butyrylcholine esterase (BCHE)
from phenotypic abnormalities, showing that BCHE activities were deficient or
diminished in sera. These genetic mutations, detected by PCR-single-strand conformation
polymorphism analysis and direct sequencing, consisted of one deletion (BCHE*FS4),
nine missense (BCHE*24 M, *1005, *250P, *267R, *330I, *365R, *418S, *515C,
43
*539T), and two nonsense mutations (BCHE*119STOP, *465STOP). All of the

individuals deficient in serum BCHE activity were homozygous for silent genes (6 of 6).
Fifty-eight percent of the individuals (31 of 53) with slightly reduced serum BCHE
activity were heterozygous for silent genes. They also showed a higher frequency (47%
as allele frequency) of the K-variant than the general population (17.5%). Finally, we
confirmed low serum BCHE activity in 10 of 23 individuals heterozygous for silent
genes.
Marrs 2003. Diazepam in the treatment of organophosphorus ester pesticide poisoning.
Toxicol Rev. 22(2):75-81.
Although the main site of action of diazepam, as with other benzodiazepines, is at the
gamma-aminobutyric acid A (GABAA) receptor, the degree to which the beneficial
actions of diazepam in organophosphorus (OP) ester pesticide poisoning are mediated
through the GABAA receptor has been a matter of controversy. Although in most series
of OP intoxications, convulsions have been relatively uncommon, it is probable that
convulsions produce long-term sequelae in the central nervous system by causing
structural damage. Animal studies have demonstrated that diazepam prevents and treats
convulsions produced by OPs and may prevent the late effects caused by damage to the
central nervous system induced by such convulsions. Consequently, the use of diazepam
is an important part of the treatment regimen of severe OP poisoning as it prevents, or at
least reduces the duration of, convulsions. In addition, case reports suggest that diazepam
will also ameliorate muscle fasciculation, a subjectively unpleasant feature of OP
pesticide poisoning. There are no data, either experimental or clinical, demonstrating any
clear effect of diazepam alone on lethality in OP poisoning. In fact, in one study of large
animals, diazepam, given alone, increased lethality. In animals experimentally poisoned
with OPs, combined treatment with atropine and diazepam significantly lowered lethality
compared with atropine treatment alone, indicating a clear beneficial effect. There are
numerous case reports of the use of diazepam, generally as an adjunct to other more
specific OP antidotes such as atropine and/or pyridinium oximes. Based on this evidence
and pharmacodynamic studies in experimental animals, diazepam should be given to
patients poisoned with OPs whenever convulsions or pronounced muscle fasciculation
are present. In severe poisoning, diazepam administration should be considered even
before these complications develop. Although diazepam has a large therapeutic index,
there appears to be no place for its routine use in OP poisoning. Diazepam should be
given intravenously to patients treated in hospital for OP poisoning, although the
intramuscular route is used to administer diazepam outside hospital, such as on the
battlefield, when an auto-injector is employed. It should be recognised, however, that
absorption by the intramuscular route is poor.
Matsuda et al. 1998. Detection of the sarin hydrolysis product in formalin-fixed brain
tissues of victims of the Tokyo subway terrorist attack. Toxicol Appl Pharmacol.
150(2):310-20.
One of the hydrolysis products of sarin (isopropyl methylphosphonofluoridate) was
detected in formalin-fixed brain tissues of victims poisoned in the Tokyo subway terrorist
attack. Part of this procedure, used for the detection of sarin hydrolysis products in
erythrocytes of sarin victims, has been described previously. The test materials were four
44
individual cerebellums, which had been stored in formalin fixative for about 2 years.
Sarin-bound acetylcholinesterase (AChE) was solubilized from these cerebellums,
purified by immunoaffinity chromatography, and digested with trypsin. Then the sarin
hydrolysis products bound to AChE were released by alkaline phosphatase digestion,
subjected to trimethylsilyl derivatization (TMS), and detected by gas chromatographymass spectrometry. Peaks at m/z 225 and m/z 240, which are indicative of TMSmethylphosphonic acid, were observed within the retention time range of authentic
methylphosphonic acid. However, no isopropyl methylphosphonic acid was detected in
the formalin-fixed cerebellums of these 4 sarin victims, probably because the isopropoxy
group of isopropyl methylphosphonic acid underwent chemical hydrolysis during storage.
This procedure will be useful for the forensic diagnosis of poisoning by protein-bound,
highly toxic agents, such as sarin, which are easily hydrolysed. This appears to be the
first time that intoxication by a nerve agent has been demonstrated by analyzing
formalin-fixed brains obtained at autopsy.
McGill et al. 2000. The "NRL-SAWRHINO": a nose for toxic gases. Sensors and
Actuators B. 65:10-13.
At the Naval Research Laboratory (NRL), surface acoustic wave (SAW) chemical sensor
systems have been in development since 1981. The primary focus has been the detection
and identification of chemical agents and other toxic gases or vapors. In the recently
developed "NRL-SAWRHINO" system (Rhino, Gr. Nose), a self-contained unit has been
developed capable of autonomous field operation. An automated dual gas sampling
system is included, for immediate and periodic detection capability. The latter, utilizes a
trap-and-purge miniature gas chromatographic column, which serves to collect,
concentrate, and separate vapor or gas mixtures prior to SAW analysis. The SAWRHINO
includes all the necessary electronic and microprocessor control, SAW sensor
temperature control, onboard neural net pattern recognition capability, and visual/audible
alarm features for field deployment. The SAWRHINO has been trained to detect and
identify a range of nerve and blister agents, and related simulants, and to discriminate
against a wide range of interferent vapors and gases.
McDonough et al. 1997. Neuropharmacological mechanisms of nerve agent-induced
seizure and neuropathology Neurosci. Biobehav. Rev. 21(5):559-79.
This paper proposes a three phase "model" of the neuropharmacological processes
responsible for the seizures and neuropathology produced by nerve agent intoxication.
Initiation and early expression of the seizures are cholinergic phenomenon;
anticholinergics readily terminate seizures at this stage and no neuropathology is evident.
However, if not checked, a transition phase occurs during which the neuronal excitation
of the seizure per se perturbs other neurotransmitter systems: excitatory amino acid
(EAA) levels increase reinforcing the seizure activity; control with anticholinergics
becomes less effective; mild neuropathology is occasionally observed. With prolonged
epileptiform activity the seizure enters a predominantly non-cholinergic phase: it
becomes refractory to some anticholinergics; benzodiazepines and N-methyl--aspartate
(NMDA) antagonists remain effective as anticonvulsants, but require anticholinergic coadministration; mild neuropathology is evident in multiple brain regions. Excessive
influx of calcium due to repeated seizure-induced depolarization and prolonged
45
stimulation of NMDA receptors is proposed as the ultimate cause of neuropathology. The

