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

  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]

  [Article in French] Affiliations PMID: 24909442 DOI: 10.1016/j.revmed.2014.05.008 Case Reports [Hemolytic anemia due to naphthalene poisoning] [Article in French] S Roumieu et al. Rev Med Interne. 2015 Jun. [pubmed.ncbi.nlm.nih.gov]

  Abstract Naphthalene moth balls are potent hemolytic agents, capable of producing an acute, severe and perhaps fatal anemia. [pediatrics.aappublications.org]

  B. (1951) – Acute haemolytic anemia related to naphthalene: Report of a case in a newborn infant. Pediatrics, 7, 172-174. [colorisk.fr]

  Anemia Over time, long-term exposure to naphthalene can lead to an anemia. Symptoms include weakness, dizziness, fatigue and fainting. [healthfully.com]

• Pain

  The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status. [symptoma.com]

  A boy, 15, sucked on moth balls too and had stomach pains and vomiting. He was diagnosed with anemia. [stethnews.com]

  They can include: Abdominal pain Nausea and vomiting Diarrhea The person may also have a fever. [medlineplus.gov]

  One of the immediate sign of naphthalene poisoning is stomach pain, but this commonly takes two days to appear, along with diarrhea, nausea and vomiting. [magicofhealth365.com]

  Stomach symptoms may be observed after a few days and may include: Nausea, vomiting Diarrhea Stomach pain Skin turns pale and yellow Feeling drowsy, confused Seizures Coma Individuals with the genetic condition glucose-6-phosphate deficiency disorder [dovemed.com]

• Fever

  Naphthalene was introduced in 1841 by Rossbach as as an antiseptic to counteract typhoid fever. [definitions.net]

  IN HUS____________> no fever HSP............ [usmleforum.com]

  Case Report A 22 years old male was hospitalized with acute abdominal pain, vomiting, diarrhoea, high grade fever and mental confusion. [jpma.org.pk]

  Case report: We report a 33-year-old woman, originating from the Comoros, hospitalized for intense fatigue associated with delirium, fever and jaundice, three days after ritual ingestion of naphthalene. [pubmed.ncbi.nlm.nih.gov]

  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]

• Fatigue

  Look for Fatigue Mothballs usually contain either dicholorobenzene or naphthalene to kill the moths. The second chemical is older and tends to cause more health problems. [livestrong.com]

  Case report: We report a 33-year-old woman, originating from the Comoros, hospitalized for intense fatigue associated with delirium, fever and jaundice, three days after ritual ingestion of naphthalene. [pubmed.ncbi.nlm.nih.gov]

  Symptoms include weakness, dizziness, fatigue and fainting. If you or someone you know has been regularly inhaling moth balls or their fumes, take them to the doctor immediately. Be sure to alert your physician of any symptoms of anemia. [healthfully.com]

  Some of the symptoms that may occur after exposure to large quantities of naphthalene are fatigue, loss of appetite, nausea, vomiting, and diarrhoea. The skin may become pale or yellow-coloured. [health.nsw.gov.au]

• Unconsciousness

  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]

  First Aid tips for Naphthalene Poisoning: If the individual with Naphthalene Poisoning is unconscious, or is experiencing life-threatening symptoms, call 911 (or your local emergency help number) immediately Call the Poison Control Center at 1-800-222 [dovemed.com]

• Respiratory Distress

  Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning. [symptoma.com]

  Effects Congestion, Acute Respiratory Distress Syndrome (noted at 2ppm) Neurologic Effects Confusion, lethargy, vertigo, fasciculations, convulsions, anesthesia, cerebral oedema, coma (coma is noted at 0.05mg/kg body weight per day) Hepatic Effects Jaundice [ncbi.nlm.nih.gov]

  Some additional signs and symptoms of naphthalene ingestion include headache, profuse sweating, tachycardia, respiratory distress, listlessness, confusion. [flipper.diff.org]

• Vomiting

  The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status. [symptoma.com]

  In April 1982, the Clark County Health Department in Jeffersonville, Indiana, received a telephone call from a 26-year-old woman whose friends were becoming ill with symptoms of headache, nausea, and vomiting while visiting her apartment. [cdc.gov]

  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]

  A boy, 15, sucked on moth balls too and had stomach pains and vomiting. He was diagnosed with anemia. [stethnews.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]

• 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]

  In April 1982, the Clark County Health Department in Jeffersonville, Indiana, received a telephone call from a 26-year-old woman whose friends were becoming ill with symptoms of headache, nausea, and vomiting while visiting her apartment. [cdc.gov]

  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]

  Check for Nausea, Vomiting and Diarrhea Anytime someone swallows poison, the body may try to get rid of it by opening up the sluices. It's actually usually a good thing because it gets the mothballs out of the system before they can do more damage. [livestrong.com]

  One of the immediate sign of naphthalene poisoning is stomach pain, but this commonly takes two days to appear, along with diarrhea, nausea and vomiting. [magicofhealth365.com]

