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Methylene Chloride Intoxication Treated With Hyperbaric Oxygen Therapy
CLINICAL COMMUNICATION TO THE EDITOR
Methylene Chloride Intoxication Treated With Hyperbaric Oxygen Therapy To the Editor: The vast majority of carbon monoxide (CO) poisoning cases are caused by direct inhalation, but it can still be an elusive diagnosis in unresponsive individuals with no known history of exposure.1 Herein, we describe a case of methylene chloride (MeCl2) intoxication after the use of this substance as a solvent for paint removal. A 45-year-old black man with no significant medical history was found unconscious with labored breathing. He Funding: None. Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this manuscript. Authorship: All authors were directly responsible for taking care of the patient and had access to the data and a role in writing the manuscript.
Figure
regained consciousness after being placed on 100% oxygen and recalled that he started stripping paint off the wall using a commercial solvent on the day of admission. He was not wearing a face mask and the room was poorly ventilated. He felt nauseous, experienced an episode of non-bloody vomiting, and subsequently passed out. He denied smoking or any other toxic ingestion. On emergency room arrival, he had a blood pressure of 142/98, respiratory rate of 20, heart rate of 94, and oxygen saturation by pulse-oximetry of 98% on 100% oxygen. He was drowsy but alert, awake, and oriented to time, place, and person. He was having a headache, with neck pain and numbness in the right thumb and index finger. His physical examination, including fundoscopy, was normal. An initial electrocardiogram, chest radiograph, and laboratory examinations, including a complete blood cell count, serum chemistries, and blood gas with co-oximetry were unremarkable. Non-contrast computed axial tomographic scan of the head revealed subtle
Carboxyhemoglobin (COHb) levels over time. The arrows indicate treatments with hyperbaric oxygen.
0002-9343/$ -see front matter © 2011 Elsevier Inc. All rights reserved.
e4 bilateral hypodensities in globus pallidus. MeCl2 as solvent for the paint remover was then confirmed from the manufacturer. His carboxyhemoglobin (COHb) level was 8.7% on presentation (normal, ⬍5% in nonsmokers), which trended up to 17.3% the next morning. He was kept on 100% oxygen and received 2 sessions of hyperbaric oxygen therapy (46 minutes each at 2.8 atmospheres) on days 1 and 2. His subsequent COHb levels trended down (Figure). The numbness in his right thumb and index fingers also resolved. He was discharged home on day 3.
The American Journal of Medicine, Vol 124, No 5, May 2011 ing can potentially identify patients at higher risk for late neurologic sequelae. A lower threshold for treatment with hyperbaric oxygen might be appropriate in cases of MeCl2 poisoning, because COHb values may continue to rise for hours after exposure. In cases of MeCl2 poisoning, subtle hypodensities in the basal ganglia are strongly indicative of CO intoxication. It is important to educate those using MeCl2-containing products about the potential hazards of exposure and to emphasize that MeCl2 should never be used in an enclosed space without adequate ventilation.
DISCUSSION MeCl2 is widely used as a solvent in paint removers.2 Exposure can easily occur by inhalation, or the solvent can enter the body through oral or dermal routes.2 Adverse effects are related both to the neurotoxic effects of the parent compound and its conversion to carbon monoxide in the liver.2 Treatment of MeCl2 intoxication includes removal from exposure, supplemental oxygen, and hyperbaric oxygen therapy for patients with neurologic symptoms, independent of the initial COHb levels.3 COHb values may continue to rise after exposure despite hyperbaric oxygen therapy, likely because of the slow release of MeCl2 from adipose tissue and its continuous metabolic transformation into CO.2,3 An interesting finding in this report was the subtle bilateral hypodensities in the globus pallidus bilaterally, which have been previously described in CO intoxication,4 but abnormal findings on neuroimaging have never been described in cases of MeCl2 poisoning. It remains to be investigated whether the abnormal findings on neuroimag-
Valerie Jorge Cabrera, MD Dimitrios Farmakiotis, MD Vikas Aggarwal, MD Department of Internal Medicine Jacobi Medical Center Albert Einstein College of Medicine Bronx, NY
doi:10.1016/j.amjmed.2010.12.010
References 1. Balzan MV, Agius G, Galea Debono A. Carbon monoxide poisoning: easy to treat but difficult to recognize. Postgrad Med J. 1996;72:470473. 2. Agency for Toxic Substances and Disease Registry Web site. Medical management guidelines for methylene chloride. Available at: http:// www.atsdr.cdc.gov/Mhmi/mmg14.html. Accessed October 4, 2010. 3. Ly BT. Methylene chloride. In: Olson KR. Poisoning and drug overdose (4th ed). New York: McGraw-Hill; 2004: pp 265–267. 4. Finck PA. Exposure to carbon monoxide: review of the literature and 567 autopsies. Milit Med. 1966;131:1513-1519.