model and data indicate that rapid and aggressive management of seizures is essential to
prevent neuropathology from nerve agent exposure.
Mientka 2002. DoD Acknowledges Civilian Exposure In SHAD Tests. USMedicine
November 12, 2002. Available at:
http://www.usmedicine.com/dailyNews.cfm?dailyID=114
Minami et al. 1997. Method for the analysis of the methylphosphonic acid metabolites
of sarin and its ethanol-substituted analogue in urine as applied to the victims of the
Tokyo sarin disaster. J Chromatogr B Biomed Sci Appl. 695(2):237-44.
An analysis method for the methylphosphonic acid metabolites of sarin in urine using
trimethylsilyl derivatization and flame photometric detection is described in this report.
Authentic reference standards of isopropyl methylphosphonic acid (IMPA) and ethyl
methylphosphonic acid (EMPA) as well as methylphosphonic acid were employed to
estimate the concentration in human urine. A sample pretreatment procedure was
developed for urine using a column of cation-loaded ion-exchange resins (Ag+ -, Ba2+ or H+ -Dowex) and adjusting the pH of the eluate from the column to 3.75-3.85
improved recovery of the target compounds. The eluate was evaporated to dryness under
vacuum prior to trimethylsilylation, to remove water and any hydroxy- or amino-carrying
volatile substances. The sarin metabolites, because of their low volatility, were
concentrated and could be derivatized for analysis. The use of synthesized authentic sarin
and ethylsarin metabolites, i.e., IMPA and EMPA, made it possible to establish the
necessary sample pretreatment procedures for derivatization and gas chromatographyflame photometric detection (GC-FPD) analysis. The detection limits were 0.025 ppm
both for EMPA and [MPA, and 0.625 microM for MPA, respectively. This method can
be useful for estimating the exposure level to sarin by assaying the metabolites in urine
and it is applicable to a large numbers of samples.
Minami et al. 1998. Biological monitoring of metabolites of sarin and its by-products in
human urine samples. J Toxicol Sci. 23 Suppl 2:250-4.
More than 20,000 passengers of Tokyo underground trains were intoxicated with warfare
toxic chemicals. Most of the patients examined had marked miosis and decreased serum
cholinesterase activity. Transient increase of serum CPK activity after 3 days of the
exposure was the another sign. We intensively analyzed the metabolites in the urine of 4
patients. The following analytic results indicated the exposure to sarin as well as
contaminated compounds such as diisopropyl methylphosphonate (DIMP), ethyl
methylphosphonate fluoridate (EMPF, or ethylsarin), diethyl methylphosphonate
(DEMP), and ethyl isopropyl methylphosphonate (EIMP). (1) Isopropanol (IPA) and
ethanol (EtOH) were detected of large quantities in the urine samples, and were thought
to be derived from sarin and the sarin counterpart, EMPF, DIMP, DEMP and EIMP. (2)
Monoalkyl methylphosphonic acids (isopropyl methylphosphonic acid (IMPA) and ethyl
methylphosphonic acid (EMPA) also were excreted in large amounts with taking the
similar excretion pattern of IPA and EtOH. (3) The metabolite only derived from sarin
and ethylsarin is F anions whose integral output in the urine was less than the equimolar
level of the excreted (IMPA + EMPA + IPA + EtOH). (4) Other corroborative findings
46
were low lethality: of more than 5,510 patients treated, 11 were acutely dead. (5) Nine
exposed males had higher sister chromatid exchange (SCE) rate (5.00 +/- 1.48/cell) than
the control (3.81 +/- 0.697/cell), because dialkyl methylphosphonates seemed to have
alkylating activity and producing DNA adducts. The SCE rate also increased after the in
vitro exposure of lymphocytes to dialkyl methylphosphonates.
Mitretek 2004. A Short History of the Development of Nerve Gases. Available at:
http://www.mitretek.org/home.nsf/Homelandsecurity/HistoryNerveGases
Moore 1998. Long term health effects of low dose exposure to nerve agent. J Physiology
(Paris) 92(3-4):325-8. Possible long-term toxic effects of nerve agents have been
investigated using sensitive toxicological screens and extensive toxicity studies in various
animal models. Data on humans have been obtained from controlled studies and
accidental exposures. Studies in the area of 'low dose' exposure to nerve agents are
currently being performed.
Morgan 1978. Jamaica ginger paralysis. Forty-seven year follow-up. Arch. Neurol.
35(8):530-532.
Eleven men who were victims of paralysis arising from ingestion of jake (Jamaica ginger
extract) adulterated with lindol (isomers of cresyl phosphate) were examined. These men
had taken the liquid in the early 1930's, when various batches of jake were distributed
containing 0.5 to 3% tri-o-cresyl phosphate (TOCP). Nine of the eleven had consumed
jake prior to this time without any ill effects. All the victims of these adulterated batches
suffered some degree of paresis of both upper and lower extremities, usually with foot
drop and wrist drop with clawed hands. All experienced complete or nearly complete
recovery of hand and arm function, but only one of the 11 was able to later walk without
use of assisting implements. Only one suffered any type of impotency for a time after the
illness. TOCP poisoning destructively involves anterior horn cells and corticospinal tracts
in the cord. Most of the evidence indicates that destruction of myelin sheaths is
associated with axonal death. While these subjects showed some signs of frontal release
and mild dementia, these could be attributed to advanced aged and cerebrovascular
atherosclerosis. However, it is suggested that there is a possibility that TOCP may also
affect cerebral function. TOCP closely resembles modern organophosphate pesticides,
although it has little utility as a pesticide itself.
Morita et al. 1995. Sarin poisoning in Matsumoto, Japan. Lancet. 346(8970):290-3.
A presumed terrorist attack with sarin occurred in a residential area of the city of
Matsumoto, Japan, on June 27, 1994. About 600 residents and rescue staff were
poisoned; 58 were admitted to hospitals, and 7 died. We examined clinical and laboratory
findings of 264 people who sought treatment and the results of health examinations on
155 residents done 3 weeks after the poisoning. Findings for severely poisoned people
were decreases in serum cholinesterase, acetylcholinesterase in erythrocytes, serum
triglyceride, serum potassium and chloride; and increases in serum creatine kinase,
leucocytes, and ketones in urine. Slight fever and epileptiform abnormalities on
electroencephalogram were present for up to 30 days. Examination revealed no persisting
abnormal physical findings in any individual. Acetylcholinesterase returned to normal
47
within 3 months in all people examined. Although subclinical miosis and neuropathy
were present 30 days after exposure, almost all symptoms of sarin exposure disappeared
rapidly and left no sequelae in most people.
Moser et al. 2004. Placental Failure and Impaired Vasculogenesis Result in Embryonic
Lethality for Neuropathy Target Esterase-Deficient Mice. Mol Cell Biol. 24(4): 1667
1679.
Age-dependent neurodegeneration resulting from widespread apoptosis of neurons and
glia characterize the Drosophila Swiss Cheese (SWS) mutant. Neuropathy target esterase
(NTE), the vertebrate homologue of SWS, reacts with organophosphates which initiate a
syndrome of axonal degeneration. NTE is expressed in neurons and a variety of
nonneuronal cell types in adults and fetal mice. To investigate the physiological functions
of NTE, we inactivated its gene by targeted mutagenesis in embryonic stem cells.
Heterozygous NTE+/ mice displayed a 50% reduction in NTE activity but underwent
normal organ development. Complete inactivation of the NTE gene resulted in embryonic
lethality, which became evident after gastrulation at embryonic day 9 postcoitum (E9).
As early as E7.5, mutant embryos revealed growth retardation which did not reflect
impaired cell proliferation but rather resulted from failed placental development; as a
consequence, massive apoptosis within the developing embryo preceded its resorption.
Histological analysis indicated that NTE is essential for the formation of the labyrinth
layer and survival and differentiation of secondary giant cells. Additionally, impairment
of vasculogenesis in the yolk sacs and embryos of null mutant conceptuses suggested that
NTE is also required for normal blood vessel development.
Munro et al. 1994. Toxicity of the organophosphate chemical warfare agents GA, GB,
and VX: implications for public protection. Environ Health Perspect 102:18-38.
Available at http://ehp.niehs.nih.gov/members/1994/102-1/munro-full.html .
The nerve agents, GA, GB, and VX are organophosphorus esters that form a major
portion of the total agent volume contained in the U.S. stockpile of unitary chemical
munitions. Congress has mandated the destruction of these agents, which is currently
slated for completion in 2004. The acute, chronic, and delayed toxicity of these agents is
reviewed in this analysis. The largely negative results from studies of genotoxicity,
carcinogenicity, developmental, and reproductive toxicity are also presented. Nerve
agents show few or delayed effects. At supralethal doses, GB can cause delayed
neuropathy in antidote-protected chickens, but there is no evidence that it causes this
syndrome in humans at any dose. Agent VX shows no potential for inducing delayed
neuropathy in any species. In view of their lack of genotoxcity, the nerve agents are not
likely to be carcinogens. The overreaching concern with regard to nerve agent exposure is
the extraordinarily high acute toxicity of these substances. Furthermore, acute effects of
moderate exposure such as nausea, diarrhea, inability to perform simple mental tasks, and
respiratory effects may render the public unable to respond adequately to emergency
instructions in the unlikely event of agent releaase, making early warning and exposure
avoidance important. Likewise, exposure or self-contamination of first responders and
medical personnel must be avoided. Control limits for exposure via surface contact of
drinking water are needed, as are detection methods for low levels in water or foodstuffs.
48
Murata et al. 1997. Asymptomatic sequelae to acute sarin poisoning in the central and
autonomic nervous system 6 months after the Tokyo subway attack. J Neurol.
244(10):601-6.
Six to eight months after the Tokyo subway attack in March 1995, the neurophysiological
effects of acute sarin poisoning were investigated in 18 passengers exposed to sarin (sarin
cases) in the subways to ascertain the focal or functional brain deficits induced by sarin.
The event-related and visual evoked potentials (P300 and VEP), brainstem auditory
evoked potential, and electrocardiographic R-R interval variability (CVRR), together
with the score on the posttraumatic stress disorder (PTSD) checklist, were measured in
the sarin cases and the same number of control subjects matched for sex and age. None of
the sarin cases had any obvious clinical abnormalities at the time of testing. The P300 and
VEP (P100) latencies in the sarin cases were significantly prolonged compared with the
matched controls. In the sarin cases, the CVRR was significantly related to serum
cholinesterase (ChE) levels determined immediately after exposure; the PTSD score was
not significantly associated with any neurophysiological data despite the high PTSD
score in the sarin cases. These findings suggest that asymptomatic sequelae to sarin
exposure, rather than PTSD, persist in the higher and visual nervous systems beyond the
turnover period of ChE; sarin may have neurotoxic actions in addition to the inhibitory
action on brain ChE.
Nagao et al. 2003. Development of forensic diagnosis of acute sarin poisoning. Leg Med
(Tokyo). 5 Suppl 1:S34-40.
On March 20, 1995, the Tokyo subway system was subjected to a horrifying terrorist
attack with sarin gas (isopropyl methylphosphonofluoridate) that left 12 persons dead and
over 5000 injured. In order to diagnose the definite cause of death of the victims, a new
method was developed to detect sarin hydrolysis products in the erythrocytes and
formalin-fixed cerebella from four victims of sarin poisoning. Sarin-bound
acetylcholinesterase (AChE) was solubilized from the specimens of sarin victims and
digested with trypsin. The sarin hydrolysis products bound to AChE were released by
alkaline phosphatase digestion. The digested sarin hydrolysis products were subjected to
trimethylsilyl derivatization and detected by gas chromatography-mass spectrometry.
Sarin hydrolysis products were detected in all sarin poisoning victims.
Nakajima et al. 1999. Sequelae of sarin toxicity at one and three years after exposure in
Matsumoto, Japan. J Epidemiol. 9(5):337-43.
In order to clarify the later sequelae of sarin poisoning that occurred in Matsumoto City,
Japan, on June 27, 1994, a cohort study was conducted on all persons (2052 Japanese
people) inhabiting an area 1050 meters from north to south and 850 meters from east to
west with the sarin release site in the center. Respondents numbered 1237 and 836 people
when surveys were conducted at one and three years after the sarin incident, respectively.
Numbers of persons with symptoms of sarin toxicity were compared between sarin
victims and non-victims. Of the respondents, 58 and 46 people had symptoms associated
with sarin such as fatigue, asthenia, shoulder stiffness, asthenopia and blurred vision at
both points of the survey, respectively. The prevalences were low; some complained of
insomnia, had bad dreams, difficulty in smoking, husky voice, slight fever and
palpitation. The victims who had symptoms one year after the incident had a lower
49
erythrocyte cholinesterase activity than did those who did not have symptoms at the early
stage; such persons lived in an area with a 500 meter long axis north east from the sarin
release site. The three-year cohort study clearly showed that the odds ratios of almost all
of the symptoms were high in the sarin-exposed group, suggesting a positive relationship
between symptoms and grades of exposure to sarin. These results suggest that symptoms
reported by many victims of the sarin incident are thought to be sequelae related to sarin
exposure.
Nakajima et al. 1998. Epidemiological study of sarin poisoning in Matsumoto City,
Japan. J Epidemiol. 8(1):33-41.
On the night of June 27, 1994, about 12 liters of sarin were released by terrorists in
Matsumoto City, Japan. In order to investigate the epidemic, community-based
questionnaire surveys were conducted. The subjects were all inhabitants (2052 people)
living and staying in an area of 1050 meters from north to south and 850 meters from east
to west including the sarin release site. Participants included 1743 people who answered
the questionnaire at the first survey; those with symptoms were contacted for follow-up at
four months and one year after the episode. The number of sarin victims were 471
persons. Muscarinic signs were common to all victims; nicotinic signs were only seen in
severely affected victims. The geographical distribution of sarin victims was closely
related to the direction of the wind. Three weeks after the intoxication, 129 victims still
had some symptoms such as dysesthesia of the extremities. At that time, many victims
had begun to experience asthenopia, which was even more frequent at four months.
Although victims who felt sarin-related symptoms had decreased by a year, some still had
symptoms such as asthenopia. Sarin released in a suburban area affected approximately
500 inhabitants living nearby; some still had symptoms a year after the intoxication.
Nasr et al. 1988. SCE induction in Chinese hamster ovary cells (CHO) exposed to G
agents. Mutat Res. 204(4):649-54.
Cultured Chinese hamster ovary (CHO) cells were exposed to two neurotoxic
organophosphates, either sarin (GBI, GBII) at 1.4 X 10(-3) M or soman (GD) at 1.1 and
2.2 X 10(-3) M for 1 h, grown and their metaphase chromosomes scored for sisterchromatid exchanges (SCE). No cytotoxicity was seen with either agent at any dose level
tested. Since histograms of SCE per cell showed that they were non-symmetrically
arrayed around the mean, the number of SCEs were analyzed by using the nonparametric
tests, Mann-Whitney and Kruskall-Wallis. Agents GBI and GBII did not show any
significant increase in SCE over baseline. On the other hand, GD demonstrated a
statistically significant increase in SCE with and without metabolic activation. Ethyl
methanesulfonate (EMS) alone at 5 X 10(-3) M and cyclophosphamide (CP) at 10(-4) M
in the presence of rat microsomes (S9) induced a 3- and 8-fold increase in SCE per cell,
respectively.
National Research Council (US) 1997, Committee on Toxicology, Subcommittee on
Toxicity Values for Selected Nerve and Vesicant Agents, Review of Acute Human-Toxicity
Estimates for Selected Chemical-Warfare Agents, National Academy Press, Washington,
D.C. Available at: http://www.nap.edu/readingroom/books/toxicity/
50
National Research Council (US) 1999. Health Risk Assessment for The Nerve Agent
GB. In Subcommittee on Chronic Reference Doses for Selected Chemical-Warfare
Agents. Review of the U.S. Army's Health Risk Assessments for Oral Exposure to Six
Chemical-Warfare Agents Appendix B, National Academy Press. Available at
http://www.nap.edu/books/0309065984/html/131.html
Newmark 2004a. The birth of nerve agent warfare: lessons from Syed Abbas Foroutan.
Neurology. 62(9):1590-6.
The author reviewed Farsi-language articles published recently by Dr. Syed Abbas
Foroutan, which constitute the only firsthand clinical descriptions of battlefield nerve
agent casualties in the world literature, and the author compares his comments with US
and North Atlantic Treaty Organization (NATO) chemical casualty care doctrine.
Foroutan's lessons learned reassure us that a robust medical evacuation system, coupled
with timely and appropriate medical care of nerve agent poisoning, will save many more
lives on future battlefields.
Niven et al. 2004. Inhalational exposure to nerve agents. Respir Care Clin N Am.
10(1):59-74.
The respiratory system plays a major role in the pathogenesis of nerve agent toxicity. It is
the major route of entry and absorption of nerve agent vapor, and respiratory failure is the
most common cause of death follow-ing exposure. Respiratory symptoms are mediated
by chemical irritation,muscarinic and nicotinic receptor overstimulation, and central
nervous system effects. Recent attacks have demonstrated that most patients with an
isolated vapor exposure developed respiratory symptoms almost immediately. Most
patients had only mild and transient respiratory effects, and those that did develop
significant respiratory compromise did so rapidly. These observations have significant
ramifications on triage of patients in a mass-casualty situation, because patients with
mild-to-moderate exposure to nerve agent vapor alone do not require decontamination
and are less likely to develop progressive symptoms following initial antidote therapy.
Limited data do not demonstrate significant long-term respiratory effects following nerve
agent exposure and treatment. Provisions for effective respiratory protection against
nerve agents is a vital consideration in any emergency preparedness or health care
response plan against a chemical attack.
Noort et al. 1998. Quantitative analysis of O-isopropyl methylphosphonic acid in serum
samples of Japanese citizens allegedly exposed to sarin: estimation of internal dosage.
Arch Toxicol. 72(10):671-5.
A convenient and rapid micro-anion exchange liquid chromatography (LC) tandem
electrospray mass spectrometry (MS) procedure was developed for quantitative analysis
in serum of O-isopropyl methylphosphonic acid (IMPA), the hydrolysis product of the
nerve agent sarin. The mass spectrometric procedure involves negative or positive ion
electrospray ionization and multiple reaction monitoring (MRM) detection. The method
could be successfully applied to the analysis of serum samples from victims of the Tokyo
subway attack and of an earlier incident at Matsumoto, Japan. IMPA levels ranging from
2 to 135 ng/ml were found. High levels of IMPA appear to correlate with low levels of
residual butyrylcholinesterase activity in the samples and vice versa. Based on our
51
analyses, the internal and exposure doses of the victims were estimated. In several cases,
the doses appeared to be substantially higher than the assumed lethal doses in man.
Nozaki et al. 1997. Relationship between pupil size and acetylcholinesterase activity in
patients exposed to sarin vapor. Intensive Care Med. 23(9):1005-7.
OBJECTIVE: To elucidate the effect of sarin vapor on pupil size and erythrocyte
acetylcholinesterase activity (AchE). DESIGN: Retrospective observational survey.
SETTING: Emergency department of an urban teaching hospital. PATIENTS: 80 patients
who were exposed to sarin in a terrorist attack in Tokyo subways. MEASUREMENTS
AND RESULTS: Pupil size and AchE activity on the day of exposure were measured.
Among the 80 patients, the pupils were miotic (< 3 mm) in 50 patients (62.5%), while
AchE activity was below the normal range (< 1.2 U) in 34 patients (42.5%). AchE was
significantly lower in the miotic group than in the group with normal pupils (1.0 +/- 0.5
U vs 1.5 +/- 0.3 U, p < 0.01). In the miotic group, AchE activity was lower than normal
in 32 patients (64.0%) but was decreased in only 2 patients in the normal pupil group
(6.7%) (p < 0.01). CONCLUSIONS: Miosis is a more sensitive index of exposure to
sarin vapor than erythrocyte AchE. Systemic poisoning is apparently less likely to
develop if the patient's pupil size is normal on arrival at the hospital.
Ohbu et al. 1997. Sarin poisoning on Tokyo subway. South Med J. 90(6):587-93.
On the day of the disaster, 641 victims were seen at St. Luke's International Hospital.
Among those, five victims arrived with cardiopulmonary or respiratory arrest with
marked miosis and extremely low serum cholinesterase values; two died and three
recovered completely. In addition to these five critical patients, 106 patients, including
four pregnant women, were hospitalized with symptoms of mild to moderate exposure.
Other victims had only mild symptoms and were released after 6 hours of observation.
Major signs and symptoms in victims were miosis, headache, dyspnea, nausea, ocular
pain, blurred vision, vomiting, coughing, muscle weakness, and agitation. Almost all
patients showed miosis and related symptoms such as headache, blurred vision, or visual
darkness. Although these physical signs and symptoms disappeared within a few weeks,
psychologic problems associated with posttraumatic stress disorder persisted longer.
Also, secondary contamination of the house staff occurred, with some sort of physical
abnormality in more than 20%.
Okudera 2002. Clinical features on nerve gas terrorism in Matsumoto. J Clin Neurosci.
9(1):17-21.
Clinical features on the first unexpected nerve gas terrorism using sarin (isopropyl
methylphosphonofluoridate) on citizens in the city of Matsumoto is described. The nerve
gas terrorism occurred at midnight on 27 June, 1994. About 600 people including
residents and rescue staff were exposed to sarin gas. Fifty-eight victims were admitted to
hospitals and seven died. Theoretically, sarin inhibits systemic acetylcholinesterase and
damages all the autonomic transmission at the muscarinic and nicotinic acetylcholine
receptor. Miosis was the most common finding in the affected people. In cases with
severe poisoning, organophosphate may affect the central nervous system and cause
cardiomyopathy. A few of the victims complained of arrhythmia and showed a decreased
cardiac contraction. Abnormal electroencephalograms were recorded in two patients. The
52
clinical features and follow-up studies are discussed with reference to the Tokyo subway
terrorism and related articles.
Okudera et al. 1997. Unexpected nerve gas exposure in the city of Matsumoto: report of
rescue activity in the first sarin gas terrorism. Am J Emerg Med. 15(5):527-8
This report describes the rescue activities and the exposure of rescue and hospital
personnel from the first unexpected nerve gas terrorist attack using sarin (isopropyl
methylphophonofluoridate) in the city of Matsumoto at midnight on June 27, 1994. The
details of the emergency activities in the disaster were studied based on the records from
emergency departments of the affiliated hospitals and records from the firehouse. About
600 people, including residents and rescue staff, were exposed to sarin gas. Fifty-eight
residents were admitted to hospitals, and 7 died. Among 95 rescuers and the duty doctor
from the doctor car, 8 had mild symptoms of poisoning. All the rescue activity took place
without gas masks or decontamination procedures. In this case of unexpected mass
exposure to sarin gas, the emergency rescue system for a large disaster in Matsumoto
city, which had been established for a conflagration or a local earthquake, was effective.
Okumura et al. 2000. Lessons Learned from the Tokyo Subway Sarin Attack. Prehosp
Disast Med 15(3):s30.
On the morning of 20 March 1995, sarin was released in the Tokyo Subway System.
There had never been such a large scale act of urban terrorism using a nerve gas. There
are many lessons to be learned from Tokyo Subway Sarin Attack. Two major lessons can
be cited in summary:
1) Absence of decontamination - In total, 1,364 EMTs were dispatched, and among them,
135 were secondarily affected. At St. Luke's hospital, 23% of the medical staff
complained of symptoms and signs of secondary exposure. Fortunately, nobody died
from the secondary exposure. The religious cult used a 30% sarin solution. If they had
used a 100% sarin solution, the outcome would have been much more tragic - secondarily
exposed prehospital and medical staff would have been killed. This is the reason for the
development of decontamination facilities and the use of personal protective equipment
(PPE) in the prehospital and hospital settings; and
2) Confusion of information and lack of coordination among related organizations - Japan
is a highly vertically structured society. Fire departments, police, metropolitan
governments, and hospitals acted independently without coordination. After the attack,
the Japanese government developed the Severe Chemical Hazard Response Team.
The Prime Minister's office created a National Security and Crisis Management Office
that calls realistic desktop hazmat drills involving the concerned organizations and
specialists
Okumura et al. 1998a. The Tokyo subway sarin attack: disaster management, Part 1:
Community emergency response. Acad Emerg Med. 5(6):613-7.
The Tokyo subway sarin attack was the second documented incident of nerve gas
poisoning in Japan. Prior to the Tokyo subway sarin attack, there had never been such a
large-scale disaster caused by nerve gas in peacetime history. This article provides details
related to how the community emergency medical services (EMS) system responded
from the viewpoint of disaster management, the problems encountered, and how they
53
were addressed. The authors' assessment was that if EMTs, under Japanese law, had been
allowed to maintain an airway with an endotracheal tube or use a laryngeal mask airway
without physician oversight, more patients might have been saved during this chemical
exposure disaster. Given current legal restrictions, advanced airway control at the scene
will require that doctors become more actively involved in out-of-hospital treatment.
Other recommendations are: 1) that integration and cooperation of concerned
organizations be established through disaster drills; 2) that poison information centers act
as regional mediators of all toxicologic information; 3) that a real-time, multidirectional
communication system be established; 4) that multiple channels of communication be
available for disaster care; 5) that public organizations have access to mobile
decontamination facilities; and 6) that respiratory protection and chemical-resistant suits
with gloves and boots be available for out-of-hospital providers during chemical
disasters.
Okumura et al. 1998b. The Tokyo subway sarin attack: disaster management, Part 2:
Hospital response. Acad Emerg Med. 5(6):618-24.
The Tokyo subway sarin attack was the second documented incident of nerve gas
poisoning in Japan. The authors report how St. Luke's Hospital dealt with this disaster
from the viewpoint of disaster management. Recommendations derived from the
experience include the following: Each hospital in Japan should prepare an emergent
decontamination area and have available chemical-resistant suits and masks. Ventilation
in the ED and main treatment areas should be well planned at the time a hospital is
designed. Hospital disaster planning must include guidance in mass casualties, an
emergency staff call-up system, and an efficient emergency medical chart system.
Hospitals should establish an information network during routine practice so that it can
be called upon at the time of a disaster. The long-term effects of sarin should be
monitored, with such investigation ideally organized and integrated by the Japanese
government.
Organisation for the Prohibition of Chemical Weapons (OPCW) 2004. Chemical
Terrorism in Japan: The Matsumoto and Tokyo Incidents. Available at:
http://www.opcw.org/resp/html/japan.html
Page 2003. Long-term health effects of exposure to sarin and other anticholinesterase
chemical warfare agents. Mil Med. 168(3):239-45.
In a telephone survey of 4,022 military volunteers for a 1955-1975 program of
experimental exposures to chemical agents at Edgewood, Maryland, the current health of
those exposed to anticholinesterase agents was compared with that of men exposed to no
active chemicals (no chemical test) and to two or more other types of chemical agents
(other chemical tests). The survey posed questions about general health and about
neurological and psychological deficits. There were only two statistically significant
differences: volunteers in anticholinesterase agent tests reported fewer attention problems
than those in other chemical tests and greater sleep disturbance than those in no chemical
tests. In contrast, volunteers who reported exposure to civilian or military chemical
agents outside of their participation in the Edgewood program reported many statistically
significant adverse neurological and psychological effects, regardless of their
54
experimental exposure. In this study, the health effects of self-reported, nonexperimental

