Sudden death in adolescents resulting from the inhalation of typewriter correction fluid

Inhalation abuse of various toxic agents continues to be a significant health problem among the younger segment of our society. We describe four cases of sudden death in adolescents associated with recreational sniffing of typewriter correction fluid occurring during the period 1979 through mid-1984. The solvents used in most of these fluids, 1,1,1-trichloroethane and trichloroethylene, are known to induce potentially fatal arrhythmias. Sniffing typewriter correction fluid poses a significant and underappreciated danger to the lives of these abusers. School health officials, public health departments, and law enforcement personnel should be alerted to the need for surveillance of this type of activity.

Long-term follow-up after single toxic exposure to trichloroethylene

In an earlier report [Feldman and Lessell, 1967], neurologic findings following acute intoxication to trichloroethylene were presented. Facial anesthesia, asymmetric pupillary responses, and electrical evidence of sensorimotor neuropathy accompanied neuropsychological deficits, manifested by difficulty in solving sequential problems and poor memory affecting the acquisition of new information. Twelve years after the initial exposure, patches of hypalgesia over the malar eminences persisted and corneal reflexes remained absent, although sensation in the snout region was totally normal. Neuropsychological test results continued to demonstrate impaired attention and short-term memory as well as diminished visuospatial organization and sequencing, 16 years after exposure. In addition, MMPI profile and interview suggested continued depressive symptomatology. Eighteen years after exposure, findings included paresthesia and hypalgesia in the malar area of the face as well as myokymia of the facial muscles. Facial nerve latency studies were normal as were pattern shift visual evoked responses. The patient continued to have large pupils that reacted asymmetrically to light. In the right eye, contraction was synchronous in all segments of the sphincter. In the left eye, there was segmental contraction, suggestive of a tonic pupil. This report offers evidence of long-term residual oculomotor and ciliary reflex dysfunction as well as impaired neuropsychological performance as a result of acute TCE intoxication.

Adolescent abuse of typewriter correction fluid

A new form of substance abuse in adolescents is the inhalation of fumes from typewriter correction fluids (Liquid Paper, Wite-Out, Snopake, etc), which are composed of various chlorinated solvents, to induce euphoria. Medical complications of such abuse and medical management of acute toxic episodes are discussed herein, along with suggestions for controlling this substance abuse.

Industrial gassing poisonings due to trichlorethylene, perchlorethylene, and 1-1-1 trichloroethane, 1961-80

During the period 1961-80, 384 cases of industrial gassing poisonings by trichlorethylene, perchlorethylene, and 1-1-1 trichloroethane (methylchloroform) were reported to HM Factory Inspectorate. A study of these data, which have been collated and analysed with particular reference to sex, age, clinical manifestations, and circumstances of the incident, is presented. Possible bias of the data owing to its source and method of extraction is discussed. The study shows the hazards inherent in the use of these narcotic solvents and discusses the circumstances that appear most likely to produce problems. The vulnerability of the younger worker is shown. Toxic effects were most commonly exerted on the central nervous system but no good evidence of cardiac or hepatic toxicity was found. In nine cases evidence of deliberate sniffing of solvent was reported. The problem of solvent abuse in an industrial context is discussed.

Time course of electrophysiological findings for patients with solvent poisoning. A descriptive study

The time course of electroencephalographic (EEG) and electroneuromyographic (ENMG) findings was studied among 87 patients (40 men and 47 women) with a diagnosis of chronic solvent intoxication after occupational exposure. Neurophysiological studies were initially performed around the time of diagnosis, and all the patients were reexamined three to nine years later. No control group was available for the follow-up. Upon diagnosis 67% of the patients had an abnormal EEG, the majority with diffuse slow-wave abnormalities. The reexamination showed improvement in the EEGs of 47%, but the percentage of patients with paroxysmal abnormalities had increased from the initial 6 to 17. The percentage of patients with neuropathic findings was 62 for the first and 74 for the second ENMG. Upon reexamination fibrillations were seen in 46% (in 38% in the initial examination), and some loss of motor units was found for 61% (for 54% in the initial examination). Mild improvement in the neuropathic findings was noted for 60%, but the neuropathic findings of 25% showed slight deterioration during the follow-up period. The EEG findings showed a time course resembling that described after external head injuries. The ENMG findings resembled those described in hexa-carbon-induced or carbon disulfide-induced neuropathy. Controlled studies are recommended to examine the observed slight associations between electrophysiological findings and the type of chemical exposure.

