Victor Owiredu, BA
Medical student
Morehouse School of Medicine
Atlanta, Georgia, United States
Caroline Pupke, DO
Resident Physician
Emory University
Atlanta, Georgia, United States
Monica S. Branch, MD
Assistant Professor
Emory University School of Medicine
Atlanta, Georgia, United States
Toxic leukoencephalopathy secondary to paradichlorobenzene ingestion
A 32-year-old female with a history of severe iron deficiency anemia (IDA) was admitted to an outside hospital for management of nausea, vomiting, and dehydration. On initial assessment, she was also found to have a diffuse ichthyosiform skin rash of unknown etiology. She subsequently developed an altered mental status manifesting as agitation and intermittent restlessness and was started on Geodon and Ativan. Her acute encephalopathy progressively worsened, requiring intubation for airway protection. She remained obtunded upon extubation with no known etiology. She was transferred to our hospital 28 days later for further workup of her progressive encephalopathy. Differential diagnosis included catatonia and encephalitis. A benzodiazepine challenge for catatonia was completed without symptom improvement. MRI of her brain was performed, which was remarkable for toxic leukoencephalopathy. It was later discovered that she had been ingesting toilet bowl deodorizers over the last year due to pica secondary to severe IDA.
Toilet bowl deodorizers contain a toxic ingredient called paradichlorobenzene (PDCB), which is a benzene derivative with misuse potential.1 Chronic PDCB ingestion can result in a toxic leukoencephalopathy and characteristic skin lesions.2 Toxicology workup for our patient revealed that her clinical presentation was consistent with PDCB ingestion. Dichlorobenzene blood analysis via gas chromatography showed an elevated P-dichlorobenzene level of 7.5 mcg/mL (reporting limit 1.0 mcg/mL), which confirmed PDCB toxicity.
Given the patient’s rapid neurologic decline during her initial hospitalization, she would have benefited from early PM&R involvement as PM&R physicians can be pivotal in assisting with diagnosis, medication management, therapy recommendations, and goals of care discussions.
There is no specific antidote for PDCB toxicity. Treatment typically focuses on avoiding further exposure, physical and occupational therapy, and providing supportive care. In many affected patients, toxic effects can persist with ongoing clinical deterioration, even after discontinuation of the toxin.