exposure, which are subject to recall bias, were greater than the health effects of
experimental exposure.
Parascandola 1995. The Public Health Service and Jamaica ginger paralysis in the
1930s. Public Health Rep. 110(3):361-3.
Peterson 2002. Lessons from Iran on facing chemical war: Scientists and doctors visit
Iran to gain expertise on handling chemical attacks. Christian Science Monitor November
19, 2002. Available at: http://www.csmonitor.com/2002/1119/p01s03-wome.html.
PIER 2004. Nerve Agent Exposure > Diagnosis. American College of Physicians,
Physicians Information and Educational Resource. Available at:
http://pier.acponline.org/physicians/public/d890/diagnosis/d890-g3.5.html
Polhuijs et al. 1997. New method for retrospective detection of exposure to
organophosphorus anticholinesterases: application to alleged sarin victims of Japanese
terrorists. Toxicol Appl Pharmacol. 146(1):156-61.
With regard to detection of exposure to anticholinesterase, the presently used methods
have the disadvantage that they cannot detect either low-level exposures with certainty or
the structure of the agent and the extent of poisoning. In principle, organophosphateinhibited butyrylcholinesterase in human plasma is the most persistent and abundant
source for biomonitoring of exposure to organophosphate anticholinesterases. Fluoride
ions reactivate the inhibited enzyme readily at pH 4, converting the organophosphate
moiety into the corresponding phosphofluoridate. Subsequent quantitation of the latter
product provides a reliable, highly sensitive and retrospective method for detection of
exposure to, or handling of, organophosphates such as nerve agents and
organophosphorus pesticides. We applied the new procedure to serum samples from
victims of the Tokyo subway attack by the AUM Shinriyko sect and from an earlier
incident at Matsumoto. In serum of 10 of 11 victims from the Tokyo incident and of 2 of
the 7 samples from the Matsumoto incident, reactivation with fluoride ions yielded sarin
concentrations in the range of 0.2-4.1 ng/ml serum. Evidently, these victims had been
exposed to an organophosphate with the structure PriO(CH3)P(O)X, presumably with X
= F (sarin). Several applications of the new procedure to establish nerve agent and/or
organophosphate (OP) pesticide exposure can be envisaged, e.g., (i) in biomonitoring of
exposure for health surveillance of those handling organophosphates, (ii) in cases of
alleged exposure to nerve agents and/or OP pesticides in armed conflict situations or
terrorist attacks, (iii) in medical treatment of intoxication, and (iv) in forensic cases
against suspected terrorists that may have handled anticholinesterases.
Quistad et al. 2003. Evidence that mouse brain neuropathy target esterase is a
lysophospholipase. Proc Natl Acad Sci USA. 100(13):79837987.
Neuropathy target esterase (NTE) is inhibited by several organophosphorus (OP)
pesticides, chemical warfare agents, lubricants, and plasticizers, leading to OP-induced
delayed neuropathy in people (>30,000 cases of human paralysis) and hens (the best
animal model for this demyelinating disease). The active site region of NTE as a
55
recombinant protein preferentially hydrolyzes lysolecithin, suggesting that this enzyme

