Sudden death due to butane abuse - An overview.

Volatile Solvents Abuse (VSA) poses major health risks, especially for young people and those living in precarious socio-economic conditions. Such substances can in fact bring about psychoactive effects such as euphoria, and even lead to sudden death from cardiac arrhythmias, respiratory depression, myocardial infarction, laryngospasm, encephalopathy, and rhabdomyolysis. The present case report is centered around a 23-year-old man who died in prison due to inhalation of a cooker gas mixture (n-butane, propane, and isobutane) inside a plastic bag. External examination and autopsy showed non-specific signs of asphyxia associated with edema and brain swelling. Histological signs of early myocardial damage and hypoxic-ischemic injury (HII) were highlighted in the brain and cerebellum, as well as activated macrophages and anthracotic-like material in the lungs. Toxicological investigations revealed the presence of propane, isobutane and n-butane in liquids and biological samples. Besides the cardiotoxic effect, there was an asphyctic component due to the plastic bag that may have facilitated death. The assessment of cerebral HII and cardiopulmonary damage in acute cases is very important to prove death by butane inhalation. In the forensic field, it may be useful to shed more light on intoxications, deaths, and butane encephalopathies, as the latter can be mistaken for a hypoxic-ischemic encephalopathy.

Nitrous Oxide Inhalant Abuse: Preliminary Results from a Cross-Sectional Study on Knowledge, Attitudes, and Practices of Italian Physicians (2023).

Background and Objectives: Nitrous oxide (N2O) has recently emerged as a cheap alternative to other recreational substances. Although legally available, its chronic use is associated with severe neurological and hematological complications due to the irreversible inactivation of vitamin B12. While no reliable data on abuse of N2O in Italy have been provided to date, we assessed the knowledge, attitudes, and practices of Italian medical professionals on the management of N2O abuse cases. Materials and Methods: A cross-sectional study was performed as a web-based survey through a series of Facebook discussion groups (targeted medical professionals: 12,103), and participants were specifically asked about their previous understanding of N2O abuse and whether they had or not any previous experience in this topic. Results: A total 396 medical professionals participated in the survey. Overall, 115 participants had previous knowledge about N2O abuse (29.04%), with higher odds for professionals with a background in emergency medicine (adjusted odds ratio (aOR) 3.075; 95% confidence intervals (95%CI) 1.071 to 8.828) and lower for specialists in psychiatry (aOR 0.328; 95%CI 0.130 to 0.825). Knowledge status on N2O abuse was largely unsatisfying, as knowledge status, reported as a percent value, was estimated to 45.33% ± 24.71. Having previously managed a case of N2O abuse was associated with higher risk perception of the actual severity of this condition (aOR 5.070; 95%CI 1.520 to 16.980). Conclusions: Our study suggests that N2O poisoning cases are occurring in Italian settings but are not reasonably reported to national authorities. As substantial knowledge gaps of Italian medical workforces were identified, we cannot rule out that the actual abuse of N2O in the population may be far larger than currently suspected.

The Clinical Assessment and Treatment of Inhalant Abuse.

Although inhalant abuse is common, it is one of the most neglected and overlooked forms of substance abuse. Inhalants refer to a wide variety of substances including volatile solvents, aerosols, gases, and nitrites. The mechanism of action of inhalants has not been fully defined. Several molecular targets contribute to the pharmacology, including ion-channel proteins that control neuronal excitability. These agents interact with various receptors and can cause changes in cell-membrane fluidity and nerve-membrane ion channels. Three main pharmacologic categories of inhalants, namely, volatile solvents and anesthetic gases, nitrous oxide, and volatile alkyl nitrites, have distinct pharmacologies, mechanisms of action, and toxicities. Inhalants are linked to multisystem damage affecting the pulmonary, cardiac, dermatologic, renal, hematologic, gastrointestinal, hepatic, and neurologic systems. Chronic inhalant abuse can also cause psychiatric, cognitive, behavioral, and anatomical deficits in humans, leading to reduced productivity and quality of life. Inhalant abuse during pregnancy is associated with fetal abnormalities. Clinical assessment for inhalant abuse should be done systematically. After decontamination and stabilization of the patient, further history and physical examination is necessary to establish an appropriate diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Laboratory testing for inhalant abuse is very limited, and imaging studies may be helpful in certain situations. The treatment of inhalant use disorder is similar to that of other substance abuse disorders and includes supportive care, pharmacotherapy, and behavioral therapy. Preventive measures are essential.

