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.

Naphthalene Poisoning stems from the following process: Poison.

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].

urogenital
Hematuria
  • Presentation urogenital Hematuria [www.symptoma.com] more... urogenital Hematuria Hematuria , acute respiratory distress (ARDS), altered consciousness, convulsions, jaundice, hepatomegaly and hemolytic anemia are notable symptoms of severe poisoning.[symptoma.com]
  • […] cells cerebral chest child Clin clinical coagulation congenital cyanosis decreased dehydration diagnosis diarrhea disease disorders dose drug dysfunction edema effects electrolyte emergency etiology evaluation factors fever fluid glucose heart failure hematuria[books.google.com]
  • […] inhaling the same noxious gas that the CDC says can cause a significant amount of unpleasantness: “Headache, confusion, excitement, malaise (vague feeling of discomfort); nausea, vomiting, abdominal pain; irritation bladder; profuse sweating; jaundice; hematuria[servprohersheyswatara.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]
  • Indandiones Initial symptoms may range from practically none to pallor, weakness, nausea, severe hematuria, epistaxis and bleeding from mouth and gums.[thebestcontrol.com]
Dark Urine
  • Urine They can develop diarrhea, vomiting, lethargy, lack of appetite, fever, abdominal pain and painful urination and dark urine .[symptoma.com]
  • They can develop diarrhea, vomiting, lethargy, lack of appetite, fever, abdominal pain and painful urination and dark urine.[healthycanadians.gc.ca]
  • Case report A 1½-year-old female child presented to pediatrics emergency unit with a complaint of dark urination.[jahjournal.org]
  • INHALATION: Inhalation may cause abdominal cramps, nausea, vomiting, diarrhea, headache, tiredness, confusion, painful urination, and bloody or dark urine (14).[pmep.cce.cornell.edu]
  • He had dark urine, which was positive for hemoglobin while urine microscopy was negative for red blood cells suggesting hemoglobinuria.[imjsu.org]
Dysuria
  • [imjsu.org] Dysuria There may be dysuria , haematuria and an acute haemolytic reaction.[symptoma.com]
  • There may be dysuria, haematuria and an acute haemolytic reaction.[inchem.org]
  • Urinary bladder irritation may cause urgency, dysuria, and the passage of dark urine with or without cast and albumin.[jahjournal.org]
Oliguria
  • [jahjournal.org] Oliguria There may be haematuria, haemoglobinuria and dysuria, progressing to oliguria or anuria.[symptoma.com]
  • There may be haematuria, haemoglobinuria and dysuria, progressing to oliguria or anuria.[inchem.org]
  • more...
  • psychiatrical
    Agitation
    • [house.wikia.com] Agitation The symptoms of mothball poisoning include: Nausea, vomiting, belly pain and diarrhea Agitation , restlessness or lethargy Fever Headache The liver can also be affected.[symptoma.com]
    • The symptoms of mothball poisoning include: Nausea, vomiting, belly pain and diarrhea Agitation, restlessness or lethargy Fever Headache The liver can also be affected.[health.uconn.edu]
  • more...
  • cardiovascular
    Orthostatic Hypotension
    • Progressive autonomic and peripheral polyneuropathy is characterized by orthostatic hypotension, greatly diminished response to pinprick.[thebestcontrol.com]
  • more...
  • gastrointestinal
    Vomiting
    • Give anti-vomiting medication, anti-seizure medication, and/or medication to protect the liver.[vcahospitals.com]
    • [petmd.com] Nausea and Vomiting An upset stomach and vomiting can both be symptoms of moth ball inhalation.[symptoma.com]
    • Nausea Vomiting Loss of appetite Lethargy Tremors Seizures Irritation of eyes and nose from vapors Burning sensation on skin from dermal exposure Severe cases will see anemia and possible vomiting of blood Dogs with extensive poisoning may have brown[wagwalking.com]
    • It may be possible to get your pet to vomit up the mothball if they have eaten it in the last couple of hours.[petmd.com]
    • Nausea and Vomiting An upset stomach and vomiting can both be symptoms of moth ball inhalation.[healthfully.com]
    Nausea
    • [stethnews.com] Nausea If the nausea does not pass or the vomiting persists, seek medical attention.[symptoma.com]
    • If the nausea does not pass or the vomiting persists, seek medical attention.[healthfully.com]
    • Sources Ingestion gives rise to abdominal cramps, nausea, vomiting and diarrhoea.[flipper.diff.org]
    • Others include vertigo, headache, nausea, and fatigue.[thebestcontrol.com]
    • […] air at just a few parts per billion by the human nose – that means you’re also inhaling the same noxious gas that the CDC says can cause a significant amount of unpleasantness: “Headache, confusion, excitement, malaise (vague feeling of discomfort); nausea[servprohersheyswatara.com]
    Diarrhea
    • [health.uconn.edu] Diarrhea Diarrhea can indicate naphthalene poisoning.[symptoma.com]
    • Diarrhea Diarrhea can indicate naphthalene poisoning.[healthfully.com]
