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Toluene Poisoning

Poisoning by Toluene

Toluene poisoning principally occurs through inhalation, either by intentional abuse or accidentally in the industrial setting, given its widespread use in the synthesis of organic solvents. Symptoms arise due to severe hypokalemia and metabolic acidosis, most prominent being weakness and paralysis, as well as neurological deficits and gastrointestinal irritation. Confirming exposure to toluene during history taking is crucial to make the diagnosis.


Presentation

Toluene is an aromatic hydrocarbon used in the production of industrial solvents that are present in paints and various chemical substances, including pharmaceutical and sanitation products [1] [2]. Thus, many occupations carry an increased risk for accidental exposure to higher concentrations of this compound. Toluene poisoning, however, is much more commonly encountered in individuals who intentionally abuse toluene through "glue sniffing", described as the second most common type of teenage substance abuse [2] [3] [4]. As a result, adolescents are the main patient group [3]. Signs and symptoms appear due to the extensive production of hydrogen ions during its metabolic degradation in the liver, leading to two major pathological mechanisms responsible for symptom appearance - severe metabolic acidosis and hypokalemia [2] [3] [4]. Furthermore, toluene can deposit in adipose tissues, implying that its metabolism requires a significant amount of time after being introduced into the human body [3]. Consequently, both acute and chronic forms of poisoning might be recognized. In the acute setting, euphoria, disinhibition, and tinnitus are prominent features [3]. Conversely, profound muscle weakness (or even paralysis) is the main symptom of chronic toluene poisoning, accompanied by gastrointestinal complaints (abdominal pain, nausea, vomiting and hematemesis) and central nervous system (CNS) abnormalities - altered mental status, confusion, hallucinations, euphoria, depression, ataxia and visual deficits [2] [5]. Fatigue, but also cardiac arrhythmias are reported by certain authors [3] [5]. In severe cases, renal failure (developing on the grounds of rhabdomyolysis and marked acidosis) and acute respiratory distress syndrome (ARDS) may occur [2].

