Mothball ingestion as a manifestation of pica, leading to paradichlorobenzene CNS toxicity.

BACKGROUND: Pica is a poorly understood psychiatric disorder that presents with the ingestion of non-nutritious substances for unclear reasons. A high index of suspicion for unusual toxin exposure aids in the diagnosis of pica patients presenting with unexplained neurodegenerative features. METHODS: We present a 47-year-old female with worsening gait over the past year. Prior to this, she was fully independent with activities of daily living, but is now mostly housebound due to frequent falls. Past medical history is significant for menorrhagia, iron deficiency anemia and pica. CBC and iron studies revealed iron deficiency with microcytic hypochromic anemia. MRI brain demonstrated symmetrical T2 hyperintensities within the middle cerebellar peduncles. RESULTS: Differential diagnoses for her clinical deficits and imaging, including Spinocerebellar Ataxia, Multiple System Atrophy and Fragile X Tremor-Ataxia Syndrome, were excluded based on neurological assessment, family history and genetic PCR testing. Collateral history revealed a regular habit of mothball ingestion and serum paradichlorobenzene levels were elevated to 15mcg/mL. The patient was treated with iron replacement therapy and her symptoms gradually improved over several months. CONCLUSION: Iron deficiency anemia is commonly associated with pica, which can lead to toxin ingestion. A high index of suspicion for toxin ingestion in pica patients can immensely aid in the diagnosis. Mothball abuse secondary to pica may affect the CNS and can present with nonspecific neurodegenerative changes. To our knowledge, there have been no reported cases in the literature with paradichlorobenzene neurotoxicity predominantly affecting the middle cerebellar peduncles.

An algorithm for identifying mothball composition.

INTRODUCTION: Unintentional mothball ingestions may cause serious toxicity in small children. Camphor, naphthalene, and paradichlorobenzene mothballs are difficult to distinguish without packaging. Symptoms and management differ based on the ingested compound. Previous studies have used a variety of antiquated, impractical and potentially dangerous techniques to identify the mothballs. The goal of this study is to discover a simplified identification technique using materials readily available in an emergency department. METHODS: Mothballs made of naphthalene and paradichlorobenzene along with camphor tablets were tested. Each material was tested both intact and after being fragmented to simulate a partially ingested mothball. Each of these six sample types were then immersed in 40 ml each of 11 fluids: water, 0.45% NaCl, 0.9% NaCl, lactated Ringer's, 5% dextrose in water, 5% dextrose in 0.9% NaCl, 50% dextrose in water, 8.4% NaHCO3, 3% H2O2, 70% isopropanol, and 91% isopropanol. All tests were conducted in standard urinalysis sample cups to replicate available materials. Three toxicologists blinded to the identities of samples and solutions visually evaluated each sample. Observations included assessing response to immersion: sink, float, or dissolve. RESULTS: All evaluators agreed in their description of 62/66 (94%) of the samples, with all four disagreements being on sinking and dissolving versus sinking only. A two-fluid algorithm utilizing 50% dextrose and water was sufficient to distinguish the sample types. Camphor will float in water while both paradichlorobenzene and naphthalene will sink. In 50% dextrose, both naphthalene and camphor will float while paradichlorobenzene will sink. CONCLUSION: Mothball materials can be distinguished by immersion in water and 50% dextrose. Limitations of this study include using camphor tablets as a substitute for mothballs given lack of availability.

Multiple sclerosis disease progression and paradichlorobenzene: a tale of mothballs and toilet cleaner.

IMPORTANCE: Environmental factors are thought to be critical in the initiation and perpetuation of multiple sclerosis disease activity. OBSERVATIONS: We describe the case of a woman in her late 30s with a diagnosis of relapsing-remitting multiple sclerosis, who continued to accumulate neurological disability despite long-term natalizumab treatment. The patient continued to have visual symptoms, left leg weakness, and gait instability. In addition, she subacutely developed an encephalopathy. Our investigations revealed that the patient had a long-standing history of chewing on toilet bowl deodorizing cakes. The main ingredient in this product is 99.9% paradichlorobenzene, which is also used in mothballs. CONCLUSIONS AND RELEVANCE: This case illustrates that environmental causes for neurological deterioration should be investigated in patients with multiple sclerosis who display a rapidly progressive disease course and in whom potent pharmacotherapies fail. One possible cause is the ingestion of paradichlorobenzene-containing mothballs and toilet cleaners.

Paradichlorobenzene (toxin)-induced leucoencephalopathy.

A 40-year-old woman with a history of polysubstance abuse, hypertension, depression and anxiety with panic attacks admitted to the emergency room at the request of her primary physician owing to progressive decline in her mental status associated with anorexia and generalised pruritic skin rashes. Initial outpatient workup and that during two previous hospital admissions including thyroid function and syphilis tests, urine toxicology screen and brain imaging studies were unremarkable. Repeat MRI of the brain during her third hospital admission showed diffuse periventricular and white matter disease. This prompted further questioning of family members which revealed chronic ingestion of mothballs and toilet cakes containing paradichlorobenzene in the patient leading to toxin-induced leucoencephalopathy consistent with her neurological symptoms of altered mental status, ataxic gait, cogwheel rigidity in the arms and characteristic skin rashes. Subsequently, a feeding tube was placed to address her worsening nutritional status and she was discharged home in a stable state.

Mothball induced encephalopathy presenting as depression: it's all in the history.