    • Signs and symptoms of rodenticide poisoning include bruising, bleeding gums, bloody diarrhea, and vomiting of blood.[health.uconn.edu]
    • Pets that eat mothballs can develop lethargy, vomiting, diarrhea, lack of appetite and tremors.[healthycanadians.gc.ca]
    • Symptoms Swallowing large amounts of copper may cause: Abdominal pain Diarrhea Vomiting Yellow skin (jaundice) Touching large amounts of copper can cause the hair to turn a different color (green).[mclaren.org]
  • more...
  • respiratoric
  • more...
  • neurologic
    Headache
    • [npic.orst.edu] more... neurologic Headache Symptoms Hemolytic anemia (destruction of red blood cells) causing tissue necrosis from a lack of oxygen, kidney and liver damage, headaches , nausea, jaundice, convulsions.[symptoma.com]
    • Symptoms Hemolytic anemia (destruction of red blood cells) causing tissue necrosis from a lack of oxygen, kidney and liver damage, headaches, nausea, jaundice, convulsions.[housediseases.com]
    • Some additional signs and symptoms of naphthalene ingestion include headache, profuse sweating, tachycardia, respiratory distress, listlessness, confusion.[flipper.diff.org]
    • These include headaches, confusion, drowsiness, jaundice, fever, low blood pressure or a racing heart rate.[sciencing.com]
    • Headahce After being exposed to naphthalene, be alert for the sudden onset of a headache.[healthfully.com]
    Excitement
    • excitement , confusion and depression.[symptoma.com]
    • If you can smell the mothball – detectable in the air at just a few parts per billion by the human nose – that means you’re also inhaling the same noxious gas that the CDC says can cause a significant amount of unpleasantness: “Headache, confusion, excitement[servprohersheyswatara.com]
    • If the vapors are inhaled, it poses as a health hazard along with the irritation of the nasal passage, lungs, throat and eventually resulting to neurological symptoms such as excitement, confusion and depression.[firstaidcpredmonton.ca]
    • Inhalation: On inhalation naphthalene cases headache, confusion, excitement, nausea, vomiting and sweating.[inchem.org]
    • Some nervous system effects have been observed through excitation of axonic transmission.[thebestcontrol.com]
    Agitation
    • [house.wikia.com] Agitation The symptoms of mothball poisoning include: Nausea, vomiting, belly pain and diarrhea Agitation , restlessness or lethargy Fever Headache The liver can also be affected.[symptoma.com]
    • The symptoms of mothball poisoning include: Nausea, vomiting, belly pain and diarrhea Agitation, restlessness or lethargy Fever Headache The liver can also be affected.[health.uconn.edu]
  • more...
  • Entire body system
    Anemia
    • He was transfused for correction of anemia.[imjsu.org]
    • Entire body system Anemia He was transfused for correction of anemia .[symptoma.com]
    • Anemia Over time, long-term exposure to naphthalene can lead to an anemia.[healthfully.com]
    • In humans, naphthalene is broken down to alpha-naphthol, which is linked to the development of hemolytic anemia.[npic.orst.edu]
    • Infants may develop hemolytic anemia from exposure to naphthalene even if not deficient in G-6-PD.[healthycanadians.gc.ca]
    Fever
    • Complications Fever . #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.[symptoma.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]
    • Breathing in copper dust and fumes may cause an acute syndrome of metal fume fever (MFF).[mclaren.org]
    • On the second day. fever appears which lasts for several days.[jpma.org.pk]
    • However, she then gets a 105 fever suggesting that the diagnosis is correct but the treatment is killing her.[housediseases.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.[housediseases.com]
    • [health.uconn.edu] 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.[symptoma.com]
    • An angiography reveals the patient has severe internal bleeding and a failing liver.[house.wikia.com]
    Agitation
    • [house.wikia.com] Agitation The symptoms of mothball poisoning include: Nausea, vomiting, belly pain and diarrhea Agitation , restlessness or lethargy Fever Headache The liver can also be affected.[symptoma.com]
    • The symptoms of mothball poisoning include: Nausea, vomiting, belly pain and diarrhea Agitation, restlessness or lethargy Fever Headache The liver can also be affected.[health.uconn.edu]
  • more...
  • Liver, Gall & Pancreas
    Jaundice
    • [symptoma.com] He was anaernic, jaundiced and dehydrated.[symptoma.com]
    • He was anaernic, jaundiced and dehydrated.[jpma.org.pk]
    • Patients develop jaundice and the chief threat to life in young infants is kernicterus that carries a high mortality.[flipper.diff.org]
    • Dogs can also develop liver problems with signs of jaundice.[second-opinion-doc.com]
    • These include headaches, confusion, drowsiness, jaundice, fever, low blood pressure or a racing heart rate.[sciencing.com]
  • more...
  • 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.

