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Naphthalene Poisoning

Naphthalene poisoning occurs primarily as a result of accidental mothball ingestion, causing symptoms such as nausea, vomiting, hematuria and severe respiratory, neurologic and hepatic effects. Patient history is vital during workup, while detection of methemoglobinemia and cyanosis requires prompt therapy consisting of methylene blue and exchange transfusion.


Presentation

The clinical presentation of naphthalene poisoning primarily includes gastrointestinal complaints such as nausea, vomiting, diarrhea and abdominal pain, but other systems are affected as well [2]. Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning [3].

Anemia
  • Two cases of naphthalene hemolytic anemia in the newborn period are reported. 2. Both exhibited glutathione instability upon incubation with acetyl phenylhydrazine and naphthol months to years later.[bloodjournal.org]
  • Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning.[symptoma.com]
  • The most severe symptoms include convulsions, unconsciousness and, after prolonged exposure, a destruction of red blood cells, anemia and dark or blood-infused urine.[sciencing.com]
  • Keywords: 1, 4 dichlorobenzene, anemia, hemolysis, mothballs, naphthalene How to cite this article: Aliyu I, Ibrahim ZF. Haemolytic anemia and mothball toxicity: A case report.[imjsu.org]
  • Hemolytic anemia in disorders of red cell metabolism. New York: Plenum Medical, 1978 2. Shannon K, Buchanan GR. . Severe hemolytic anemia in black children with glucose-6-phosphate dehydrogenase deficiency . Pediatrics 1982 ;70: 364 9 3.[nejm.org]
Fever
  • Case Report A 22 years old male was hospitalized with acute abdominal pain, vomiting, diarrhoea, high grade fever and mental confusion.[jpma.org.pk]
  • These include headaches, confusion, drowsiness, jaundice, fever, low blood pressure or a racing heart rate. The poison can also hit your digestive tract and cause vomiting, diarrhea and abdominal pain.[sciencing.com]
  • They can include: Abdominal pain Nausea and vomiting Diarrhea The person may also have a fever.[medlineplus.gov]
  • The signs and symptoms of Naphthalene Poisoning may include: Fever Urination difficulties (decreased urine flow, pain during urination) Blood in urine (hematuria) Breathing difficulties Rapid pulse and increased heart-rate Decreased blood pressure (hypotension[dovemed.com]
  • . #396854 samomcos - 03/27/09 21:24 A 3 year old boy develops abdominal pain, and the next day fever, pain on urinating and brown-red urine, and is taken to the ER.[usmleforum.com]
Internal Bleeding
  • They get in a car crash and Keith's case is taken up by the team because he has had internal bleeding for three weeks. He displays all four stages of Lupus, expect in the span of a week.[housediseases.com]
Vomiting
  • The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status.[symptoma.com]
  • We are reporting a case of a 22 year old male, with known psychiatric illness presenting to the hospital emergency room with history of vomiting and red colored urine after alleged consumption of mothballs (Naphthalene).[eprints.manipal.edu]
  • They can include: Abdominal pain Nausea and vomiting Diarrhea The person may also have a fever.[medlineplus.gov]
  • Induced vomiting may help removing moth balls from the stomach 10 .[jpma.org.pk]
  • The poison can also hit your digestive tract and cause vomiting, diarrhea and abdominal pain.[sciencing.com]
Nausea
  • Naphthalene poisoning occurs primarily as a result of accidental mothball ingestion, causing symptoms such as nausea, vomiting, hematuria and severe respiratory, neurologic and hepatic effects.[symptoma.com]
  • They can include: Abdominal pain Nausea and vomiting Diarrhea The person may also have a fever.[medlineplus.gov]
  • […] difficulties (decreased urine flow, pain during urination) Blood in urine (hematuria) Breathing difficulties Rapid pulse and increased heart-rate Decreased blood pressure (hypotension) Stomach symptoms may be observed after a few days and may include: Nausea[dovemed.com]
  • During first 24 hours of ingestion nausea and vomiting of varying intensity arc noted. On the second day. fever appears which lasts for several days. Pallor, prostation, haemolysis, jaundice and haemoglobinuria appear on third day.[jpma.org.pk]
  • Nausea and Vomiting An upset stomach and vomiting can both be symptoms of moth ball inhalation. If the nausea does not pass or the vomiting persists, seek medical attention.[healthfully.com]
Diarrhea
  • The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status.[symptoma.com]
  • The poison can also hit your digestive tract and cause vomiting, diarrhea and abdominal pain.[sciencing.com]
  • They can include: Abdominal pain Nausea and vomiting Diarrhea The person may also have a fever.[medlineplus.gov]
  • […] decreased urine flow, pain during urination) Blood in urine (hematuria) Breathing difficulties Rapid pulse and increased heart-rate Decreased blood pressure (hypotension) Stomach symptoms may be observed after a few days and may include: Nausea, vomiting Diarrhea[dovemed.com]
  • Diarrhea Diarrhea can indicate naphthalene poisoning. Do not ignore this symptom in young children, because it can lead to severe dehydration. Anemia Over time, long-term exposure to naphthalene can lead to an anemia.[healthfully.com]
Jaundice
  • Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning.[symptoma.com]
  • These include headaches, confusion, drowsiness, jaundice, fever, low blood pressure or a racing heart rate. The poison can also hit your digestive tract and cause vomiting, diarrhea and abdominal pain.[sciencing.com]
  • He was anaernic, jaundiced and dehydrated. Liver was palpable 2 cm below the costa! margin and tender. Chest auscultation revealed bilateral basal crepitations. Occular fundi were normal.[jpma.org.pk]
  • […] symptoms also may occur: Coma Confusion Convulsions Drowsiness Headache Increased heart rate ( tachycardia ) Low blood pressure Low urine output (may stop completely) Pain when urinating (may be blood in the urine) Shortness of breath Yellowing of skin (jaundice[medlineplus.gov]
  • Some people develop a fever and the symptoms get worse over time, which may include: Headache Convulsions Low blood pressure Jaundice Confusion Shortness of breath Urinary problems Tachycardia or increased heart rate Unfortunately, some people end up[magicofhealth365.com]
Hepatomegaly
  • Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning.[symptoma.com]
Headache
  • The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status.[symptoma.com]
  • These include headaches, confusion, drowsiness, jaundice, fever, low blood pressure or a racing heart rate. The poison can also hit your digestive tract and cause vomiting, diarrhea and abdominal pain.[sciencing.com]
  • Over time, the following symptoms also may occur: Coma Confusion Convulsions Drowsiness Headache Increased heart rate ( tachycardia ) Low blood pressure Low urine output (may stop completely) Pain when urinating (may be blood in the urine) Shortness of[medlineplus.gov]
  • Symptoms Paralysis , difficulty in coordination and speech, seizures, headaches, bleeding from hemorrhages , heart failure, and other problems depending on the location of the AVM.[housediseases.com]
  • Some people develop a fever and the symptoms get worse over time, which may include: Headache Convulsions Low blood pressure Jaundice Confusion Shortness of breath Urinary problems Tachycardia or increased heart rate Unfortunately, some people end up[magicofhealth365.com]
Dark Urine
  • They can develop diarrhea, vomiting, lethargy, lack of appetite, fever, abdominal pain and painful urination and dark urine. Pets that eat mothballs can develop lethargy, vomiting, diarrhea, lack of appetite and tremors.[healthycanadians.gc.ca]
  • Urinary bladder irritation may cause urgency, dysuria, and the passage of dark urine with or without cast and albumin.[jahjournal.org]
  • He had dark urine, which was positive for hemoglobin while urine microscopy was negative for red blood cells suggesting hemoglobinuria.[imjsu.org]
Hematuria
  • Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning.[symptoma.com]
  • The signs and symptoms of Naphthalene Poisoning may include: Fever Urination difficulties (decreased urine flow, pain during urination) Blood in urine (hematuria) Breathing difficulties Rapid pulse and increased heart-rate Decreased blood pressure (hypotension[dovemed.com]
Dysuria
  • Urinary bladder irritation may cause urgency, dysuria, and the passage of dark urine with or without cast and albumin.[jahjournal.org]

