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Whilst the acute effects of sulfur mustard have been relatively well characterised, the chronic effects of short term but significant exposures are still evolving. The approximately 30,000 Iranian victims of CW exposure from the 1980 to 1988 Iran-Iraq war who are currently being followed form a key population who are now 20 years post-exposure. The key chronic findings in this population reflect the common acute effects of sulfur mustard, and are related to the skin, eye and respiratory system. Excluding pruritus, skin changes appear to settle. Eye symptoms are slowly progressive, however a severe, rapid onset form of keratitis is seen to develop in a number of patients after a latent period of 15-20 years. The respiratory tract also shows progressive deterioration, with bronchiolitis obliterans now being considered the main pathological feature of "mustard lung". In addition, there are other potential effects of sulfur mustard exposure which become evident only in the longer term and which are being investigated, including the development of cancer, immunological and neuropsychiatric changes, and reproductive effects. Finally, a chronic effect of sulfur mustard exposure that is now becoming apparent is the wider long-term social and economic effects of these illnesses on individuals and their families.

Sulfur mustard (SM) is a strong vesicant agent which has been used in several military conflicts. Large stockpiles still exist to the present day. SM is believed to be a major threat to civilian populations because of the persistent asymmetric threat by non-state actors, such as terrorist groups, its easy synthesis and handling and the risk of theft from stockpiles. Following an asymptomatic interval of several hours, acute SM exposure produces subepidermal skin blisters, respiratory tract damage, eye lesions and bone marrow depression. Iranian victims of SM exposure during the Iran-Iraq (1984-1988) war were treated at intensive care units of 3 Munich hospitals. All 12 patients were injured following aerial attacks with SM filled bombs, which exploded in a distance between 5 and 30m. All patients soon noted an offensive smell of garlic, addle eggs or oil roasted vegetables. No individual protective equipment was used. Eye itching and skin blistering started 2h after SM exposure. Some patients complained of nausea, dizziness and hoarseness. 4h after exposure, most patients started vomiting. Eye symptoms worsened and most patients suffered from temporary blindness due to blepharospasm and lid oedema. Additionally, pulmonary symptoms such as productive cough occurred. Patients were transferred to Munich 4-17 days after SM exposure. On admission all patients showed significant skin blistering and pigmentation. Conjunctivitis and photophobia were the major eye symptoms. Pulmonary symptoms, including productive cough were persistent. Bronchoscopy revealed massive inflammation of the trachea with signs of necrosis. 3 patients needed tracheotomy. Chest X-ray did not yield abnormal observations. This presentation summarizes the experience of treating SM victims in Munich and discusses therapeutic implications.