Methylene Chloride Intoxication Treated With Hyperbaric Oxygen Therapy To the Editor: The vast majority of carbon monoxide (CO) poisoning cases are caused by direct inhalation, but it can still be an elusive diagnosis in unresponsive individuals with no known history of exposure.1 Herein, we describe a case of methylene chloride (MeCl2) intoxication after the use of this substance as a solvent for paint removal. A 45-year-old black man with no significant medical history was found unconscious with labored breathing. He Funding: None. Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this manuscript. Authorship: All authors were directly responsible for taking care of the patient and had access to the data and a role in writing the manuscript.
Figure
regained consciousness after being placed on 100% oxygen and recalled that he started stripping paint off the wall using a commercial solvent on the day of admission. He was not wearing a face mask and the room was poorly ventilated. He felt nauseous, experienced an episode of non-bloody vomiting, and subsequently passed out. He denied smoking or any other toxic ingestion. On emergency room arrival, he had a blood pressure of 142/98, respiratory rate of 20, heart rate of 94, and oxygen saturation by pulse-oximetry of 98% on 100% oxygen. He was drowsy but alert, awake, and oriented to time, place, and person. He was having a headache, with neck pain and numbness in the right thumb and index finger. His physical examination, including fundoscopy, was normal. An initial electrocardiogram, chest radiograph, and laboratory examinations, including a complete blood cell count, serum chemistries, and blood gas with co-oximetry were unremarkable. Non-contrast computed axial tomographic scan of the head revealed subtle
Carboxyhemoglobin (COHb) levels over time. The arrows indicate treatments with hyperbaric oxygen.
0002-9343/$ -see front matter © 2011 Elsevier Inc. All rights reserved.
e4 bilateral hypodensities in globus pallidus. MeCl2 as solvent for the paint remover was then confirmed from the manufacturer. His carboxyhemoglobin (COHb) level was 8.7% on presentation (normal, ⬍5% in nonsmokers), which trended up to 17.3% the next morning. He was kept on 100% oxygen and received 2 sessions of hyperbaric oxygen therapy (46 minutes each at 2.8 atmospheres) on days 1 and 2. His subsequent COHb levels trended down (Figure). The numbness in his right thumb and index fingers also resolved. He was discharged home on day 3.
The American Journal of Medicine, Vol 124, No 5, May 2011 ing can potentially identify patients at higher risk for late neurologic sequelae. A lower threshold for treatment with hyperbaric oxygen might be appropriate in cases of MeCl2 poisoning, because COHb values may continue to rise for hours after exposure. In cases of MeCl2 poisoning, subtle hypodensities in the basal ganglia are strongly indicative of CO intoxication. It is important to educate those using MeCl2-containing products about the potential hazards of exposure and to emphasize that MeCl2 should never be used in an enclosed space without adequate ventilation.
DISCUSSION MeCl2 is widely used as a solvent in paint removers.2 Exposure can easily occur by inhalation, or the solvent can enter the body through oral or dermal routes.2 Adverse effects are related both to the neurotoxic effects of the parent compound and its conversion to carbon monoxide in the liver.2 Treatment of MeCl2 intoxication includes removal from exposure, supplemental oxygen, and hyperbaric oxygen therapy for patients with neurologic symptoms, independent of the initial COHb levels.3 COHb values may continue to rise after exposure despite hyperbaric oxygen therapy, likely because of the slow release of MeCl2 from adipose tissue and its continuous metabolic transformation into CO.2,3 An interesting finding in this report was the subtle bilateral hypodensities in the globus pallidus bilaterally, which have been previously described in CO intoxication,4 but abnormal findings on neuroimaging have never been described in cases of MeCl2 poisoning. It remains to be investigated whether the abnormal findings on neuroimag-
Valerie Jorge Cabrera, MD Dimitrios Farmakiotis, MD Vikas Aggarwal, MD Department of Internal Medicine Jacobi Medical Center Albert Einstein College of Medicine Bronx, NY
doi:10.1016/j.amjmed.2010.12.010
References 1. Balzan MV, Agius G, Galea Debono A. Carbon monoxide poisoning: easy to treat but difficult to recognize. Postgrad Med J. 1996;72:470473. 2. Agency for Toxic Substances and Disease Registry Web site. Medical management guidelines for methylene chloride. Available at: http:// www.atsdr.cdc.gov/Mhmi/mmg14.html. Accessed October 4, 2010. 3. Ly BT. Methylene chloride. In: Olson KR. Poisoning and drug overdose (4th ed). New York: McGraw-Hill; 2004: pp 265–267. 4. Finck PA. Exposure to carbon monoxide: review of the literature and 567 autopsies. Milit Med. 1966;131:1513-1519.