may be a type of lysophospholipase (LysoPLA) with lysolecithin as its physiological
substrate. This hypothesis is tested here in mouse brain by replacing the phenyl valerate
substrate of the standard NTE assay with lysolecithin for an NTE-LysoPLA assay with
four important findings. First, NTE-LysoPLA activity, as the NTE activity, is 4145%
lower in Nte-haploinsufficient transgenic mice than in their wild-type littermates. Second,
the potency of six delayed neurotoxicants or toxicants as in vitro inhibitors varies from
IC50 0.02 to 13,000 nM and is essentially the same for NTE-LysoPLA and NTE (r2 =
0.98). Third, the same six delayed toxicants administered i.p. to mice at multiple doses
inhibit brain NTE-LysoPLA and NTE to the same extent (r2 = 0.90). Finally, their in
vivo inhibition of brain NTE-LysoPLA generally correlates with delayed toxicity.
Therefore, OP-induced delayed toxicity in mice, and possibly the hyperactivity associated
with NTE deficiency, may be due to NTE-LysoPLA inhibition, leading to localized
accumulation of lysolecithin, a known demyelinating agent and receptor-mediated signal
transducer. This mouse model has some features in common with OP-induced delayed
neuropathy in hens and people but differs in the neuropathological signs and apparently
the requirement for NTE aging.
Raveh et al. 1993. Human butyrylcholinesterase as a general prophylactic antidote for
nerve agent toxicity. In vitro and in vivo quantitative characterization. Biochem
Pharmacol. 45(12):2465-74.
Butyrylcholinesterase purified from human plasma (HuBChE) was evaluated both in
vitro and in vivo in mice and rats as a single prophylactic antidote against the lethal
effects of highly toxic organophosphates (OP). The variation among the bimolecular rate
constants for the inhibition of HuBChE by tabun, VX, sarin, and soman was 10-fold (0.47
to 5.12 x 10(7) M-1 min-1; pH 8.0, 26 degrees). The half-life of HuBChE in blood after
its i.v. administration in mice and rats was 21 and 46 hr, respectively. The peak bloodenzyme level was obtained in both species approximately 9-13 hr following i.m. injection
of HuBChE, and the fraction of the enzyme activity absorbed into the blood was 0.9 and
0.54 for rats and mice, respectively. The stoichiometry of the in vivo sequestration of the
anti-cholinesterase toxicants was consistent with the HuBChE/OP ratio of the molar
concentration required to inhibit 100% enzyme activity in vitro. Linear correlation was
demonstrated between the blood level of HuBChE and the extent of protection conferred
against the toxicity of nerve agents. Pretreatment with HuBChE alone was sufficient not
only to increase survivability following exposure to multiple median lethal doses of a
wide range of potent OPs, but also to alleviate manifestation of toxic symptoms in mice
and rats without the need for additional post-exposure therapy. It appeared that in order to
confer protection against lethality nerve agents had to be scavenged to a level below their
median lethal dose LD50 within less than one blood circulation time. Since the high rate
of sequestration of nerve agents by HuBChE is expected to underlie the activity of the
scavenger in other species as well, a reliable extrapolation of its efficacy from
experimental animals to humans can be made.
Rengstorff 1985. Accidental exposure to sarin: vision effects. Arch Toxicol. 56(3):201-3.
Two men were accidentally exposed to vapors of sarin, a cholinesterase inhibitor and
extremely toxic nerve gas. Diagnosis was confirmed by depressed cholinesterase activity,
56
and fixed extremely miotic pupils. No other signs or symptoms developed and neither
man required treatment. Recovery to normal cholinesterase activity was gradual over a
90-day period. Pupillary reflexes were not detectable until 11 days after exposure; the
miotic pupils dilated slowly over a 30-45 day-period. Eye pain and blurred vision did not
occur; visual acuity and amplitude of accommodation were improved for several weeks.
Other functions not affected significantly were intraocular pressure, visual fields, color
vision, heterophorias, and vergences.
Ritter 2004. Iraq Sarin Shell is not Part of a Secret Cache. Christian Science Monitor
May 21, 2004. Available at: http://www.commondreams.org/views04/0521-06.htm
Rostker 1997. Information Paper: M8A1 Automatic Chemical Agent Alarm.
Department of Defense. Available at: http://www.gulflink.osd.mil/m8a1alarms/
Scremin et al. 2003. Delayed neurologic and behavioral effects of subtoxic doses of
cholinesterase inhibitors. J Pharmacol Exp Ther. 304(3):1111-9.
We tested the hypothesis that pyridostigmine bromide (PB) intake and/or low-level sarin
exposure, suggested by some as causes of the symptoms experienced by Persian Gulf
War veterans, induce neurobehavioral dysfunction that outlasts their effects on
cholinesterase. Adult male Sprague-Dawley rats were treated during 3 weeks with s.c.
saline, PB in drinking water (80 mg/l), sarin (62.5 microg/kg; 0.5x LD(50), three
times/week s.c.), or PB in drinking water + sarin. Animals were tested for passive
avoidance, nociceptive threshold, acoustic startle, and open field activity 2, 4, or 16
weeks after treatment. Two weeks after sarin, acoustic startle was enhanced, whereas
distance explored in the open field decreased. These effects were absent with PB + sarin
or PB by itself. No effect on any variable was found at 4 weeks, whereas at 16 weeks
sarin induced a decrease and PB + sarin induced an increase in habituation in the open
field test. Nociceptive threshold was elevated in the PB + sarin group at 16 weeks. No
effect of treatment on passive avoidance was noted in any group. Brain regional
acetylcholinesterase and cholineacetyltransferase activities were not affected at any time
after treatment, but muscarinic receptors were down-regulated in hippocampus, caudate
putamen, and mesencephalon in the sarin group at 2 weeks. In conclusion, this study
gives further support to the use of PB against nerve agent poisoning and does not support
the hypothesis that delayed symptoms experienced by Persian Gulf War veterans could
be due to PB, alone or in association with low-level sarin exposure.
Senanayake et al. 1987. Neurotoxic effects of organophosphorus insecticides. An
intermediate syndrome. N Engl J Med. 316(13):761-3.
Acute neurotoxic effects during the cholinergic phase of organophosphorus insecticide
poisoning and delayed neurotoxic effects appearing two to three weeks later are well
recognized. We observed 10 patients who had paralysis of proximal limb muscles, neck
flexors, motor cranial nerves, and respiratory muscles 24 to 96 hours after poisoning,
after a well-defined cholinergic phase. The compounds involved were fenthion,
monocrotophos, dimethoate, and methamidophos. Four patients urgently required
ventilatory support. The paralytic symptoms lasted up to 18 days. A delayed
polyneuropathy later developed in one patient. Three patients died. Electromyographic
57
studies showed fade on tetanic stimulation, absence of fade on low-frequency