Workup

A carefully obtained patient history is vital during workup, as key information regarding the source of symptoms and the mode of poisoning can be obtained. Assessment of hepatic and renal function, urinalysis, and arterial blood gasses are necessary for determining the state of tissue oxygenation and the degree of organ damage.

Heinz Bodies
  • Heinz bodies appear before haemolytic process becomes evident and hence has a prognostic valve for development of haemolysis 10 . There is no specific treatment for naphthalene poisoning.[jpma.org.pk]
  • Red cells may contain Heinz bodies and the cells may be fragmented showing anisocytosis and poikilocytosis. Serum bilirubin is elevated.[flipper.diff.org]
  • After metabolism in liver, the most potent derivative of naphthalene, naphthol-alpha causes hemolysis and Heinz bodies formation.[jahjournal.org]
Microcytosis
  • The peripheral blood smear showed microcytosis, anisocytosis, polychromatophilia and nucleated red cells. ESR was 33 mm for 1st hour, westergen. Bone marrow revealed erythroid hyperplasia. No malarial parasite was seen in blood smear or bone marrow.[jpma.org.pk]
Bone Marrow with Erythroid Hyperplasia
  • Bone marrow revealed erythroid hyperplasia. No malarial parasite was seen in blood smear or bone marrow. Urine contained albumin, free haemoglobin and red blood cells. Blood urea was 184 mg/dl and serum creatinine 7.4 mg/dl.[jpma.org.pk]

Treatment

As soon as a presumptive diagnosis is made, immediate administration of methylene blue is indicated. Methylene blue is able to revert the process of hemoglobin conversion to methemoglobin due to its electron-absorbing properties and it effectively scavenges the remaining free radicals [3]. In addition, exchange transfusion is recommended in more severe cases like the G6PD deficiency patients [3]. Supportive measures consisting of adequate airway management as well as the use of fluids and inotropic drugs to sustain normal pressure are vital in preserving the cardiovascular and pulmonary systems [3].

