This is a case report of massage practitioners exposed to bacterial endotoxins in a work environment from a seaweed massage.

Holm M, Johannesson S, Torén K, Dahlman-Höglund A. Acute effects after occupational endotoxin exposure at a spa. Scand J Work Environ Health. 2009;35(2):153–155.

Objectives Two spa workers reported symptoms such as fever, shivering, palpitation, arthralgia, and diarrhea after performing seaweed massages on clients at a spa center. This study was carried out to determine whether the symptoms were related to exposure to endotoxin.

Methods Personal and stationary air sampling for the measurement of airborne endotoxin was carried out at the spa during the preparation of a bath and the following seaweed massage. In addition, the impact of storage time on the concentration of endotoxin in the seaweed was investigated.

Results The measurements confirmed exposure to aerosolized endotoxin at the spa (11 ng/m²[sic] and 22 ng/m³). The endotoxin concentration in the stored seaweed increased as the storage time increased, from 360 ng/g seaweed for fresh seaweed to 33 100 ng/g seaweed for seaweed stored for >20 weeks.

Conclusions Organic dust toxic syndrome was diagnosed for two workers who performed seaweed massages at a spa center at which aerosolized endotoxin was measured. In order to minimize entotoxin exposure during massages, it is important to use fresh seaweed or seaweed kept well cooled for no more than 2–3 weeks.

Key terms algae; case report; Fucus serratus; measurement; seaweed; work-related disease.

Because of copyright, I can't reproduce the article here, but you can access the free fulltext article for yourself.

Since I can't analyze the article line-by-line, here's a summary review of what I consider the important take-home points.

Case 1, with additional background knowledge information:

• healthy 40-year-old man
• had worked about 2 years in spa when he went to doctor about these symptoms--no longer employed at spa
• after seaweed massages: complained of fever, arthralgia, shivering
  arthralgia (Ancient Greek αρθρος [arthros], "a joint, limb" + Ancient Greek ἄλγος [algos, “pain”]): pain in a joint, especially when not caused by arthritis (meaning, not inflammatory)
• symptoms started about 5 hours after massage, lasted 6-7 hours, then went away completely
• reports this has happened 15-20 times
• lungs normal, based on testing--ruled out allergies and fungal/mold lung infection (Aspergillus)
  Aspergillus mold on a tomato:
  
  Source: http://upload.wikimedia.org/wikipedia/commons/a/ad/Aspergillus_on_tomato.jpg accessed 2 August 2012
  
  Pulmonary aspergillosis ("the condition of Aspergillus mold infection in the lungs") seen under a microscope--notice the black dots and the rod-looking filaments in the lung tissue
  
  Source: http://upload.wikimedia.org/wikipedia/commons/c/cd/Pulmonary_aspergillosis.jpg accessed 2 August 2012
   
• diagnosed with suspected inhalation fever from endotoxins
  To understand what an endotoxin is, we first need to get on the same page about how the word "toxin" is used in biomedical science and practice. Wikipedia's information on the subject is a pretty good introduction to the issues involved:

Toxin: A toxin (from Ancient Greek: τοξικόν toxikon) is a poisonous substance produced within living cells or organisms; man-made substances created by artificial processes are thus excluded. The term was first used by organic chemist Ludwig Brieger (1849–1919)...Toxins can be small molecules, peptides, or proteins that are capable of causing disease on contact with or absorption by body tissues interacting with biological macromolecules such as enzymes or cellular receptors. Toxins vary greatly in their severity, ranging from usually minor and acute (as in a bee sting) to almost immediately deadly (as in botulinum toxin). (Wikipedia: "Toxin" accessed 2 August 2012)

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Poisonous substance: In the context of biology, poisons are substances that cause disturbances to organisms,[1] usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism. The fields of medicine (particularly veterinary) and zoology often distinguish a poison from a toxin, and from a venom. Toxins are poisons produced by some biological function in nature, and venoms are usually defined as toxins that are injected by a bite or sting to cause their effect, while other poisons are generally defined as substances absorbed through epithelial linings such as the skin or gut. (Wikipedia: "Poison" accessed 2 August 2012)

This definition is why lactic acid and similar metabolites are not toxins, despite the fact that the term is often misused by MTs in that way. Lactic acid does not cause damage on the molecular scale, nor does its buildup cause a chemical reaction.

So a toxin is a biologically-produced substance that causes harm to body tissues on contact by a chemical reaction on a molecular scale.