    Laboratory

    Serum
    Heinz Bodies
    • More severe reactions also include Heinz body formation, haemoglobinuria and mild methaemoglobinaemia.[flipper.diff.org]
    • [flipper.diff.org] Heinz body was positive.[symptoma.com]
    • Heinz body was positive.[jahjournal.org]
    • Heinz bodies appeared in the circulating red cells before haemolysis was evident.[inchem.org]
    • Blood: Hemolytic anemia associated with decreased hemoglobin and hematocrit values, increased reticulocyte counts, Heinz bodies, and bilirubin levels is the most commonly observed effect in humans following acute exposure to naphthalene.[rais.ornl.gov]
  • more...
  • 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.

    Complications

    Fever
    • Complications Fever . #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.[symptoma.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]
    • Breathing in copper dust and fumes may cause an acute syndrome of metal fume fever (MFF).[mclaren.org]
    • On the second day. fever appears which lasts for several days.[jpma.org.pk]
    • However, she then gets a 105 fever suggesting that the diagnosis is correct but the treatment is killing her.[housediseases.com]
    Acute Kidney Failure
    • [health.uconn.edu] Acute Kidney Failure Eating just one mothball containing naphthalene can damage a young child’s red blood cells.... [7] Exposure to naphthalene promotes hemolytic anemia, associated with fatigue in mild cases and acute kidney failure[symptoma.com]
    • Eating just one mothball containing naphthalene can damage a young child’s red blood cells.... [7] Exposure to naphthalene promotes hemolytic anemia, associated with fatigue in mild cases and acute kidney failure in severe cases.[inspectapedia.com]
    Jaundice
    • [symptoma.com] He was anaernic, jaundiced and dehydrated.[symptoma.com]
    • He was anaernic, jaundiced and dehydrated.[jpma.org.pk]
    • Patients develop jaundice and the chief threat to life in young infants is kernicterus that carries a high mortality.[flipper.diff.org]
    • Dogs can also develop liver problems with signs of jaundice.[second-opinion-doc.com]
    • These include headaches, confusion, drowsiness, jaundice, fever, low blood pressure or a racing heart rate.[sciencing.com]
    Methemoglobinemia
    • Pulse oximetry may become unreliable in the setting of methemoglobinemia because of false high in patients with severe methemoglobinemia and false low in patients with mild methemoglobinemia.[jahjournal.org]
    • Keywords Methemoglobinemia Naphthalene Intravascular hemolysis Methylene blue References 1.[link.springer.com]
    • Pulse oximetry may become unreliable in the setting of methemoglobinemia because of false high in patients with severe methemoglobinemia and false low in patients with mild methemoglobinemia .[symptoma.com]
    • In methemoglobinemia, the cat or dog develops brown or blue colored gums.[pethelpful.com]
    • Methemoglobinemia is another problem that arises from the poisoning of moth balls.[second-opinion-doc.com]
    Anemia
    • He was transfused for correction of anemia.[imjsu.org]
    • Entire body system Anemia He was transfused for correction of anemia .[symptoma.com]
    • Anemia Over time, long-term exposure to naphthalene can lead to an anemia.[healthfully.com]
    • In humans, naphthalene is broken down to alpha-naphthol, which is linked to the development of hemolytic anemia.[npic.orst.edu]
    • Infants may develop hemolytic anemia from exposure to naphthalene even if not deficient in G-6-PD.[healthycanadians.gc.ca]
    Hypovolemic Shock
    Acute Hemolytic Anemia
    • [rais.ornl.gov] Acute Hemolytic Anemia Acute hemolytic anemia due to ingestion of naphthalene moth balls.[symptoma.com]
    • Acute hemolytic anemia due to ingestion of naphthalene moth balls.[rais.ornl.gov]
    • Acute hemolytic anemia in the newborn due to naphthalene poisoning: Report of two cases with investigations into the mechanism of the disease.[imjsu.org]
    • Acute hemolytic anemia related to naphthalene; report of a case in a newborn infant.[inspectapedia.com]
    • "Association of naphthalene with acute hemolytic anemia".[en.wikipedia.org]
    Hallucinations
    • House asks the patient’s father about why the patient said "Jules" during his hallucination.[house.wikia.com]
    • [en.wikipedia.org] Hallucinations House asks the patient’s father about why the patient said "Jules" during his hallucination .[symptoma.com]
    • The boy’s condition starts declining rapidly; blindness in one eye, anal bleeding, and hallucinations.[venjanztruth.blogspot.com]
    • A hallucination of a dead cat prompts House to perform a biopsy on the cat and diagnose Keith with naphthalene poisoning caused by the release of naphthalene gas stored in Keith's fat that was burned as he sat at the hospital, inhaled in his home from[housediseases.com]
    • Inhalation of high concentrations for short periods has caused headache, dizziness, nausea, hallucinations, delirium, progressive paralysis and death from respiratory failure.[thebestcontrol.com]

