Toluene Toxicity Clinical Presentation

  • Author: Nathanael J McKeown, DO; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 11, 2011
 

History

Determining a history of toluene exposure or risk of exposure on admission is important, as well as the the route of exposure, whether inhalation, ingestion, or transdermal absorption.

  • History of huffing or bagging before presentation or history of previous abuse of inhalants
  • History of other drugs that may be in the patient's system, including alcohol (ETOH), cocaine, and marijuana
    • Toluene intoxication has a similar presentation to alcohol intoxication.
    • Alcohol inhibits the metabolism of toluene and raises the concentration of toluene in the blood 2-fold.
    • Cocaine, or any sympathomimetic use, may increase risks of fatal arrhythmias.
  • History of workers' occupations (eg, painters, chemists, textile workers, gasoline refinery workers, rubber industry workers) to assess whether workers may have had nonintentional acute or chronic exposure and may be at risk
  • Hobbies or activities that lead to nonintentional or intentional exposure
    • Model airplane glues and rubber cements are sources of toluene.
    • Varnishes may affect people refinishing wooden furniture.
  • Toxicities and risks that vary with routes of exposure
    • Ingestion may cause hematemesis and abdominal pain.
    • Inhalation is a risk for airway compromise secondary to aspiration and induction of bronchospasm; subsequent hypoxemia from chemical pneumonitis and acute lunge injury also may occur.
    • Cutaneous exposure may result in coagulation necrosis without copious skin irrigation.
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Physical

Physical examination is an important aid in confirming a suspected diagnosis of toluene poisoning. Patients with acute toluene poisoning may present with a range of pulmonary and CNS symptoms depending on duration, route of exposure, and level of toluene in the air or liquid.

Patients with chronic exposure may present with wide variety of complaints.

  • General/vitals
    • Patients may be tachypneic, tachycardic, and hypoxic on initial evaluation.
    • Hypotension may be present.
    • Fever may be present, secondary to aspiration pneumonitis.
    • Sweet smelling odor: Hair, breath, and clothing may smell of solvent. Twenty percent of inhaled toluene is expired from the lungs unchanged.
    • Paint or oil stains may be seen on clothing.
  • Head, eyes, ears, nose, and throat (HEENT)
    • "Huffer's eczema": Perioral defatting dermatitis secondary to contact of solvent vapors with skin may be noted.
    • Mucosal irritation (eg, burning mouth, eyes, throat)
    • Injected sclera
    • Nystagmus
  • Neurologic
    • Decreased level of consciousness leading to coma
    • Dizziness and headaches
    • Confusion
    • Hallucinations
    • Amnesia
    • Seizure activity
    • Paresthesias (Toluene has anesthetic effects.)
    • Decreased deep tendon reflexes
    • Cerebellar signs
      • Decreased motor coordination
      • Impaired fine motor movements
      • Ataxia
      • Balance problems
      • Anesthesia
  • Pulmonary
    • Respiratory distress
    • Dyspnea
    • Chest pain (with aspiration)
    • Tachypnea
    • Cyanosis
    • Wheezing from bronchospasm
  • Gastrointestinal
    • Nausea
    • Vomiting
    • Abdominal pain
    • Hematemesis
    • Jaundice
  • Dermatologic
    • Itching or burns from skin contact
    • Glue sniffer's rash (see in HEENT)
  • Musculoskeletal: Profound muscle weakness due to hypokalemia; muscle pain
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Causes

Inhalation of airborne toluene is the most common cause of exposure.

Exposure can occur in several occupations including paint workers, dye makers, and workers in the chemical and petrochemical industry.

Toluene toxicity can occur from the following:

  • Nonintentional or deliberate inhalation of fumes
  • Ingestion
  • Absorption through the skin

Toluene is found in the following:

  • Gasoline
  • Acrylic paints
  • Varnishes
  • Lacquers
  • Paint thinners
  • Adhesives
  • Glues
  • Rubber cement
  • Airplane glue
  • Shoe polish
  • Typewriter erasing fluid
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Contributor Information and Disclosures
Author

Nathanael J McKeown, DO  Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University

Nathanael J McKeown, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Debra Slapper, MD  Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Kevin A Martin, MD, to the development and writing of this article.

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