An unusual case of Pick's disease

A man aged 64, with a history of chronic trichloroethylene intoxication, presented early headache, impairment of memory, and "stehende Redensarten", later on mental deterioration with muteness and oral tendency. He died of bronchopneumonia. The brain was studied by light and electron microscopy. Numerous inflated cells, intraneuronal argentophil Pick bodies and central chromatolysis of neurons were found throughout the cerebral cortex. Widespread diffuse fibrillary gliosis was the finding bearing a striking resemblance to "progressive subcortical gliosis". Severe loss of nerve cells was observed in the temporal lobe (except the posterior of T 1) and moderate or mild loss in the gyrus rectus, insula, gyrus cinguli, and partial areas of the frontal, parietal, and occipital lobes. By electron microscopy, the argentophil Pick bodies consisted of a conglomeration of randomly arranged short 100-150 A filaments, ribosomes, vesicles, mitochondria, and scanty paired helical filaments. The present case was considered to represent a rare case of Pick's disease of the temporo-fronto-parieto-occipital type or panencephalic type.

[EEG in the prognosis of toxic coma: reflections apropos of unusual data]

During acute intoxications, the first EEG may show persistence or abolition of cerebral activity, but the possibility of recovery after isoelectric tracing in toxic comas must be emphasized. EEG patterns frequently suggest the probability of hypnotic tranquilizer poisoning; 4 types of EEG are encountered corresponding to different grades of toxic coma. Recurrent periods of electrical silence alternating with bursts of activity are habitually recorded in carus comas with hypothermia due to acute barbiturate intoxication, with good prognosis. The possibility of a neurological disturbance associated with drug overdose must be raised whenever an asymmetric tracing is encountered. Serial recordings may detect complications such as: a localized lesion, anoxia or, very rarely, typical paroxysmal abnormalities reappearing in comitial patients before emergence from a toxic coma. Paradoxical monomorphic delta activity corresponding to improvement must not be considered as an aggravation. Peculiar EEG findings occur after oral trichlorethylene poisoning, with temporary clinical deterioration and intermittent periods of electrical silence; recovery is possible. An alpha-like pattern after cardiac arrest of toxic origin has a poor prognosis. The appearance of alternating patterns suggests the development of irreversible brain damage.

Overall prognosis of patients with diagnosed chronic organic solvent intoxication

The prognosis of 87 patients (mean age 38.6 years) was examined who had been diagnosed 3-9 years earlier as having chronic organic solvent intoxication due to trichloroethylene, perchloroethylene, or a mixture of solvents. The methods comprised an interview, a clinical neurological examination, neurophysiological examinations (EEGs and electroneuromyographs), and a psychological examination. In order to assess the prognosis, the patient's condition at the time of diagnosis was evaluated from the hospital records, and the condition upon reexamination was compared to that at the time of diagnosis. At the time of diagnosis, 31 patients had objective clinical signs in the neurological examination, whereas the remaining 56 had only subjective symptoms and neurophysiological or psychological findings attributed to the slight solvent intoxication. Upon reexamination, 42 patients had clinical neurological signs. Based on the clinical overall evaluation, the condition of 21 patients had deteriorated during the follow-up period, the condition of 23 had improved, and that of 43 had remained unchanged. The prognoses of the results of the separate examinations correlated poorly with each other. No statistically significant correlation was found between the overall prognosis and age, sex, the duration and the level of exposure, the termination of exposure after diagnosis, the presence of other diseases, or the use of alcohol.