• Diarrhea

  The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status. [symptoma.com]

  The biggest concern with vomiting and diarrhea is dehydration; the body expels a lot of water along with the mothballs. Give the victim plenty of water in small but steady doses or have him suck on ice if he can't keep fluids down. [livestrong.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]

  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]

  The poison can also hit your digestive tract and cause vomiting, diarrhea and abdominal pain. [sciencing.com]

• Abdominal Pain

  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]

  #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]

  They can include: Abdominal pain Nausea and vomiting Diarrhea The person may also have a fever. [medlineplus.gov]

  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]

• Cyanosis

  Patient history is vital during workup, while detection of methemoglobinemia and cyanosis requires prompt therapy consisting of methylene blue and exchange transfusion. [symptoma.com]

  Methylene blue treatment was not given as there was no cyanosis which excluded any possibility of methemoglobinemia. The urine color becomes lighter and clear after 4 days. [jahjournal.org]

  When the concentration of methaemoglobin in the blood is above 1.5%, the patient develops cyanosis [7]. Treatment [7] Specific Treatment - Specific treatment includes the use of methylene blue and exchange transfusion. [ncbi.nlm.nih.gov]

• Jaundice

  She was pale and jaundiced. Heart sounds were normal. The lungs were filled with crepts. The abdomen was soft with no guarding. No organomegaly was noted. On neurological examination, there was no focal neurological deficit. [ncbi.nlm.nih.gov]

  Case report: We report a 33-year-old woman, originating from the Comoros, hospitalized for intense fatigue associated with delirium, fever and jaundice, three days after ritual ingestion of naphthalene. [pubmed.ncbi.nlm.nih.gov]

  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]

  Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning. [symptoma.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]

• Hepatomegaly

  Hematuria, acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning. [symptoma.com]

  Congestion, Acute Respiratory Distress Syndrome (noted at 2ppm) Neurologic Effects Confusion, lethargy, vertigo, fasciculations, convulsions, anesthesia, cerebral oedema, coma (coma is noted at 0.05mg/kg body weight per day) Hepatic Effects Jaundice, hepatomegaly [ncbi.nlm.nih.gov]

• Headache

  In April 1982, the Clark County Health Department in Jeffersonville, Indiana, received a telephone call from a 26-year-old woman whose friends were becoming ill with symptoms of headache, nausea, and vomiting while visiting her apartment. [cdc.gov]

  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]

  The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status. [symptoma.com]

  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]

• Irritability

  You can spot more direct signs by looking at her nose and throat for redness, swelling or irritation. The eyes might be red and bloodshot too. [livestrong.com]

  Ocular exposure to naphthalene has been seen to result in eye irritation, corneal damage, lens opacities and the formation of cataracts. [flipper.diff.org]

  Fecal transplant is used to treat gut infections and is now being studied as a treatment for obesity, urinary tract infections, irritable bowel syndrome and more. [nytimes.com]

  Inhalation of naphthalene may cause skin and eye irritation; gastrointestinal symptoms, such as nausea, vomiting, abdominal cramps, and diarrhea; neurologic symptoms, such as confusion, excitement, and convulsions; renal problems, such as acute renal [cdc.gov]

  Urinary bladder irritation may cause urgency, dysuria, and the passage of dark urine with or without cast and albumin. [jahjournal.org]

• Excitement

  Find out more about this exciting new development through this step by step guide. [cabdirect.org]

  Inhalation of naphthalene may cause skin and eye irritation; gastrointestinal symptoms, such as nausea, vomiting, abdominal cramps, and diarrhea; neurologic symptoms, such as confusion, excitement, and convulsions; renal problems, such as acute renal [cdc.gov]

• Altered Mental Status

  The other symptoms may include a headache, vomiting, diarrhea, abdominal pain and altered mental status. [symptoma.com]

• Stroke

  Click on the brush button to enter characters just by drawing them with the correct stroke order. Stroke order animation. Sample. [yellowbridge.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]

  [Table/Fig-2]: Systemic effects of naphthalene exposure [3] Gastrointestinal Effects Nausea, vomiting, abdominal pain, diarrhoea Renal Effects Increased creatinine level, increased serum urea nitrogen level, hematuria, renal tubular acidosis Respiratory [ncbi.nlm.nih.gov]

• Kidney Failure

  The possible effects of inhaling or ingesting mothballs include kidney failure and liver damage. Fortunately, swallowing a mothball is rarely fatal. Remain calm. Panicking in any situation like this makes it seem worse. [healthyliving.azcentral.com]

  Symptoms Kidney failure, flu-like symptoms, respiratory damage, osteopenia (loss of calcium from bones) which causes brittleness and makes bones break. [housediseases.com]

• Dysuria

  Urinary bladder irritation may cause urgency, dysuria, and the passage of dark urine with or without cast and albumin. [jahjournal.org]

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

  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]

  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]

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].

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.

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].

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.

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].

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.

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].

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.

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.