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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.