HEMOLYTIC ANEMIA

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    Mothballs are commonly composed of

    naphthalene or paradichlorobenzene (PDB).

    Differentiation between the two types is

    difficult because they have similar odors and

    are both white, crystalline solids at room

    temperature. PDB is commonly found here in

    the Philippines as a component of toilet

    deodorant blocks, but mothballs sold from

    the streets commonly contain this chemical

    as well.

    Between naphthalene and PDB, the latter is

    the less common component of mothballs

    and the less acutely toxic of the two.

    However, like naphthalene, it has also been

    known to induce hemolytic anemia because it

    possesses one benzene ring. However, there

    is only one report in literature about this

    occurrence.

    We report a case of a man who ingested 3

    mothballs made of paradicholorobenzene and

    subsequently experienced severe hemolytic

    anemia that necessitated blood transfusion.

    ABSTRACT

    HEMOLYTIC ANEMIA PRESENTING AS

    HEMOGLOBINURIA FROM MOTHBALL INGESTION

    Mary Ondinee U. Manalo, MD, Resident, Department of Medicine, UP-PGH Cherie Grace G. Quingking, MD, Fellow, Department of Toxicology, National Poison Control Center, UP-PGH

    A 24-year old man was diagnosed with

    hemolytic anemia when he presented with

    hemoglobinuria, low hemoglobin, and

    increased bilirubins, after ingesting

    mothballs. The content of the mothball was

    established to be paradichlorobenzene using

    the floatation test. Patient was given high-

    flow oxygen and ascorbic acid for his

    methemoglobinemia. He was discharged

    improved after blood transfusion. Hemolytic

    anemia is a very rare complication of

    paradichlorobenzene ingestion. There is only

    one report in literature citing this rare event.

    To date, this is the first reported case of

    hemolytic anemia, presenting initially as

    hemoglobinuria, from mothball ingestion in

    the Philippines.

    Carissa Paz C. Dioquino, MD, Consultant, Department of Toxicology, National Poison Control Center, UP-PGH German J. Castillo Jr., MD, Consultant, Section of Hematology, Department of Medicine, UP-PGH

    INTRODUCTION

    THE CASE

    A 24-year old man was admitted for

    persistent vomiting three days after ingestion

    of three crushed mothballs.

    Three days PTA, he intentionally swallowed

    three crushed mothballs after he found out

    that his partner left him for another man. After

    an hour, he experienced nausea and vague

    abdominal pain. Two days PTA, he

    experienced post-prandial vomiting and

    generalized weakness. A day PTA, he

    presented with persistent vomiting and

    passed out dark stools. Eight hours PTA,

    vomiting became more frequent and was now

    associated with coffee-ground material. He

    was then brought to PGH-ER.

    The patient presented at the ER with stable

    vital signs, icteric sclerae, and severe

    epigastric tenderness. Chest, cardiovascular,

    and digital rectal examination were

    unremarkable. An NGT was inserted and this

    evacuated coffee-ground gastric secretions.

    Since he came in 3 days post-ingestion,

    administration of activated charcoal had no

    value.

    DIAGNOSTICS & COURSE

    DISCUSSION

    Filter paper test to screen for

    methemoglobinemia turned out to be positive

    (Fig 1). Floatation test was done and the sinking

    of the mothball in hypertonic saline favored that

    the mothball was made of PDB (Fig 2). Initial

    hemoglobin was 12.0 mg/dL. PBS revealed

    normocytic, normochromic anemia. PT was

    normal but aPTT was 1.6x elevated.

    On the patients 2nd hospital day, patient

    developed hematuria. On urinalysis, the patients

    urine tested positive for hemoglobin. Since PDB

    acts as an oxidative stressor in glycolysis,

    administration of ascorbic acid was the plan

    since it acts as an antioxidant.

    On the patients 5th hospital day, he

    complained of extreme weakness and deepening

    icterizia. Hemoglobin went down to 5.3 mg/dL

    (from an initial of 12.0 mg/dL). Blood transfusion

    was hastened. During this time, the assessment

    of the toxicology service was hemolytic anemia

    from paradicholorobenzene ingestion on the

    basis of 1.) hemoglobinuria; 2.) high LDH, TB,

    DB, IB; 3.) abrupt onset of anemia; and 4.) a

    history of ingestion of a known oxidant. He was

    discharged improved after 6 units of PRBC and 8

    units of FFP.

