FIGURE 132.8 A patient with mustard-induced skin blisters (Reprinted with permission from Greenberg MI Greenberg’s Text-Atlas of Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2005:968.) Vapor exposure results in later, and usually milder, skin injury Ocular lesions from vapor include conjunctival inflammation and corneal damage Permanent blindness is a rare complication, but many patients presenting for treatment may be functionally blind from pain and blepharospasm Vapor-induced pulmonary effects begin, typically after a delay of to several hours, with upper respiratory tract irritation and may progress through dyspnea and a productive cough to a severe necrotizing tracheobronchitis with pseudomembrane formation Patients may succumb to secondary bacterial bronchopneumonia Bone marrow damage may occur in severe cases on about the third to fifth day after exposure and manifest as progressive pancytopenia Leukocyte counts less than 500/mm3 or precipitous decreases in the leukocyte count portend a serious risk of sepsis and death Experience with children exposed to vesicants is limited An accident involving the explosion of a mustard-containing shell caused a heavy exposure to three children These patients presented acutely with altered mental status, and two of them died to hours after exposure A case series of Iranian children and adolescents exposed to mustard during the Iraq–Iran War found that they exhibited a shorter onset and more severe dermal lesions compared with adults