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Toluene Toxicity Clinical Presentation

  • Author: Nathanael J McKeown, DO; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Feb 01, 2015
 

History

Identifying toluene exposure or risk of exposure admission is important, as well as the route of exposure, whether inhalation, ingestion, or transdermal absorption. Any history of "huffing" or "bagging" before presentation, or a history of previous abuse of inhalants, should be elicited.

An occupational history should be taken, to identify workers whose occupation may result in nonintentional acute or chronic exposure. Examples of workers who may be at risk include the following:

  • Painters
  • Chemists
  • Textile workers
  • Gasoline refinery workers
  • Rubber industry workers

Hobbies or activities that lead to nonintentional or intentional exposure should be reviewed. Model airplane glues and rubber cements are sources of toluene. Varnishes may affect people refinishing wooden furniture.

Toxicities and risks vary with the route of exposure, as follows:

  • 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 lung injury also may occur
  • Cutaneous exposure may result in coagulation necrosis unless copious skin irrigation is performed

The history should also identify any other drugs that may be in the patient's system, including alcohol, cocaine, and marijuana. Alcohol intoxication and toluene intoxication have a similar presentations. Alcohol inhibits the metabolism of toluene and raises the concentration of toluene in the blood twofold. Cocaine, or any sympathomimetic use, may increase risks of fatal arrhythmias.

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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 central nervous system (CNS) symptoms, depending on duration of exposure, route of exposure, and level of toluene in the air or liquid.

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

General /vital sign manifestations include the following:

  • 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; 20% 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) manifestations include the following:

  • "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 manifestations are as follows:

  • 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 include the following:

  • Decreased motor coordination
  • Impaired fine motor movements
  • Ataxia
  • Balance problems
  • Anesthesia

Pulmonary manifestations include the following:

  • Respiratory distress
  • Dyspnea
  • Chest pain (with aspiration)
  • Tachypnea
  • Cyanosis
  • Wheezing from bronchospasm

Gastrointestinal manifestations include the following:

  • Nausea
  • Vomiting
  • Abdominal pain
  • Hematemesis
  • Jaundice

Dermatologic manifestations include the following:

  • Itching or burns from skin contact
  • Glue sniffer's rash (see in HEENT)

Musculoskeletal manifestations include the following:

  • 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, Department of Emergency Medicine, Oregon Health and Science University School of Medicine; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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 Attending Physician in Emergency Medicine, Excela Health System

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

Debra Slapper, MD Physician, Southwest Washington Free Clinic System-Urgent Care; Former FEMA Physician and Military Contractor; Former Associate Professor, University of Miami, Leonard M Miller School of Medicine and University of South Florida Morsani College of Medicine

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

Disclosure: Nothing to disclose.

Acknowledgements

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

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