Prognosis

Early recognition of the condition and prompt initiation of therapy carries a good prognosis, but various complications may arise, most notable being profound cyanosis induced by methemoglobinemia [2]. Additionally, severe hemolysis may occur in patients suffering from glucose-6-phosphate dehydrogenase (G6PD) deficiency, in whom a very low tolerance to oxidative stress exists [5], and renal failure may ensue in these patients without removal of naphthalene from the circulation.

Etiology

Naphthalene is an aromatic hydrocarbon that is insoluble in water and poisoning almost universally occurs due to accidental ingestion of mothballs that are used as insect repellents [4]. An additional mode may be intentional ingestion, as suicide attempts with mothballs have been reported [1] [4].

Epidemiology

Exact rates of poisoning are unknown, but in the United States, approximately 1500 cases were reported in 2007 and 2008 [2]. The majority of patients are children.

Sex distribution
Age distribution

Pathophysiology

Once naphthalene is introduced into the human body, most likely through accidental ingestion, it is degraded in the liver by cytochrome P450 enzymes [2]. However, an abundance of free oxygen radicals is released during this process, leading to marked oxidative stress that causes lipid peroxidation, DNA damage and formation of methemoglobin [2].

Prevention

Because of the fact that naphthalene poisoning is accidental in most cases, avoiding the use of mothballs in households or placing them out of children's reach can be an effective preventive measure.

Summary

Naphthalene poisoning is very rarely encountered in clinical practice and the majority of cases are children who accidentally ingest mothballs that contain this aromatic hydrocarbon [1]. After ingestion naphthalene causes marked oxidative stress resulting in methemoglobinemia and hemolysis of red blood cells [2]. Methemoglobinemia is the most significant manifestation of toxicity by naphthalene. The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status [3]. The diagnosis mandates a thorough patient history that can reveal the source of symptoms, whereas a complete laboratory workup is necessary to define the extent of organ damage. Treatment mandates prompt administration of methylene blue, which is able to reverse the effects of free radical damage, but also exchange transfusion, in the attempt to remove naphthalene from the circulation [1].

Patient Information

Naphthalene is an aromatic hydrocarbon that is ubiquitously present in the air in very low concentrations, but its most frequent household use is in mothballs as an insect repellent. Consequently, naphthalene poisoning almost universally occurs after accidental ingestion of mothballs by children. Once this substance enters the body, it causes damage to cell membranes and releases numerous free radical that are responsible for tissue destruction. The most important consequence of poisoning, however, is the conversion of hemoglobin to methemoglobin, which has reduced ability to bind to oxygen. Within several hours or few days, symptoms like nausea, vomiting, diarrhea, abdominal pain, together with cyanosis, darkening of urine due to the presence of hemoglobin and confusion, altered consciousness, and even lethargy may occur. The diagnosis can be made by obtaining a meticulous patient history that will reveal the source of poisoning. Treatment mandates the use of methylene blue, which effectively reduces the harmful effects of naphthalene. Special care is needed for individuals suffering from glucose-6-phosphate dehydrogenase (G6PD) deficiency, as they are more susceptible to free radical damage. In this subgroup, a procedure known as exchange transfusion is necessary to perform.

References

Article

  1. Lim HC, Poulose V, Tan HH. Acute naphthalene poisoning following the non-accidental ingestion of mothballs. Singapore Med J. 2009;50(8):e298-301
  2. Sudakin DL, Stone DL, Power L. Naphthalene Mothballs: Emerging and Recurring Issues and their Relevance to Environmental Health. Curr Top Toxicol. 2011;7:13-19.
  3. Kundra TS, Bhutatani V, Gupta R, Kaur P. Naphthalene Poisoning following Ingestion of Mothballs: A Case Report. Journal of Clinical and Diagnostic Research : JCDR. 2015;9(8):UD01-UD02.
  4. Chauhan V, Sharma R, Sharma K, Sharma G, Jitender S, Jearth V. Naphthalene Poisoning Manifesting as Hemoglobinuria. Toxicol Int. 2014;21(3):314-315.
  5. Kapoor R, Suresh P, Barki S, Mishra M, Garg MK. Acute Intravascular Hemolysis and Methemoglobinemia Following Naphthalene Ball Poisoning. Indian J Hematol Blood Transfus. 2014;30(1):317-319.

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Last updated: 2018-06-22 02:22