Here, we are talking about endotoxins, as opposed to exotoxins.

Exotoxin: An exotoxin is a toxin secreted by a microorganism, like bacteria, fungi, algae, and protozoa. An exotoxin can cause damage to the host by destroying cells or disrupting normal cellular metabolism. (Wikipedia: "Exotoxin" accessed 2 August 2012)

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Endotoxin: The term endotoxin was coined by Richard Friedrich Johannes Pfeiffer, who distinguished between exotoxin, which he classified as a toxin that is released by bacteria into the environment, and endotoxin, which he considered to be a toxin kept "within" the bacterial cell and to be released only after destruction of the bacterial cell wall. Today, the term 'endotoxin' is used synonymously with the term lipopolysaccharide, which is a major constituent of the outer cell membrane of Gram-negative bacteria. Larger amounts of endotoxins can be mobilized if Gram-negative bacteria are killed or destroyed by detergents. The term "endotoxin" came from the discovery that portions of Gram-negative bacteria themselves can cause toxicity, hence the name endotoxin. Studies of endotoxin over the next 50 years revealed that the effects of "endotoxin" are, in fact, due to lipopolysaccharide.

The key effects of endotoxins on vertebrates are mediated by their interaction with specific receptors on immune cells such as monocytes, macrophages, dendritic cells, and others. Upon challenge with endotoxin, these cells form a broad spectrum of immune mediators such as cytokines, nitric oxide, and eicosanoids. [1] (Wikipedia: "Endotoxin" accessed 2 August 2012)

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Lipopolysaccharide: a molecule with a lipid (fat) component and a saccharide (sugar) component. They are a very important component of the cell wall of Gram-negative bacteria.

Source: http://upload.wikimedia.org/wikipedia/commons/8/82/LPS_en.svg accessed 2 August 2012

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Gram-negative bacteria: Bacteria can be classified according to the biochemical properties of the cell wall that encloses the bacterial cell. Bacteria of one type, Gram-positive bacteria, have a cell wall structure that holds a purple stain, visible on a microscope slide, when dyed according to a particular cell-staining protocol. Gram-negative bacteria have a different cell wall structure that does not hold the stain from that dye, and so they do not appear purple. The same cell wall structure that does not hold the dye is also responsible for the endotoxins that Gram-negative bacteria release when the cell wall is broken, meaning that Gram-negative bacteria are often very strong pathogens (causes of disease).

In this photo, the small blue spheres (cocci) are a Gram-positive bacteria, so they stain purple. The long rods (bacilli) are a Gram-negative bacteria, so they do not hold the purple stain, and appear pink.

Source: "A Gram stain of mixed Staphylococcus aureus (Gram positive cocci) and Escherichia coli (Gram negative bacilli), the most common Gram stain reference bacteria" http://upload.wikimedia.org/wikipedia/commons/8/8f/Gram_stain_01.jpg accessed 2 August 2012

The first Gram-negative stain I ever did, Klebsiella pneumoniae, a Gram-negative rod, implicated in pneumonia and urinary tract infections. Stained 23 September 2009, Bellevue College, Bellevue, WA.

Case 2:

• 27-year-old woman, history of celiac disease [American spelling], otherwise healthy

Coeliac disease [British spelling]...is an autoimmune disorder of the small intestine that occurs in genetically predisposed people of all ages from middle infancy onward. Symptoms include chronic diarrhoea, failure to thrive (in children), and fatigue, but these may be absent, and symptoms in other organ systems have been described...Coeliac disease is caused by a reaction to gliadin, a prolamin (gluten protein) found in wheat, and similar proteins found in the crops of the tribe Triticeae (which includes other common grains such as barley and rye). Wikipedia: "Coeliac disease" accessed 2 August 2012

• had worked about 3 months at same spa as case 1 worked when she went to doctor about these symptoms--no longer employed at spa
• after seaweed massages: complained of 12-18-hour-long episodes of shivering, palpitation, fever, and diarrhea, that then went away completely
• diagnosed with suspected inhalation fever from endotoxins

• symptoms started about 5 hours after facial seaweed or algae massage treatment for clients

Seaweed is a loose colloquial term encompassing macroscopic, multicellular, benthic marine algae. The term includes some members of the red, brown and green algae. (Wikipedia: "Seaweed" accessed 2 August 2012)