Inhalant Abuse of Ethyl Chloride Spray: A Case Report.

Ethyl chloride spray, which is usually used to relieve pain after injuries, is increasingly being used as a sniffing alternative. The number of people using this is rising due to its easy availability, cost-effectiveness and legality. The high lipid solubility of ethyl chloride leads to a rapid absorption of it in the lungs. However, data on the biotransformation of ethyl chloride in humans are sparse. We present the case of a 53-year-old male who had been inhaling ethyl chloride up to 3 times a week since 25 years, and describe his symptoms and the circumstances of abuse. This should help raise awareness of this issue so that abuse can be recognized early and rapid action taken.

Toluene-induced leukodystrophy from glue sniffing.

A 33-year-old man with a history of chronic toluene abuse through glue sniffing, developed tremors, cerebellar signs and cognitive decline. MR scan of the brain showed global cerebral and cerebellar atrophy with symmetrical T2-weighted hypointensities in the basal ganglia, thalami and midbrain. After stopping glue sniffing, his tremors, ataxia of gait, speech and cognition partially improved. Early recognition and intervention of toluene-induced leukodystrophy could prevent ongoing morbidity and premature mortality.

Nitrous oxide inhalant abuse and massive pulmonary embolism in COVID-19.

A patient presented to the emergency department with altered mental status and lower extremity weakness in the setting of nitrous oxide inhalant abuse and Coronavirus Disease-2019 (COVID-19) infection. He subsequently developed hypotension and severe hypoxia, found to have a saddle pulmonary embolus (PE) with right heart strain requiring alteplase (tPA).

Adrenoleukodystrophy presenting as glue sniffing.

Adrenoleukodystrophy classically presents in childhood with bronze skin, spastic tetraparesis, dysphagia, behavioural abnormalities and adrenal insufficiency. However, atypical presentations are known. Here we report an adolescent with adrenoleukodystrophy who first sought medical attention for glue sniffing.

Pernicious azotaemia? A case series of subacute combined degeneration of the cord secondary to nitrous oxide abuse.

Nitrous oxide abuse is a rare cause of vitamin B12 deficiency and consequent subacute combined degeneration of the spinal cord. Worldwide and Australian statistics indicate that recreational use of nitrous oxide is increasing. We report four cases of females aged 18-24 years presenting with clinical symptoms of subacute combined degeneration of the spinal cord. MRI during admission demonstrated the classic findings of T2 hyperintensity, predominantly within the dorsal columns of the spinal cord, with variable involvement of the lateral corticospinal tracts. These cases highlight the ready availability of nitrous oxide and the fact that heavy prolonged recreational use is occurring in the community. It is important that clinicians in emergency and community settings are alerted to this unusual cause of subacute combined degeneration of the spinal cord because early aggressive vitamin B12 replacement together with behavioural change can reverse this disabling neurological syndrome.

The effect of adolescent inhalant abuse on energy balance and growth.

The abuse of volatile solvents such as toluene is a significant public health concern, predominantly affecting adolescents. To date, inhalant abuse research has primarily focused on the central nervous system; however, inhalants also exert effects on other organ systems and processes, including metabolic function and energy balance. Adolescent inhalant abuse is characterized by a negative energy balance phenotype, with the peak period of abuse overlapping with the adolescent growth spurt. There are multiple components within the central and peripheral regulation of energy balance that may be affected by adolescent inhalant abuse, such as impaired metabolic signaling, decreased food intake, altered dietary preferences, disrupted glucose tolerance and insulin release, reduced adiposity and skeletal density, and adrenal hypertrophy. These effects may persist into abstinence and adulthood, and the long-term consequences of inhalant-induced metabolic dysfunction are currently unknown. The signs and symptoms resulting from chronic adolescent inhalant abuse may result in a propensity for the development of adult-onset metabolic disorders such as type 2 diabetes, however, further research investigating the long-term effects of inhalant abuse upon energy balance and metabolism are needed. This review addresses several aspects of the short- and long-term effects of inhalant abuse relating to energy and metabolic processes, including energy balance, intake and expenditure; dietary preferences and glycemic control; and the dysfunction of metabolic homeostasis through altered adipose tissue, bone, and hypothalamic-pituitary-adrenal axis function.

Postmortem Diagnosis of Myocardial Infarction Due to Butane Gas Intoxication in a Child: A Case Report.