    On follow-up, CBC was within normal range.

    A blood sample was extracted to screen for

    G6PD deficiency to screen for other possible

    causes of hemolytic anemia, but his enzyme was

    within normal range for age.

    TABLES & FIGURES

    2,4-PDB Naphtha Camphor

    Physical Wet and oily Dry Wet or dry

    Water Sink Sink Float

    4 oz water + 3

    heaping tsp of

    salt

    Sink Float Float

    Drop of

    turpentine

    Soluble Moderately

    soluble

    -

    Heating Green color No color -

    Fig 3. The role of glycolysis in the Emdben-Mayerhof pathway

    and the role of ascorbic acid in methemoglobinemia.

    Fig 1. Filter paper test

    indicating methemo-

    globinemia

    Fig 2. The floatation test

    indicated that the

    mothball was

    composed of PDB.

    Table 1. Comparison of the different physical characteristics

    of mothballs.

    We have presented a man who ingested

    mothballs made of PDB and developed

    hemolytic anemia. To date, this is the first

    reported case of hemolytic anemia, presenting

    initially as hemoglobinuria from mothball

    ingestion in the Philippines. This report will be

    submitted to DOH, BFAD, and FPA to reiterate

    the importance of appropriate warnings on all

    products that contain PDB. //

    CONCLUSION & RECOMMENDATIONS

    Mothballs in the Philippines are composed of

    naphthalene, paradicholorobenzene, or camphor.

    Most that are sold in groceries and hardware

    stores are made of naphthalene but those that are

    marketed in the streets could contain any of the

    three compounds.

    It then presents as a problem to identify the

    composition of these unlabeled mothballs.

    Fortunately, they can be differentiated using

    simple bedside tests (Table 1).

    PDB is rapidly absorbed through the lungs

    and GI tract. Oral absorption is complete while it

    is only 20% absorbed via inhalation. Half-life is

    10.12 hours. The acute oral LD 50 is >500 mg/kg.

    Various toxicities that manifested in our

    patient are GI bleeding, hemolysis,

    methemoglobin formation, and hepatitis. The

    hepatotoxicity is likely due to the formulations of

    toxic intermediates formed while converting 1,4-

    PDB to 2,5-dichlorophenol by cytP450, by

    depletion of glutathione at higher doses, or both.

    Since PDB exerts oxidative stress on the red

    blood cell, a bedside test was done to screen for

    methemoglobin. Oxidized iron can be reduced

    non-enzymatically using ascorbic acid and

    reduced glutathione as electron donors, but this

    is slow and quantitatively less important (Fig 3).

    Oxidants damage the erythrocyte at different

    locations in different entities. Hemolysis occurs

    when oxidants damage the hemoglobin chain

    directly, causing denaturation and precipitation of

    the protein. These precipitates form Heinz bodies

    within the erythrocytes that are removed by the

    reticuloendothelial system, fragmenting cells to

    produce hemolysis.

    Hemolysis is far more reported and is more

    severe in naphthalene exposure. This is because

    PDB contains only one benzene ring while

    naphthalene consists of two benzene rings. It has

    been said that the benzene ring intercalates

    between the bonds of normal hemoglobin and

    causes its destruction.

    On review of literature, we found only one

    case report that dealt with hemolysis after

    ingestion of PDB. This was of 3-year old child

    who presented with acute onset of jaundice and

    anemia. Exhaustive work-up after a week

    revealed methemoglobinemia, negative coombs,

    RBC fragility, and no enzyme deficiencies.

    Upon admission, it was considered that the

    child was probably suffering from infectious

    disease. However, workup was negative. Inquiries

    were then directed to poisons and drugs. His

    mother then revealed that the child had been

    playing with a small canister labeled as

    Demothing Crystals. Urine examination

    revealed the metabolite 2,5-dichlorophenol. The

    patient was given mega doses of ascorbic acid

    and was transfused with blood components. He

    was discharged well.