Gastric Lavage
  • lavage ) Surgery to remove burned skin Breathing support, including tube through the mouth into the lungs and breathing machine (ventilator) How well someone does depends on how severe the poisoning is and how quickly treatment is received.[medlineplus.gov]
  • lavage for elimination of the substance from the stomach (irrigation using special solutions) Wash skin and eyes repeatedly and thoroughly (irrigation), to eliminate any remaining hazardous compound Following this, a suitable skin or eye ointment may[dovemed.com]
  • This technique, which is known as gastric lavage, involves introducing 20-30 mL of tap water or 9% saline solution into the patient's digestive tract and removing the stomach contents with a siphon or syringe.[medical-dictionary.thefreedictionary.com]
  • Gastric lavage (“stomach pumping”) for patients who have ingested toluene-containing substances. Irrigation (“washing out”) of the skin at points of contact with toluene-containing substances.[healthhype.com]
Anemia
  • Action of pure TNT and of impurities Action of TNT in the system and the connection of minor TNT illness toxic jaundice and aplastic anemia Action of TNT on the blood Aplastic anemia causing TNT poisoning Cases skewing intimate relation between cyanosis[momicoh.pastperfectonline.com]
  • Hematologic consequences of exposure may include: lymphocytosis, macrocytosis, eosinophilia, hypochromia, and basophilic stippling, and in severe cases, aplastic anemia.[getwellstaywellathome.com]
Nausea
  • Conversely, profound muscle weakness (or even paralysis) is the main symptom of chronic toluene poisoning, accompanied by gastrointestinal complaints (abdominal pain, nausea, vomiting and hematemesis) and central nervous system (CNS) abnormalities - altered[symptoma.com]
  • Severity of symptoms can range from headache and nausea to convulsions and death.[medical-dictionary.thefreedictionary.com]
  • Those who have pursued toluene poisoning claims have often complained of headaches, nausea and lack of coordination as initial symptoms. When there has been an extreme amount of vapours inhaled poisoning can lead to unconsciousness or death.[jefferies-solicitors.com]
  • EYES, EARS, NOSE, AND THROAT Blurred vision Burning pain Hearing loss STOMACH AND INTESTINES Bloody stools Abdominal pain (severe) Loss of appetite Nausea Vomiting (may be bloody) HEART AND BLOOD VESSELS Irregular heartbeat Low blood pressure KIDNEYS[medlineplus.gov]
  • The signs and symptoms of Toluene Poisoning may include: Skin turns pale; dry skin that starts cracking Respiratory difficulties, which may be severe if the chemical is inhaled Chest pain and cough Headache Nausea, vomiting; appetite loss Blood in stools[dovemed.com]
Vomiting
  • Emetic — A medication or substance given to induce vomiting.[medical-dictionary.thefreedictionary.com]
  • The signs and symptoms of Toluene Poisoning may include: Skin turns pale; dry skin that starts cracking Respiratory difficulties, which may be severe if the chemical is inhaled Chest pain and cough Headache Nausea, vomiting; appetite loss Blood in stools[dovemed.com]
  • Conversely, profound muscle weakness (or even paralysis) is the main symptom of chronic toluene poisoning, accompanied by gastrointestinal complaints (abdominal pain, nausea, vomiting and hematemesis) and central nervous system (CNS) abnormalities - altered[symptoma.com]
  • These include vomiting, convulsions, or a decreased level of alertness. If the person breathed in fumes, move them to fresh air right away.[medlineplus.gov]
  • Differential Diagnosis Disease/Condition Differentiating Signs/Symptoms Differentiating Tests Viral infection Should be determined from the history whether the nausea, vomiting, diarrhea may be due to a viral infection such as influenza or food poisoning[online.epocrates.com]
Failure to Thrive
  • Fred Ferri’s popular "5 books in 1" format provides quick guidance on menorrhagia, Failure to Thrive (FTT), Cogan’s syndrome, and much more.[books.google.com]
Chest Pain
  • pain Cough Rapid, shallow breathing NERVOUS SYSTEM Convulsions Dizziness Drowsiness Extreme feeling of well-being (euphoria) Headache Memory loss Nervousness Staggering Tremors Unconsciousness SKIN Dry, cracked skin Pale skin Get medical help right away[medlineplus.gov]
  • The signs and symptoms of Toluene Poisoning may include: Skin turns pale; dry skin that starts cracking Respiratory difficulties, which may be severe if the chemical is inhaled Chest pain and cough Headache Nausea, vomiting; appetite loss Blood in stools[dovemed.com]
  • There was no history of fever, cough, dyspnea, or chest pain prior to this episode. Patient had tachycardia, hypotension, tachypnea, agitated behavior, and coarse crepitations all over chest.[mjdrdypu.org]
  • pain Wheezing Nausea Vomiting Jaundice Abdominal pain Muscle weakness Muscle pain Glue Sniffer’s Rash Many of the symptoms of acute and chronic toluene exposure can be attributed to various other, and more common, diseases.[healthhype.com]
  • Decreased deep tendon reflexes Cerebellar signs include the following: Decreased motor coordination Impaired fine motor movements Ataxia Balance problems Anesthesia Pulmonary manifestations include the following: Respiratory distress Dyspnea Chest pain[emedicine.medscape.com]

Workup

The diagnosis of toluene poisoning rests on the ability of the physician to recognize signs and symptoms and confirm exposure to this aromatic hydrocarbon. For this reason, a properly obtained patient history (often requiring hetero-anamnestic data) and a detailed physical examination are perhaps essential steps during the diagnostic workup. In the presence of characteristic signs and symptoms, patients should be asked about their occupancy and whether exposure to toluene could have possibly occurred at the workplace, while intentional abuse must also be excluded. Laboratory studies, particularly the acid-base status and urinalysis, is the next step in solidifying clinical suspicion, showing hypokalemia, hypophosphatemia and a normal (or sometimes elevated) anion gap acidosis [1] [2] [3] [5]. In addition, kidney function tests will reveal elevated creatine kinase (CK) levels in the presence of renal impairment, whereas severely acidic urine is also a common feature [2] [3]. Some studies have confirmed that chronic toluene poisoning leads to marked structural changes and demyelination in the CNS, and typical findings on magnetic resonance imaging (MRI) include lesions of the white matter that transmit a hyperintense signal on T2-weighted studies and hypointensity of the thalamus [6]. Thus, imaging studies may be beneficial in the presence of neurological deficits.