    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.

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    References

    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.

    • A rare fatal case of wood preservative, monochloro-naphthalene (MCN), poisoning - S Tsunenari, K Yonemitsu, Y Uchimura - Forensic Science , 1982 - Elsevier
    • 1. NAME - , M Balls, CORUN Naphthalene, MUN Naphthalene - Management - inchem.org
    • Accidental poisoning in children in Jaipur (Rajasthan) - U Sharma, SS Jaipur - Indian Journal of Pediatrics, 1974 - Springer
    • Acute hemolytic anemia due to ingestion of naphthalene moth balls - JV Mackell, F RIEDERS, H BRIEGER, EL BAUER - Pediatrics, 1951 - Am Acad Pediatrics
    • Accidental poisoning - R Khadgawat, P Garg, P Bansal, A Arya - Indian , 1994 - indianpediatrics.net
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    • Acute hemolysis due to naphthalene inhalation - T Valaes, SA Doxiadis, P Fessas - The Journal of pediatrics, 1963 - Elsevier
    • 2, 3, 7, 8-Tetrachlorodibenzo-para-dioxin: Effects and mechanisms - JG Vos - Ecological Bulletins, 1978 - JSTOR
    • A comparative study of the kinetics and bioavailability of pure and soil-adsorbed naphthalene in dermally exposed male rats - RM Turkall, GA Skowronski, AM Kadry - Archives of , 1994 - Springer
    • Acute toxicity due to the confirmed consumption of synthetic cannabinoids: Clinical and laboratory findings - M Hermanns‐Clausen, S Kneisel, B Szabo - , 2012 - Wiley Online Library
    • Acute haemolytic anaemia with distortion and fragmentation of erythrocytes in children - AC Allison - British journal of haematology, 2008 - Wiley Online Library
    • 9 CHEMICAL HAZARDS AND TOXICOLOGY - JM Harrington, G Petherbridge - The Paper Conservator, 1980 - Taylor & Francis
    • 1. NAME - , M Balls, CORUN Naphthalene, MUN Naphthalene - Management - inchem.org
    • Application of Pseudomonas putida PpG 786 containing P-450 cytochrome monooxygenase for removal of trace naphthalene concentrations - GP Kulisch, VL Vilker - Biotechnology Progress, 1991 - ACS Publications
    • A 5 year retrospective study of poisoning cases in paediatric age group at the district hospital Belgaum - RS Honnungar - 2006 - 119.82.96.198
    • 1. NAME - , M Balls, CORUN Naphthalene, MUN Naphthalene - Management - inchem.org
    • 1. NAME - , M Balls, CORUN Naphthalene, MUN Naphthalene - Management - inchem.org
    • 1. NAME - , M Balls, CORUN Naphthalene, MUN Naphthalene - Management - inchem.org
    • Acanthocytosis Without - EMR Critchley, DB Clark, A Wikler - Archives of Neurology, 1968 - Am Med Assoc
    • Acute Poisoning - BV Bhat, B Adhisivam - R AP Emergency Ped. Spl Vol. 8, 2001 - books.google.com
    • Approach to the poisoned patient - EP Krenzelok, JB Leikin - Disease-a-Month, 1996 - Elsevier
    • 1. NAME - , M Balls, CORUN Naphthalene, MUN Naphthalene - Management - inchem.org
    • 2-Methylbutane (isopentane) - JB Galvin, F Marashi - Toxicology and Environmental Health Part A, 1999 - Taylor & Francis

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