Acute toluene intoxication–clinical presentation, management and prognosis: a prospective observational study

Abstract

BackgroundToluene is one of the most widely abused inhaled drugs due to its acute neurologic effects including euphoria and subsequent depression. However, dangerous metabolic abnormalities are associated to acute toluene intoxication. It has been previously reported that rhabdomyolysis and acute hepatorenal injury could be hallmarks of the condition, and could constitute risk factors for poor outcomes. The objective was to describe the clinical presentation, to characterize the renal and liver abnormalities, the management and prognosis associated to acute toluene intoxication.MethodsWe prospectively assessed 20 patients that were admitted to a single center’s emergency department from September 2012 to June 2014 with clinical and metabolic alterations due to acute toluene intoxication.ResultsThe main clinical presentation consisted of weakness associated to severe hypokalemia and acidosis. Renal glomerular injury (proteinuria) is ubiquitous. Biliary tract injury (alkaline phosphatase and gamma-glutamyl transpeptidase elevations) disproportional to hepatocellular injury is common. Rhabdomyolysis occurred in 80 % of patients, probably due to hypokalemia and hypophosphatemia. There were three deaths, all female, and all associated with altered mental status, severe acidosis, hypokalemia and acute oliguric renal failure. The cause of death was in all cases due to cardiac rhythm abnormalities.ConclusionThe hallmarks of acute toluene intoxication are hypokalemic paralysis and metabolic acidosis. Liver injury and rhabdomyolysis are common. On admission, altered mental status, renal failure, severe acidemia and female gender (not significant in our study, but present in all three deaths) could be associated with a poor outcome, and patients with these characteristics should be considered to be treated in an intensive care unit.

A `glue sniffer` teenager with anuric renal failure and hepatitis

“…Differently, it was reported that ALP was not elevated and GGT was only mildly elevated in patients who died. 12 In our patient although ALP and GGT levels were normal; both jaundice, which is a sign of hepatobiliary injury, and elevated transaminases were the evidences of hepatotoxicity.…”

“…11 Previous reports showed that acute inhalation produces a biphasic response with an initial CNS excitation followed by CNS depression. 11,12 We believe that the first stage, in our case which is thought to be euphoria, happened before admission.…”

“…Although the toxic effects of toluene mainly occur on urinary system serum creatinine increases in nearly 20% of patients. 12 Wide spectrum of renal diseases may develop in association with toluene inhalation. They include rhabdomyolysis, distal renal tubular acidosis, and anti-glomerular basement membrane antibody mediated glomerulonephritis.…”

Expanding the differential: toluene-induced toxicity

“…Resolution of symptoms is often rapid. Nevertheless, toluene abuse is neither harmless nor an insignificant consideration—mortality of 15% was reported in a recent study 12. Toluene abuse is an important, yet often missed, differential diagnosis for the patient with weakness, abdominal complaints and metabolic abnormalities.…”

Indoor Air Pollution: Btex in Occupational Environments

“…Thus, considering the use of BTEX in several industrial segments, its difficulty in dispersing in these environments, its toxic potential and the permanence of the worker for extended periods of time in the work place [11], [12], it is important to monitor these compounds in the occupational environment. Although there are previous reports on the toxicity of the BTEX constituents [13]- [15], there is little information about the toxicity of BTEX as a group.…”