Volatile substance addiction and toxic gas inhalation are now an important health problem. The pleasure-based inhalation of butane gas, also known as lighter refill gas, is especially prevalent among children and young people. The most important reasons for this situation are that they are cheap and easy to obtain and lack of legal supervision. The exhaled gas is absorbed through the alveolar surface and rapidly enters the bloodstream and leads to clinical signs. It can cause dizziness, nausea, vomiting, confusion, hallucinations, and euphoria in the acute phase. In severe cases, bronchospasm, hypoxia, ventricular arrhythmia, cardiopulmonary arrest, and death can occur. Our case is one of the rare cases in the literature that was diagnosed by postmortem histopathological examination. Our case is a 15-year-old girl who was found in front of a tobacco product store. On gross examination, there was a hemorrhagic area under the aortic valve that continued to interventricular septum. There was no coronary artery lesion. Histopathological examination revealed hypereosinophilia and contraction band necrosis in myocardial fibers, which was more intense in papillary muscle. Immunohistochemical studies also supported early myocardial ischemic changes. Upon toxicological examination, butane gas was detected in lung and blood samples.

Multi-Organ System Injury from Inhalant Abuse.

We present an illustrative case of a 24-year old male who developed cardiovascular and multi-organ system toxicity after inhaling a keyboard dust cleaner containing a halogenated hydrocarbon. In the field, the patient demonstrated neurotoxic effects in addition to electrocardiographic changes concerning for toxic myocarditis. We discuss the types of hydrocarbons, methods of abuse, and toxic effects of their inhalation including "sudden sniffing death" from myocardial sensitization.

Growth changes after inhalant abuse and toluene exposure: A systematic review and meta-analysis of human and animal studies.

Inhalant abuse is a significant public health issue, particularly for adolescents, the predominant group of inhalant users. Adolescence is a critical growth period, and inhalant abuse has been associated with growth impairments, including reduced body weight and height. However, the extent to which inhalant abuse affects growth remains unquantified, and potential moderators remain unknown. To address this knowledge gap, a systematic review and meta-analysis of clinical human and preclinical animal studies utilizing toluene exposure (the primary solvent in abused products) was conducted. Five-hundred and sixty-nine studies were screened; 31 met inclusion criteria, yielding 64 toluene-control comparisons for body weight and 6 comparisons for height. Toluene exposure was negatively associated with body weight ( d = -0.73) and height ( d = -0.69). Concentration of inhaled toluene, but not duration, moderated the effect of toluene exposure on body weight, with more severe impairments at higher concentrations. Differences in effect size for body weight were observed for study characteristic subgroups including sex, age at first exposure, administration route and species. However, these findings should be interpreted cautiously due to low study numbers. Growth impairments, particularly during adolescence, can cause long-term health consequences. These effects on growth are therefore an important clinical outcome for individuals with a history of inhalant abuse.

Cardiac arrest by inhalation of deodorant spray.

Drug abuse by inhalation of volatile household product substances is uncommon, however, it can have devastating consequences. This case report describes the fatal outcome of deodorant inhalation by a 19-year-old patient in a detoxification clinic who developed a cardiac arrest after inhaling butane from a deodorant spray. Despite initial successful resuscitation, he developed a postanoxic encephalopathy with a status epilepticus resistant to extensive treatment. Inhalant abuse can be a cause of death in young patients.

A `glue sniffer` teenager with anuric renal failure and hepatitis.

Yurtseven A, Türksoylu M, Yazici P, Karapinar B, Saz EU. A `glue sniffer` teenager with anuric renal failure and hepatitis. Turk J Pediatr 2018; 60: 206-209. `Inhalant abuse` is a common form of volatile drug abuse throughout the world especially in developing countries. This substance mainly contains toluene. Acute toluene inhalation produces a biphasic response with an initial central nervous system (CNS) excitation followed by CNS depression as well as various metabolic alterations. Chronic inhalational abuse is associated with muscular weakness, gastrointestinal symptoms, renal and hepatic injury. In this report, a 16-year-old boy presented with jaundice, nausea, vomiting and reduced urine output. He developed severe acute renal/hepatic damage due to abuse of gas products. Since toluene is the main toxic agent involved in glue sniffing which is metabolized to hippuric acid, the present case was treated with continuous hemodiafiltration, plasma exchange and conservative therapy to eliminate hippuric acid. The jaundice gradually disappeared, he had complete recovery of renal/hepatic functions in ten days. We aimed to increase the awareness among emergency physicians that ``glue sniffing` should be considered in the differential diagnosis of unexplained reversible acute renal/hepatic damage.