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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 patient’s 2nd hospital day, patient

developed hematuria. On urinalysis, the patient’s

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 patient’s 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 coomb’s,

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.