Treatment

  • Treatment Treatment for poisoning depends on the poison swallowed or inhaled. Contacting the poison control center or hospital emergency room is the first step in getting proper treatment.[medical-dictionary.thefreedictionary.com]
  • Treatment with agonists of GABA such as, benzodiazepines provide some mitigation of earthquakes induced by toluene, as ataxia. An alternative to drug treatment is the thalamotomie.[dd-database.org]
  • Each chapter includes key clinical features and potential treatment options to help physicians to assess the potential severity of the poisoned patient and provide the optimum clinical care.[books.google.com]

Prognosis

  • […] appropriate medication and early support, the outcome is generally good However, severe poisoning can result in serious complications and the prognosis can be ascertained only on a case-by-case basis.[dovemed.com]
  • Altered mental status Dysrhythmias Hepatic dysfunction Renal failure Rhabdomyolysis Severe metabolic derangements Refractory hypokalemia Myocardial sensitization to catecholamines: Possibility of sudden dysrhythmia/death Cardiac dysrhythmias have poor prognosis[5minuteconsult.com]
  • Prognosis The outcome of poisoning varies from complete recovery to death, and depends on the type and amount of the poison, the health of the victim, and the speed with which medical care is obtained.[medical-dictionary.thefreedictionary.com]

Etiology

  • Although any of these could be considered the etiology of intestinal obstruction, we could not find any tumors, obvious intestinal adhesions, hernias, inflammatory bowel diseases, volvulus or intussusceptions in clinical and paraclinical evaluations and[theijoem.com]

Epidemiology

  • Additionally, in human epidemiological studies and in animal studies, this chemical has been associated with toxicity to the immune system and also possibly with blood cancers such as malignant lymphoma [3] .[safecosmetics.org]
  • .: Epidemiology of thinner-sniffing [in Japanese with English abstrat], Japan. J.[link.springer.com]
  • Methanol outbreak in Norway 2002-2004: epidemiology, clinical features and prognostic signs. J Intern Med. 2005 Aug;258(2):181-90. [Pubmed] 5. Sefidbakht S, Rasekhi AR, Kamali K, Borhani Haghighi A, Salooti A, Meshksar A, et al.[revistanefrologia.com]
  • Epidemiology of inhalant use. Curr Opin Psychiatry . 2008 May. 21(3):247-51. [Medline] . Chao TC, Lo DS, Koh J, et al. Glue sniffing deaths in Singapore--volatile aromatic hydrocarbons in post-mortem blood by headspace gas chromatography.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • Other sequelae include muscle weakness, nasal ulcerations, recurrent epistaxis, chronic rhinitis, neuropsychiatric abnormalities, GI symptoms, and peripheral neuropathies (see Pathophysiology).[emedicine.medscape.com]

Prevention

  • M46 Catalog Number 2016.25.249 Author Moore, Benjamin Summary The Causation and Prevention of Tri-Nitro-Toluene Poisoning; 1917.[momicoh.pastperfectonline.com]
  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • This report will inform planning, response, and prevention in the community, the workplace, transportation, the military, and the remediation of Superfund sites.[books.google.com]

References

Article

  1. Camara-Lemarroy CR, Rodríguez-Gutiérrez R, Monreal-Robles R, González-González JG. Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study. BMC Emerg Med. 2015;15:19.
  2. Omar AS, Rahman M ur, Abuhasna S. Reported survival with severe mixed acidosis and hyperlactemia after toluene poisoning. Saudi J Anaesth. 2011;5(1):73-75.
  3. Dickson RP, Luks AM. Toluene toxicity as a cause of elevated anion gap metabolic acidosis. Respir Care. 2009;54(8):1115-1117.
  4. Carlisle EJ, Donnelly SM, Vasuvattakul S, Kamel KS, Tobe S, Halperin ML. Glue-sniffing and distal renal tubular acidosis: sticking to the facts. J Am Soc Nephrol 1991;1:1019e27.
  5. Tsao JH, Hu YH, How CK, et al. Atrioventricular conduction abnormality and hyperchloremic metabolic acidosis in toluene sniffing. J Formos Med Assoc. 2011;110(10):652-654.
  6. Aydin K, Sencer S, Demir T, Ogel K, Tunaci A, Minareci O. Cranial MR findings in chronic toluene abuse by inhalation. AJNR Am J Neuroradiol. 2002;23(7):1173-1179.

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Last updated: 2018-06-22 06:23