stimulation, and absence of post-tetanic facilitation, suggestive of a postsynaptic defect.
This neuromuscular junctional defect may have been the predominant cause of the
paralytic symptoms, with neural and central components contributing to various degrees.
Our patients appeared to have a distinct clinical entity (a so-called intermediate
syndrome) that developed after the acute cholinergic crisis and before the expected onset
of the delayed neuropathy.
Seto 2001. The sarin gas attack in Japan and the related forensic investigation.
Organisation for the Prohibition of Chemical Weapons Summer/June 2001. Available at:
http://www.opcw.org/synthesis/html/s6/p14prt.html.
Sidell et al. 1992. Chemical warfare agents: II. Nerve agents. Ann Emerg Med.
21(7):865-71.
Nerve agents are highly potent and rapidly acting organophosphorus compounds that
irreversibly bind and inactive acetylcholinesterase. Only rarely have they been used in
warfare, but their great lethality and the threat that they pose have encouraged production
and stockpiling in large quantities. They differ in a number of important ways from
common agricultural organophosphate insecticides. In light of recent threats of chemical
warfare and the possibilities of chemical acts of terrorism, North American physicians
should be knowledgeable of the effects of these agents and the care of exposure victims.
Sidell 1997. Nerve Agents. In Medical Aspects of Chemical and Biological Warfare.
(Sidell FR, Takafuji ET, Franz DR Eds.) Chapter 5, Office of the Surgeon General, Dept.
of the Army, United States of America.
Available at http://www.bordeninstitute.army.mil/cwbw/Ch5.pdf
Sidell et al. 1997. Longterm Health Effects of Nerve Agents and Mustard. In Medical
Aspects of Chemical and Biological Warfare. (Sidell FR, Takafuji ET, Franz DR Eds.)
Chapter 8, Office of the Surgeon General, Dept. of the Army, United States of America.
Available at http://www.bordeninstitute.army.mil/cwbw/Ch8.pdf
Silveira et al. 1990. Putative M2 muscarinic receptors of rat heart have high affinity for
organophosphorus anticholinesterases. Toxicol Appl Pharmacol. 103(3):474-81.
The M2 subtype of muscarinic receptor is predominant in heart, and such receptors were
reported to be located in muscles as well as in presynaptic cholinergic and adrenergic
nerve terminals. Muscarinic receptors of rat heart were identified by the high affinity
binding of the agonist (+)-[3H]cis-methyldioxolane ([3H]CD), which has been used to
label a high affinity population of M2 receptors. A single population of sites (KD 2.74
nM; Bmax of 82 fmol/mg protein) was detected and [3H]CD binding was sensitive to the
M2 antagonist himbacine but much less so to pirenzepine, the M1 antagonist. These
cardiac receptors had different sensitivities to NiCl2 and N-ethylmaleimide from brain
muscarinic receptors, that were also labeled with [3H]CD and considered to be of the M2
subtype. Up to 70% of the [3H]CD-labeled cardiac receptors had high affinities for
several organophosphate (OP) anticholinesterases. [3H]CD binding was inhibited by the
nerve agents soman, VX, sarin, and tabun, with K0.5 values of 0.8, 2, 20, and 50 nM,
58
respectively. It was also inhibited by echothiophate and paraoxon with K0.5 values of
100 and 300 nM, respectively. The apparent competitive nature of inhibition of [3H]CD
binding by both sarin and paraoxon suggests that the OPs bind to the acetylcholine
binding site of the muscarinic receptor. Other OP insecticides had lower potencies,
inhibiting less than 50% of 5 nM [3H]CD binding by 1 microM of EPN, coumaphos,
dioxathion, dichlorvos, or chlorpyriphos. There was poor correlation between the
potencies of the OPs in reversibly inhibiting [3H]CD binding, and their anticholinesterase
activities and toxicities. Acetylcholinesterases are the primary targets for these OP
compounds because of the irreversible nature of their inhibition, which results in building
of acetylcholine concentrations that activate muscarinic and nicotinic receptors and
desensitize them, thereby inhibiting respiration. Nevertheless, the high affinities that
cardiac muscarinic receptors have for these toxicants point to their extra vulnerability. It
is suggested that the success of iv administration of the muscarinic receptor inhibitor
atropine in initial therapy of poisoning by OP anticholinesterases may be related in part to
the extra sensitivity of M2 receptors to certain OPs.
Singer et al. 1987. Cardiomyopathy in Soman and Sarin intoxicated rats. Toxicol Lett.
36(3):243-9.
Rats surviving various single dose of the organophosphorus anticholinesterase nerve
agents Soman and Sarin were examined by light microscopy at intervals up to 35 days
post-exposure. Brain lesions, identical to those that have been reported elsewhere were
present, as well as a previously unreported finding associated with Soman or Sarin
intoxication: half of all animals that had brain lesions also had areas of myocardial
degeneration and necrosis. Depending upon the point in time at which cardiac tissues
were examined, findings varied from areas of acute myolysis and necrosis to areas
undergoing resolution of damage. The finding of brain lesions in those animals having
cardiac lesions suggests a relationship between the convulsion induced neurologic and
cardiac lesions. These studies suggest that convulsive doses of chemical warfare agents
induce pathological changes in the cardiovascular system of laboratory animals.
Smart 1997. History of Chemical and Biological Warfare: An American Perspective. In
Medical Aspects of Chemical and Biological Warfare. Eds. Sidell FR, Takafuji ET, Franz
DR. 1997. Office of the Surgeon General, Dept. of the Army, United States of America.
Available at: http://www.bordeninstitute.army.mil/cwbw/default_index.htm.
Smith et al. 1930. The pharmacological action of certain phenol esters with special
reference to the etiology of so-called ginger paralysis. Public Health Rep. 45:250924.
Spencer et al. 2000. Sarin, Other Nerve Agents, and Their Antidotes. In Experimental
and Clinical Neurotoxicology 2nd Ed. (Spencer PS, Schaumburg HH, Eds.) Oxford
University Press, New York pp 1073-1093.
Spruit et al. 2000. Intravenous and inhalation toxicokinetics of sarin stereoisomers in
atropinized guinea pigs. Toxicol Appl Pharmacol. 169(3):249-54.
We report the first toxicokinetic studies of (+/-)-sarin. The toxicokinetics of the
stereoisomers of this nerve agent were studied in anesthetized, atropinized, and restrained
59
guinea pigs after intravenous bolus administration of a dose corresponding to 0.8 LD50
and after nose-only exposure to vapor concentrations yielding 0.4 and 0.8 LCt50 in an 8min exposure time. During exposure the respiratory minute volume and frequency were
monitored. Blood samples were taken for gas chromatographic analysis of the nerve
agent stereoisomers and for measurement of the activity of blood acetylcholinesterase
(AChE). In all experiments, the concentration of (+)-sarin was below the detection limit
(<5 pg/ml). The concentration-time profile of the toxic isomer, i.e., (-)-sarin, after an
intravenous bolus was adequately described with a two-exponential equation. (-)-Sarin is
distributed ca. 10-fold faster than C(-)P(-)-soman, whereas its elimination proceeds
almost 10-fold slower. During nose-only exposure to 0.4 and 0.8 LCt50 of (+/-)-sarin in 8
min, (-)-sarin appeared to be rapidly absorbed. The blood AChE activity decreased during
the exposure period to ca. 15 and 70% of control activity, respectively. There were no
effects on the respiratory parameters. A significant nonlinearity of the toxicokinetics with
dose was observed for the respiratory experiments.
Street et al. 1975. Alteration of induced cellular and humoral immune responses by
pesticides and chemicals of environmental concern: quantitative studies of
immunosuppression by DDT, aroclor 1254, carbaryl, carbofuran, and methylparathion.
Toxicol Appl Pharmacol. 32(3):587-602.
Dose-dependent, immunosuppressive effects of continued dietary treatment of rabbits
with DDT, Aroclor 1254, carbaryl, carbofuran, and methylparathion were studied. The
animals were given a diet containing graded amounts of chemicals for 4 wk and
challenged with sheep red blood cells and Freund's adjuvant. The testing followed for an
additional 4 wk while the animals were maintained on the same diets as before. The most
sensitive indication of immunosuppression was based on evaluation of lymphatic organs,
primarily those dependent on thymus-derived lymphocytes. The chemical treatments
resulted in a decreased count of plasma cells in popliteal lymph nodes (except with
carbaryl), reduction of germinal centers in the spleen, and increasing atrophy of thymus
cortex. These responses were generally scaled to increasing levels of the compounds
tested. Hemolysin and hemagglutinin titers were not significantly affected by any of the
chemical treatments nor were consistent trends observed. The antigen-induced increase in
serum gamma-globulin was consistently decreased with DDT, Aroclor, carbaryl, and
carbofuran treatments, but only carbaryl produced significant changes (at 10 days
postantigen). DDT groups showed significantly higher preantigen gamma-globulin values
which were less evident following antigen challenge. Skin sensitivity to tuberculin was
decreased (except with carbaryl) but generally only at high dosages of the test chemicals.
None of the compounds showed any effect on growth, food consumption, leucocyte
count, or on organ to body weight ratios for liver, kidney, spleen, and adrenal, except for
slight liver enlargement caused by Aroclor 1254.
Suziki et al. 1997. Eighteen cases exposed to sarin in Matsumoto, Japan. Intern Med.
36(7):466-70.
Forty-six patients who were exposed to sarin consulted our hospital because of darkness
of vision, and ocular pain, vomiting, dyspnea and headaches on June 27 and 28, 1994.
Eighteen patients were admitted and 4 of them were in the critical state. There were 6
features: 1) depression of plasma cholinesterase activity (17 of 18 patients, 94%), 2)
60
hypokalemia (4/18, 22%), 3) depression of triglyceride (12/18, 67%), 4) hypocapnia