Case reports of mothball ingestion have shown that paradichlorobenzene, the organic compound found in mothballs, can induce multiple organ effects, including encephalopathy. Psychiatrists are often involved in these cases due to presumed depression. Diagnosis is frequently delayed and/or inaccurate due to the inability to obtain a full history. A delay in diagnosis may result in an inappropriate treatment plan. We present a case involving a woman who ingested mothballs due to Pica emphasizing the importance and challenges of getting a thorough history. Barriers include cultural differences, shame and obtaining collateral information.

Hemolytic anemia induced by ingestion of paradichlorobenzene mothballs.

Hemolytic anemia and methemoglobinemia are well-known adverse effects that follow ingestion of naphthalene mothballs. They are only rarely reported in association with ingestion of paradichlorobenzene mothballs. An asymptomatic boy presented to our pediatric emergency department after ingesting paradichlorobenzene mothballs. Three daysafter the ingestion, the boy returned with hemolysis and mild methemoglobinemia.

Pica with paradichlorobenzene mothball ingestion associated with toxic leukoencephalopathy.

This is a case report of central nervous system toxicity associated with paradichlorobenzene (PDCB) ingestion. The patient had ingested mothballs composed of 99.99% PDCB for a period of 7 months. She was admitted for depression and had no neurologic symptoms. Later she developed an acute cerebellar syndrome followed by stupor and coma. An extensive workup was negative except for decreasing levels of PDCB in her serum. Imaging revealed a diffuse leukoencephalopathy. Her clinical picture was attributed to PDCB toxicity.

Probabilistic ecological risk assessment of 1,2,4-trichlorobenzene at a former industrial contaminated site.

Measured concentrations of 1,2,4-trichlorobenzene (1,2,4-TCB) in soil and groundwater detected in an industrial contaminated site were used to test several probabilistic options for refining site-specific ecological risks assessment, ranging from comparison of single effects and exposure values through comparison of probabilistic distributions for exposure and effects to the use of distribution based quotients (DBQs) obtained through Monte Carlo simulations. The results of the deterministic approach, which suggest that risk exceeds a level of concern for soil organisms, were influenced mainly by the presence of hot spots reaching concentrations able to affect acutely a large proportion of species, while the large majority of the area presents 1,2,4-TCB concentrations below those reported as toxic. Ground-(pore)water concentrations were compared with aquatic ecotoxicity data in orderto obtain an estimation of the potential risk for aquifers and streams in the adjacent area as well as for soil-dwelling organisms exposed via pore water. In this case, the risk is distributed over a large proportion of the site, while the local risk of hot spots was low, showing that risk characterization based exclusively on soil concentrations might be insufficient.

[Elevation of serum creatine kinase and low serum aldolase in the patients with KANEMI YUSHOU].

We studied the rates of the patient with the elevation of serum creatine kinase using the routine medical checkup data from KANEMI YUSHOU patients between 1995 and 2001. We also studied the serum aldolase level and light microscopic observation of muscle tissue in rats during strenuous exercise given the polychlolinated biphenyls. Fifteen percent of the patients showed the elevation of serum creatine kinase. The patients with the elevation of serum creatine kinase also showed a higher concentration of polychlolinated biphenyls in their blood. 47.7% of the patients show low aldolase. There is no interrelation between the aldolase levels and PCBs or PCQs. There is also no interrelation between the serum levels of aldolase and creatine kinase. The rats given polycholorinated biphenyls showed a slight increase of necrotic fibers during strenuous exercise. Polycholorinated biphenyls may play some role for muscle necrosis. We could not clarify the significance of low serum aldolase in KANEMI YUSHOU.

Medical complications due to mothball abuse.

Inhalant abuse is a major public health problem that has been associated with numerous acute and chronic medical problems. Inhalants are defined as volatile organic substances and are found in common household and commercial products that are easily accessible, inexpensive, and legally obtained. We discuss a rare case of mothball abuse predominantly by inhalation. The patient had acute peripheral neuropathy and chronic renal failure, both of which were concluded to be casually related to mothball abuse. We briefly review the abuse potential and medical complications of naphthalene and paradichlorobenzene, the compounds in mothballs. Our case illustrates that common household products not usually identified as recreational drugs can be abused; furthermore, linking specific medical problems with particular inhalants can be difficult because of confounding variables.

Radiopacity of household deodorizers, air fresheners, and moth repellents.

Household deodorizers and moth repellents are common agents implicated in many childhood poisonings. Their ingredients usually include either paradichlorobenzene or naphthalene compressed into a solid ball or another shape, sometimes with added essential oils and fragrances. Because medically naphthalene is a more important toxin than paradichlorobenzene, with hematologic and nervous system effects, clinicians often seek to discern which product has been ingested. We discovered fortuitously that a mothball swallowed by a retarded adult was radiopaque, and so designed an in vitro experiment to study the radiopacity of a variety of household deodorizers and products. Of 10 products screened for radiopacity by two radiologists, those containing paradichlorobenzene were consistently strongly radiopaque; those containing naphthalene were radiolucent. A third alternative ingredient which is used in some toilet bowl deodorizers, cetrimonium bromide, was also radiopaque. Radiopacity of paradichlorobenzene or cetrimonium bromide-containing products did not dissipate with time. We speculate that the halogen within the chemical structure of these compounds accounts for their radiopacity. We conclude that paradichlorobenzene-containing commercial products can be distinguished clinically from those containing naphthalene by the performance of an abdominal radiograph.