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Algae are a very large and diverse group of simple, typically autotrophic [synthesizing their own food, instead of eating other living things] organisms, ranging from unicellular to multicellular forms, such as the giant kelps that grow to 65 meters in length. Most are photosynthetic like plants, and "simple" because their tissues are not organized into the many distinct organs found in land plants. The largest and most complex marine forms are called seaweeds. (Wikipedia: "Algae" accessed 2 August 2012)

Massagenerd has YouTube videos of how to perform a seaweed treatment--Spa Seaweed Treatment 1 of 2:

and Spa Seaweed Treatment 2 of 2

She makes what is, unfortunately, a very common mistake among MTs at the 30-second time-point. Where she says, "The seaweed mixture acts as a detoxification", that is simply factually wrong, and you should not believe that. It's a very common massage myth.

She also does something very, very right at the 17-second time-point, something that I was very happy to see: before actually applying the seaweed paste, she tested the temperature on a small spot with her client to make sure that it was not too hot.

You should always do that when applying any kind of heat therapy.

The maximum safe temperature for human skin is around 110 F, while the pain threshold is at about 105 F.

The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit (Source: http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf accessed 3 August 2012)

So tap water can actually be hot enough to burn the client's skin, and you should always check with the client to make sure the temperature of your heat therapy is safe and comfortable.

Based on the symptoms, test results, and apparent exposure to endotoxins, an investigation was carried out at the spa to detect whether employees were exposed to endotoxins present in the environment there.

At the spa, 1 kg of brown seaweed (Fucus serratus) was placed in a bathtub with water heated to 38°C. Clients were normally treated in the bathtub for about 30 minutes, including 10 minutes of massage. The storage time and handling procedure for the seaweed used on this occasion were not known.

Source: http://upload.wikimedia.org/wikipedia/commons/8/89/Fucus_serratus2.jpg accessed 2 August 2012

A sample was taken from the water prepared with seaweed, and it was sent to the laboratory for analysis. The sample was found to contain an endotoxin concentration of 800 ng/ml.

Later in the article, they point out that this number is 100 to 1000 times the amount acceptable to find in normal drinking water.

In another test at the same workplace,

The personal air sample contained an endotoxin concentration of 11 ng/m³, and that of the stationary sample was 22 ng/m³.

The investigators concluded that the turbid water,

caused by adding the seaweed to the bathwater, was forming an aerosol (a suspension of tiny particles in air), that was carrying the endotoxins into the workers' lungs.

Often the spa workers had several clients in succession, leading to extended exposure. However, there were no symptoms if exposure was avoided. Adding seaweed to the bath made the water somewhat turbid. It is likely that an aerosol was formed from small droplets or splashes being produced when the clients were massaged with the seaweed. It was concluded that the spa workers’ symptoms had probably been caused by the aerosolized endotoxin they were exposed to during the massage procedure.

They analyzed the seaweed to see if the amount of endotoxin increased as the seaweed was stored for longer times before being used.

Levels of endotoxin found in seaweed stored for longer times, measured in units of ng endotoxin/g seaweed

They found not only that it did increase with time, as expected, but also that gram-negative bacteria was present--that would account for the endotoxin, as we discussed previously about the lipopolysaccharides in the cell walls of Gram-negative bacteria as sources for endotoxins.

In conclusion, ODTS [organic dust toxic syndrome] was diagnosed for two staff members performing seaweed massages at a spa center at which aerosolized endotoxin was measured. Endotoxin was found in fresh seaweed, and the concentration increased markedly with an increase in the length of storage of the seaweed. In minimizing endotoxin exposure, it is important to use either fresh seaweed or seaweed kept well cooled for no more than 2–3 weeks in a refrigerator.

What do these case reports mean for your responsibilities toward your clients and your employees if you are a spa owner?

What do these case reports mean for your responsibilities toward your clients and your employer if you work as an employee or a contractor at a spa?

UPDATE, 3 August 2012, 10:34 AM PDT

Elsewhere, Robin Byler Thomas asked an excellent and profoundly client-centered question about this study:

What about the client's exposure?

A very important question.

What do we know about its answer from the article?

Were the clients exposed to endotoxins at all?

If they were exposed, were they affected by the exposure?

How did any potential client exposure compare to MT exposure?

What followup were the occupational health team able to take with the spa?

What changes in their procedures did the spa make in order to protect their clients and MTs from exposure to endotoxins?