(5/17, 29%), 5) partial pressure of oxygen (PaO2) <80 mmHg, or requirement of O2
inhalation (15/18, 83%), 6) white blood cells (WBC) >9,000 per mm3 (13/18, 72%).
Seventeen patients were discharged from hospital, but one patient is still suffering from
akinetic mutism after two years.
Tochigi et al. 2002. Serum cholesterol, uric acid and cholinesterase in victims of the
Tokyo subway sarin poisoning: a relation with post-traumatic stress disorder. Neurosci
Res. 44(3):267-72.
Cholesterol and uric acid, which might correlate with steroidogenesis and monoamine
functions, may change under emotionally stressful conditions and in mental disturbances.
Among anxiety disorders, an increase of serum cholesterol has been observed in panic
disorder. However, the issue has not been adequately investigated in other anxiety
disorders, including post-traumatic stress disorder (PTSD). The present study
investigated serum cholesterols, uric acid and cholinesterase in victims of the Tokyo
subway sarin poisoning, 1995, in a series of 5-year follow-ups. Cholinesterase was
studied, in relevance with serum lipid changes and symptoms of PTSD, and also in light
of a biological effect of sarin. Out of 34 victims, eight developed PTSD and two were
currently diagnosed with PTSD using the Clinician-Administered PTSD Scale (CAPS).
No significant relationship was observed between PTSD and serum cholesterols or uric
acid. Several factors including co-occurrence of other mental disturbances with PTSD, in
addition to the limited sample size, might have affected the result. In contrast, serum
cholinesterase level was significantly reduced in the victims with the development of
PTSD, compared with the matched controls (P<0.02, t-test). This might partly reflect a
long-term remnant effect of sarin intoxication, although an effect of the psychological
experience could not be totally excluded.
Trovero et al. 1998. Pharmacological profile of CEB-1957 and atropine toward brain
muscarinic receptors and comparative study of their efficacy against sarin poisoning.
Toxicol Appl Pharmacol. 150(2):321-7.
This study consists of two parts, first to compare the pharmacological profile of atropine
and CEB-1957 substance toward muscarinic receptor subtypes. In various rat brain
structures, binding properties were determined by competition experiments of
[3H]pirenzepine, [3H]AF-DX 384, and [3H]4-DAMP in quantitative autoradiography of
M1, M2, and M3 muscarinic receptor subtypes, respectively. Competition curves have
shown that atropine presents similar nanomolar inhibition constants toward each subtype,
while CEB-1957 has distinct affinities (Ki from 0.26 to 73 nM) with the following range
order: M3 > or = M2 > M1. The second part is to compare atropine and CEB-1957 (in
combination with pralidoxime) for their ability to protect against the lethality induced by
2 x LD50 of the acetylcholinesterase inhibitor sarin. CEB-1957 reduced the mortality at
doses 10 times lower than atropine. Finally, from these results, it is proposed that a
selective blockade of M2 and M3 receptor subtypes could play a pivotal role in the
protective effect against sarin poisoning.
Tuovinen 2004. Organophosphate-induced convulsions and prevention of
neuropathological damages. Toxicology. 196(1-2):31-9.
61
Such organophosphorus (OP) compounds as diisopropylfluorophosphate (DFP), sarin and