[Exogenous-toxic bilateral basal ganglia necroses in computer tomography]

By means of cranial computer tomography, it is possible to demonstrate the cerebral consequences of severe intoxications in vivo. A variety of different toxic agents produce similar disease patterns, which are thought to be due to fall in blood pressure caused by the toxin. The lesions are mainly localised in the basal ganglia at the borders of contiguous vascular territories. Six patients observed by the authors are described.

Cerebrospinal fluid cells and proteins in patients occupationally exposed to organic solvents

Cerebrospinal fluid (CSF) cells and proteins were determined for 33 patients exposed to industrial organic solvents. A lymphoid reaction, i.e., a pathologically elevated number or percentage of enlarged lymphoid cells was observed in one-third of the patients, more often in patients with chronic intoxication (40%) than in those currently exposed to organic solvents (32%). An almost significant decrease of small lymphocytes in the CSF was observed among patients who had a past history of chronic solvent intoxication but no recent exposure. No cytological evidence of tissue destruction was found. Signs of slight blood--CSF barrier damage occurred in 5 (23%) of the currently exposed patients, but intrathecal IgG synthesis was not observed. Increased cellular activity in the CSF was also accentuated in principal component analysis. The results suggest slight nonspecific immunoactivation in the central nervous system of subjects exposed to organic solvents.

Evoked trigeminal nerve potential in chronic trichloroethylene intoxication

Results of a study of trigeminal nerve impairment resulting from trichloroethylene intoxication by the somatosensory-evoked potential method reveal three kinds of abnormalities: increased stimulation voltage, excessive latency delay with morphological abnormalities, and excessive graph amplitude. These abnormalities confirm clinical disturbance (hypesthesia of the trigeminal nerve area) and open debate about the real mechanism of trichloroethylene neurotoxicity. Industrial intoxication by solvents, particularly trichloroethylene, is common. We have conducted a study of 188 workers chronically exposed to trichloroethylene and have confirmed the selective neurological disturbances of this intoxication in the trigeminal nerve (20%) [3, 10]. We utilized a new experimental method, developed for studies of chronic intoxications effecting the median nerve [5, 8], of recording the somatosensory evoked potential following stimulation of the trigeminal nerve [4, 6, 7]. The workers in this study were selected following clinical evaluation of their facial sensitivity and trigeminal nerve reflexes. In this paper we present our preliminary results on 11 workers, 9 suffering effects of intoxication and 2 controls.

[Value of the study of trigeminal nerve evoked potentials in chronic trichloroethylene poisoning. Preliminary results]

Results of a study concerning the trigeminal nerve impairment as the one caused by trichlorethylene chronic intoxication by somatosensory evoked potential reveal three kinds of anomalies: increase of the stimulation voltage, excessive latency delay with morphological anomalies and excessive graph amplitude. These anomalies confirm clinical disturbance (hypoesthesia in the trigeminal area) and open a debate about the real mechanism of the trichlorethylene neurotoxicity.

[Radiopacity produced by the stomach contents in a case of trichlorethylene poisoning (author's transl)]

A lethal case of trichlorethylene poisoning is reported. A 50-year-old woman had drunk some 100 ml of pure trichlorethylene. The trichloracetic acid found only in traces in her urine indicated that death apparently occurred very rapidly. Furthermore, substances contained in the hair tonic "K5-Tinktur" were found in remnants of the corps in safekeeping. Skin burns around the mouth, and also on the mucous membrane of the vestibule of the mouth, were striking. The special odor during the autopsy indicated poisoning by organic solvents. The fact trichlorethylene taken orally produces an intense X-ray attenuation is mentioned with regard to the diagnosis of poisoning by halogenized hydrocarbons and to therapeutic measures. The lethal result was due to the narcotic effect of trichlorethylene.