Case 298: Skeletal Fluorosis Secondary to Huffing.

History A 37-year-old man from the United States presented with a 1-year history of neck pain and stiffness that had been unsuccessfully treated with manipulative therapy by a chiropractor at another institution. Past medical history was remarkable only for marijuana and air duster abuse. He denied use of any prescription medications. Physical examination was notable for markedly reduced range of motion of the cervical spine. Laboratory work-up revealed an elevated alkaline phosphatase level (302 U/L [5.0 µkat/L]; normal range, 40-100 U/L [0.7-1.67 µkat/L]), but all other laboratory findings, including complete blood count, renal function, liver function, vitamin A level, serum protein electrophoresis, and hepatitis C antibodies were within normal limits. Cervical spine radiography was performed, followed by MRI. Subsequently, a full skeletal survey was ordered. Included are representative radiographs of the pelvis, left forearm, and distal right leg with ankle.

Toxicity from fluoropolymer-containing grout, tile and stone floor sealants reported to the UK National Poisons Information Service 2009-2015.

CONTEXT: Grout, tile and floor stone sealants contain a solvent, a water-repelling agent and in the case of aerosols a propellant. The water-repelling agent used is typically a fluoropolymer resin, a silicon-based resin, or a combination of both. OBJECTIVE: To report the clinical course in patients exposed to fluoropolymer-containing sealants referred to the United Kingdom National Poisons Information Service. METHODS: A retrospective analysis was performed of telephone enquiries received between 2009 and 2015. RESULTS: 101 enquiries involving 96 exposures were received. The majority of the exposures (n = 88) occurred when the sealant was delivered from an aerosol. Twelve patients were exposed occupationally and the remainder were exposed while using the product at home. Eighty-nine exposures were as a result of inhalation alone, two followed ingestion, three skin contact and one eye contact; one involved inhalation and eye contact. All 90 patients exposed by inhalation developed clinical features: 31 had a World Health Organisation/International Programme on Chemical Safety/European Commission/European Association of Poison Centres and Clinical Toxicologists Poisoning Severity Score of 1 (minor toxicity), 51 patients had features of moderate toxicity (PSS 2) and eight were graded PSS 3 (severe poisoning). The most common features were dyspnea (n = 52; 57.8%; 95% CI = 47.0-68.5), chest pain/tightness (n = 34; 37.8%; 95% CI = 27.2-48.4), coughing (n = 27; 30.0%; 95% CI = 20.0-40.0) and sinus tachycardia (n = 11; 12.2%; 95% CI = 4.1-18.2); hypoxemia was present in 20 (22.2%; 95% CI = 13.1-31.4). At the time of the enquiry a chest X-ray had been performed on 15 patients: in eight patients (all of whom were PSS 3) the X-ray was reported as being abnormal and showed bilateral shadowing. CONCLUSIONS: This study demonstrates that if fluoropolymer-containing sealants are inhaled then clinical features may occur and in a small proportion (9%) these features may be severe.

Cardiomyopathy from 1,1-Difluoroethane Inhalation.

Consumer aerosol products can be inhaled for their psychoactive effects, but with attendant adverse health effects including "sudden sniffing death." Cardiomyopathy has rarely been described in association with 1,1-difluoroethane (DFE), a common aerosol propellant. We report a 33-year-old male who developed acute myocardial injury and global hypokinesis along with rhabdomyolysis, acute kidney injury, and fulminant hepatitis after 2 days' nearly continuous huffing. Workup for other causes, including underlying coronary artery disease, was negative. His cardiac function improved over time. The exact mechanism of DFE's effects is uncertain but may include catecholamine-induced cardiomyopathy, coronary vasospasm, or direct cellular toxicity.

Huffing-induced cardiomyopathy: a case report.

The intentional inhalation of fumes from gasoline or solvents for recreational purposes is commonly known as Huffing, Sniffing or Dusting (Anderson and Loomis in Am Fam Physician 68(5):869-874, 2003). Inhalant abuse is known to be "Cardio-toxic", causing sudden death and chronic myocardial damage (Meadows and Verghese in South Med J 89(5):455-462, 1996; Anderson and Loomis in Am Fam Physician 68(5):869-874, 2003). We report a 20-year-old white man who presented with altered mental status following ingestion of multiple alprazolam and oxycodone tablets. He was found to have diffused ST-T changes on his EKG. Cardiac enzymes were found to be elevated-CK: 599 U/L, CK-MB: 16.8 ng/mL and Troponin: 0.78 ng/mL. A transthoracic echocardiogram (TTE) revealed global left ventricular (LV) dysfunction with an ejection fraction (EF) of 10-15%. During hospitalization, the cardiac enzymes started trending downward and this was followed by spontaneous resolution of the LV dysfunction. The patient also admitted to inhaling "Dust-Off" spray 2-3 days prior to admission. Inhalant abuse can cause cardiomyopathy and should be considered a probable cause in patients presenting with cardiac dysfunction of unknown etiology, particularly in teenagers and young adults.

Vinyl chloride propellant in hair spray and angiosarcoma of the liver among hairdressers and barbers: case reports.

Two cases of angiosarcoma of the liver (ASL) are, to the best of our knowledge, the first literature reports of such cases identified among hairdressers and barbers who used hair sprays containing vinyl chloride (VC) as a propellant. The cases were exposed to VC aerosols between 1966 and 1973, for 4-5 year periods. Modeling indicates estimated peak levels of VC exposure ranging from 129 ppm to 1234 ppm, and average exposure ranging from 70 ppm to 1037 ppm, based upon assumptions of use and number of air exchanges per hour. As ASL is a sentinel cancer for exposure to VC, identification of these cases raises concern about the contribution of VC to hepatocellular carcinoma (HCC), a much more common type of liver cancer, as well as other VC-related cancers among hairdressers and barbers. Had manufacturers acted in a responsible manner, VC never would have been introduced as a propellant into consumer products such as hair sprays, pesticides, and paints.

Death due to fluorocarbon inhalation.

The abuse of inhalation of aerosol preparations containing fluorocarbons as the propellant is a potentially lethal act. I report a death believed due to inhalation of an aerosol propellant.

Toxicity of aerosol propellants in the respiratory and circulatory systems. VI. Influence of cardiac and pulmonary vascular lesions in the rat.

Three propellants were selected for investigation in rats because of their non-uniform effect in mice and monkeys. Trichlorofluoromethane (FC 11) provoked arrhythmia in all three animal species, dichlorodifluoromethane (FC 12) in monkeys and rats but not in mice, and difluoroethane (FC 152a) only in rats. In rats the alterations in heart rate and electrocardiographic pattern during inhalation of these propellants are largely brought about by release of catecholamines from the adrenal gland, because adrenalectomy or prior injection of beta-adrenergic blocking drugs decreased the incidence of cardiac effects. Rats that have pulmonary vascular thrombosis or cardiac necrosis become more sensitive to proarrhythmic activity of these propellants.