soman are potent inhibitors of acetylcholinesterases (AChEs) and butyrylcholinesterases
(BChEs). The acute toxicity of OPs is the result of their irreversible binding with AChEs
in the central nervous system (CNS), which elevates acetylcholine (ACh) levels. The
protective action of subcutaneously (SC) administered antidotes or their combinations in
DFP (2.0 mg/kg BW) intoxication was studied in 9-10-weeks-old Han-Wistar male rats.
The rats received AChE reactivator pralidoxime-2-chloride (2PAM) (30.0 mg/kg BW),
anticonvulsant diazepam (2.0 mg/kg BW), A(1)-adenosine receptor agonist N(6)cyclopentyl adenosine (CPA) (2.0 mg/kg BW), NMDA-receptor antagonist dizocilpine
maleate (+-MK801 hydrogen maleate) (2.0 mg/kg BW) or their combinations with
cholinolytic drug atropine sulfate (50.0 mg/kg BW) immediately or 30 min after the
single SC injection of DFP. The control rats received atropine sulfate, but also saline and
olive oil instead of other antidotes and DFP, respectively. All rats were terminated either
24 h or 3 weeks after the DFP injection. The rats treated with DFP-atropine showed
severe typical OP-induced toxicity signs. When CPA, diazepam or 2PAM was given
immediately after DFP-atropine, these treatments prevented, delayed or shortened the
occurrence of serious signs of poisoning. Atropine-MK801 did not offer any additional
protection against DFP toxicity. In conclusion, CPA, diazepam and 2PAM in
combination with atropine prevented the occurrence of serious signs of poisoning and
thus reduced the toxicity of DFP in rat
Tuovinen et al. 1999. Success of pyridostigmine, physostigmine, eptastigmine and
phosphotriesterase treatments in acute sarin intoxication. Toxicology. 134(2-3):169-78.
The acute toxicity of organophosphorus (OP) compounds in mammals is due to their
irreversible inhibition of acetylcholinesterase (AChE) in the nervous system, which leads
to increased synaptic acetylcholine levels. The protective actions of intravenously (i.v.)
administered pyridostigmine, physostigmine, eptastigmine, and an organophosphate
hydrolase, phosphotriesterase, in acute sarin intoxication were studied in mice. The acute
intragastric (i.g.) toxicity (LD50) of sarin with and without the pretreatments was tested
by the up-and-down method. The mice received pyridostigmine (0.06 mg/kg body
weight), physostigmine (0.09 mg/kg body weight), the physostigmine derivative
eptastigmine (0.90 mg/kg body weight) or phosphotriesterase (104 U/g, 10.7 microg/g
body weight) 10 min prior to the i.g. administration of sarin. Physostigmine was also
administered with phosphotriesterase. Phosphotriesterase was the most effective antidote
in sarin intoxication. The LD50 value for sarin increased 3.4-fold in mice receiving
phosphotriesterase. Physostigmine was the most effective carbamate in sarin exposure.
The protective ratios of physostigmine and pyridostigmine were 1.5- and 1.2-1.3-fold,
respectively. Eptastigmine did not give any protection against sarin toxicity. Both the
phosphotriesterase and physostigmine treatments protected the brain AChE activities
measured 24 h after sarin exposure. In phosphotriesterase and physostigmine-treated
mice, a 4- and 2-fold higher sarin dose, respectively, was needed to cause a 50%
inhibition of brain AChE activity. Moreover, the combination of phosphotriesterasephysostigmine increased the LD50 value for sarin 4.3-fold. The animals pretreated with
phosphotriesterase-ephysostigmine tolerated four times the lethal dose in control animals,
furthermore their survival time was 2-3 h in comparison to 20 min in controls. In
conclusion, phosphotriesterase and physostigmine were the most effective treatments
62
against sarin intoxication. However, eptastigmine did not provide any protection against
sarin toxicity.
WHO 2004. Chemical Terrorism in Japan: The Matsumoto and Tokyo Incidents. In
Health Aspects of Biological and Chemical Weapons, 2nd edition Available at
http://www.opcw.org/resp/html/japan.html
Wiener et al. 2004. Nerve Agents: A Comprehensive Review J Intensive Care Med.
19(1):22-37
Nerve agents are perhaps the most feared of potential agents of chemical attack. The
authors review the history, physical characteristics, pharmacology, clinical effects, and
treatment of these agents. Available at: http://jic.sagepub.com/cgi/framedreprint/19/1/22
Wilson et al. 2002. Actions of pyridostigmine and organophosphate agents on chick
cells, mice, and chickens. Drug Chem Toxicol. 25(2):131-9.
Gulf War veterans were given pyridostigmine bromide (PB) tablets to enhance the
therapeutic effect of antidotes to nerve agents in the event of exposure. The goal of this
research is to examine whether combined exposure to PB and sarin (agent GB) is more
neurotoxic to sensitive surrogate animals, mice and chickens, than if given separately.
Scoping trials were performed to establish appropriate dose-response ranges for sarin and
control chemicals. IC50 values were determined in chickens and mice for in vitro
inhibition of acetylcholinesterase (AChE) and neuropathy target esterase (NTE). The
results indicated PB neither inhibits NTE nor does it spare sarin's inhibition of AChE.
Chick embryo nerve cells in vitro showed more inhibition of AChE activity and no faster
recovery when PB treatment was followed by DFP treatment than the other way around.
Experiments on chickens also indicated that PB treatment did not inhibit NTE and that it
crossed the blood brain barrier inhibiting brain AChE although to a lesser extent than it
inhibited blood cholinesterases. Other experiments determined multiple dose levels in
chickens for sarin and DFP that inhibited > 80% of NTE, considered a threshold for
triggering organophosphate-induced delayed neuropathy.
Winkenwerder 2002a. Technical Report: Modeling and Risk Characterization
of US Demolition Operations at the Khamisiyah Pit. APPENDIX B Hazard
Identification (Detailed Description)-Tab BI Chemical properties. Department of Defense
Available at: http://www.gulflink.osd.mil/khamisiyah_tech/kham_tech_tabbi.htm appbTABBIChemicalPropertiesofSarinandCyc
Winkenwerder 2002b. Case Narrative: US Demolition Operations at Khamisiyah Final
Report. Available at http://www.gulflink.osd.mil/khamisiyah_iii/index.htm
Veterans Administration 2004. Project 112 and Project SHAD (Deseret Test Center)
Pocket Guide. Available at: http://www1.va.gov/shad/docs/RevisedProject112SHADPocketCardJan04.pdf

