The Expanding Spectrum of Fuel Toxicity: A Migration‐Related Toxic Syndrome

We thank Pititto et al. for their commentary, which places our observation within a broader and interesting perspective [1]. Their reading of our series is scientifically productive, since they contextualize the cholestatic phenotype we described as a new organ‐specific manifestation of a migration‐related toxic syndrome that has been revealing its full dimensions through the work of multiple groups over the past few years.

We fully agree with their central argument. The coexistence of conjugated hyperbilirubinemia and methemoglobinemia in patients with confined‐space exposure during Mediterranean crossings is difficult to reconcile with ordinary gasoline intoxication alone [2]. Our report was conceived as an early safety alert, not a definitive characterization of the underlying toxic agent, and they are right to call for a multidisciplinary research agenda.

Their own prior work is particularly instructive: Pulin et al. demonstrated that two migrant deaths initially attributed to drowning were in fact due to fatal acute hydrocarbon intoxication with pulmonary edema and cardiorespiratory arrest, a finding that underscores how systematically misattributed these toxic injuries can be when evaluated outside a framework that explicitly considers fuel exposure [3].

That framework is now being built piece by piece and our cases add an important brick. If the same class of compounds capable of causing cutaneous chemical burns, methemoglobinemia and fatal respiratory toxicity can also produce acute cholestatic hepatitis, then the liver should be regarded as a possible target organ in every patient presenting after exposure at sea. This has some triage implications: bilirubin fractionation, liver function testing and methemoglobin measurement should arguably be part of a standardized reception protocol, alongside the cutaneous and respiratory assessments that are already more routinely performed. The family cluster we described, two asymptomatic children and two critically ill parents sharing an identical exposure environment, reinforces the notion of age‐dependent susceptibility, given that children and women are disproportionately confined to the lower holds of overcrowded vessels where fuel and seawater accumulate.

The convergence of our observations with those of Pititto et al. and collaborators suggests that migration‐related hydrocarbon and fuel toxicity is neither a rare event nor a single‐organ disease. It is a heterogeneous, multisystemic syndrome whose full extent has yet to be mapped, and a possible new fuel composition to be studied. We hope that our report, read alongside their commentary, will encourage coordinated prospective surveillance across reception centers, forensic pathology units, and humanitarian organizations operating along Mediterranean routes.

Author Contributions

Antonio Corsello: conceptualization, methodology, writing – original draft, writing – review and editing. Simone Maria Calogero Gramaglia: visualization, validation, formal analysis, supervision. Giuseppe Gramaglia: validation, investigation. Gerlando Verruso: visualization, data curation. Giusy Ranucci: validation, project administration, conceptualization, methodology.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Linked Articles

This article is linked to Corsello et al. papers. To view this articles, visit https://doi.org/10.1111/apa.70550 and https://doi.org/10.1111/apa.70575.

Data Availability Statement

Available upon reasonable request.