63
Yamasaki 1997. The Arg192 isoform of paraoxonase with low sarin-hydrolyzing

activity is dominant in the Japanese. Hum Genet. 101(1):67-8.
The high-density-lipoprotein-associated enzyme paraoxonase, which has a role in the
detoxification of organophosphorus compounds, is known to be polymorphic in humans.
The Arg192 isoform of paraoxonase hydrolyzes paraoxon more rapidly than the Gln192
isoform. However, with respect to the hydrolysis of toxic nerve agents, such as diazoxon,
soman, and sarin, the Arg192 isoform displays a lower activity than the other isoform. To
evaluate the possibility that the genetic polymorphism was involved in the aggravated
extent of human injury in the sarin gas poisoning incident in the Tokyo subway in March
1995, we investigated the prevalance of this polymorphism in the Japanese population.
We found that the Arg192 allele is more common in the Japanese (allele frequency: 0.66)
than in people of other races (ranging 0.24-0.31). In the Japanese, 135 out of the 326
subjects (41.4%) investigated were homozygous for the Arg192 allele, which shows a
very low hydrolysis activity for sarin. Thus, there seems to be a racial difference in
vulnerability to toxic nerve agents, such as sarin. The dominance of the Arg192 allele in
the Japanese population probably worsened the tragedy of March 1995 in the Tokyo
subway.
Yamasue et al. 2003. Voxel-based analysis of MRI reveals anterior cingulate graymatter volume reduction in posttraumatic stress disorder due to terrorism. Proc Natl Acad
Sci U S A. 100(15):9039-43.
MRI studies using the manual tracing method have shown a smaller-than-normal
hippocampal volume in patients with posttraumatic stress disorder (PTSD). However,
these studies have yielded inconsistent results, and brain structures other than the
hippocampus have not been well investigated. A recently developed, fully automated
method called voxel-based morphometry enables an exploration of structural changes
throughout the brain by applying statistical parametric mapping to high-resolution MRI.
Here we first used this technology in patients with PTSD. Participants were 9 victims of
the Tokyo subway sarin attack with PTSD and 16 matched victims of the same traumatic
event without PTSD. The voxel-based morphometry showed a significant gray-matter
volume reduction in the left anterior cingulate cortex (ACC) in trauma survivors with
PTSD compared with those without PTSD. The severity of the disorder was negatively
correlated with the gray-matter volume of the left ACC in PTSD subjects. There were no
significant differences in other gray-matter regions or any of the white-matter regions
between two groups. The present study demonstrates evidence for structural
abnormalities of ACC in patients with PTSD. Together with previous functional
neuroimaging studies showing a dysfunction of this region, the present findings provide
further support for the important role of ACC, which is pivotally involved in attention,
emotional regulation, and conditioned fear, in the pathology of PTSD.
Yanno et al. 1997. Neuroparalytic agent acute poisoning and its long-term effects.
Meditsina Truda I Promyshlennaya Ekologiya; 6:5-7.
The authors analyzed over 200 cases of acute poisoning with sarin, soman and VX
chemical, determined risk of the poisoning in various conditions. The clinical
manifestations of acute poisoning and the long-term effects are presented.
64
Yokoyama et al. 1998. Chronic neurobehavioral effects of Tokyo subway sarin

poisoning in relation to posttraumatic stress disorder. Arch Environ Health. 53(4):249-56.
Chronic neurobehavioral effects of acute sarin poisoning were evaluated in 9 male and 9
female patients who were exposed to sarin poisoning in the Tokyo subway incident in
Japan. The investigators used nine neurobehavioral tests, as well as a posttraumatic stress
disorder checklist, 6-8 mo after the poisoning occurred. Serum cholinesterase activity in
patients on the day of poisoning (i.e., March 20, 1995) ranged from 13 to 131 IU/l
(mean=72.1 IU/l). The results of analysis covariance, in which age, education level,
alcohol consumption, and smoking status (covariates) were controlled in 18 sarin cases
and in 18 controls, showed that the score on the digit symbol (psychomotor performance)
test was significantly lower in the sarin cases than in controls. Nonetheless, the scores for
the General Health Questionnaires, fatigue of Profile of Mood States, and posttraumatic
stress disorder checklist were significantly higher in the sarin cases than controls. The
investigators added posttraumatic stress disorder to the covariates, and only the score on
the digit symbol test was significantly lower in sarin cases. In addition, the results of
stepwise multiple regression analysis in 18 sarin cases revealed that scores for the
General Health Questionnaires, fatigue of Profile of Mood States (i.e., fatigue, tensionanxiety, depression, and anger-hostility)-together with the paired-associate learning testwere associated significantly with posttraumatic stress disorder. The association did not
remain significant for the digit symbol test score. Perhaps a chronic effect on
psychomotor performance was caused directly by acute sarin poisoning; on the other
hand, the effects on psychiatric symptoms (General Health Questionnaire) and fatigue
(Profile of Mood States) appeared to result from posttraumatic stress disorder induced by
exposure to sarin.
Zabrodskii et al. 2003. Anticholinesterase mechanism as a factor of immunotoxicity of
various chemical compounds. Bull Exp Biol Med. 136(2):176-8.
Experiments on Wistar rats showed that acute poisoning with chemicals in a dose of 0.75
LD(50) (dimethyl dichlorovinyl phosphate, sarin, VX substance, sulfur yperite, lewisite,
tetraethyl lead, dichloroethane) inhibiting platelet acetylcholine esterase, alpha-naphthylAS-acetate esterase, and alpha-naphthyl-butyrate esterase suppressed T cell-mediated
immune reactions.
Zacharias 2002. Depot studies. Utah incident. Tri-City Herald 8/18/2002.

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Contract No.

SARIN NERVE AGENT

Submitted to Dr. William Page, Program Officer, Advisory Panel for

This report is subject to the copyright and reproduction arrangements defined in

Principal Investigator: Victor Miller

Contract No. IOM-2794-04-001

SPECIAL NOTE ON PSYCHOGENIC SEQUELAE OF PERCEIVED

Contract No. IOM-2794-04-001

III. PATHOGENESIS & FORENSIC DIAGNOSTICS.... 14

IV. HEALTH EFFECTS..

VI. TREATMENT & PREVENTION

VII. SECONDARY SOURCE COMMENT..

VIII. BIBLIOGRAPHY WITH ABSTRACTS

Contract No. IOM-2794-04-001

Neuromuscular effects are common as acetylchloline is a primary neurotransmitter at the

Contract No. IOM-2794-04-001

II. BACKGROUND: CHEMISTRY & HISTORY

CAS Number: 107-44-8

Decomposition Temp. = 150 C

Contract No. IOM-2794-04-001

Contract No. IOM-2794-04-001

III. PATHOGENESIS & FORESNIC DIAGNOSTICS

reactivate butyrylcholinesterase and/or AChE and then quantitates by GC the arin

Contract No. IOM-2794-04-001

IV. HEALTH EFFECTS

Table derived from National Research Council (US) 1999.

Nervous System Effects

Contract No. IOM-2794-04-001

Contract No. IOM-2794-04-001

Contract No. IOM-2794-04-001

VI. TREATMENT & PREVENTION

Contract No. IOM-2794-04-001

VII. SECONDARY SOURCE COMMENT

Contract No. IOM-2794-04-001

VIII. BIBLIOGRAPHY WITH ABSTRACTS

methylphosphonofluoridate), sarin (isopropyl methylphosphonofluoridate, tabun (ethyl

Contract No. IOM-2794-04-001

Fernando et al. 1985. Variability of neurotoxicity of and lack of tolerance to the

intracellular calcium following TCR ligation. These concentrations of sarin altered

Zealand White (NZW) rabbits on d 6-19 of gestation at dose levels of 0, 5, 10, or 15

effect of Dimethyl 2,2-dichlorovinyl phosphate (DDVP), an OP on murine splenic NK,

*539T), and two nonsense mutations (BCHE*119STOP, *465STOP). All of the

stimulation of NMDA receptors is proposed as the ultimate cause of neuropathology. The

experimental exposure. In this study, the health effects of self-reported, nonexperimental

recombinant protein preferentially hydrolyzes lysolecithin, suggesting that this enzyme

studies showed fade on tetanic stimulation, absence of fade on low-frequency

hypokalemia (4/18, 22%), 3) depression of triglyceride (12/18, 67%), 4) hypocapnia

Such organophosphorus (OP) compounds as diisopropylfluorophosphate (DFP), sarin and

Contract No. IOM-2794-04-001

Yamasaki 1997. The Arg192 isoform of paraoxonase with low sarin-hydrolyzing

Yokoyama et al. 1998. Chronic neurobehavioral effects of Tokyo subway sarin

Contract No. IOM-2794-04-001

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539T), and two nonsense mutations (BCHE119STOP, *465STOP). All of the