Correspondence

Twin Girls with Neurocutaneous Symptoms Caused by Mothball Intoxication

N Engl J Med 2006; 355:423-424July 27, 2006

Article

To the Editor:

An 18-year-old 12th-grade student presented with a one-month history of an ichthyosis-like dermatosis (Figure 1Figure 1Dermatologic Involvement in PDB Poisoning.), which symmetrically involved the lower limbs, elbows, and hands. Blood tests demonstrated iron-deficiency anemia and lymphoneutropenia. The patient also had an unsteady gait, urinary retention, signs of intracranial hypertension, a cerebellar syndrome, pyramidal signs in all limbs without weakness, and mental sluggishness. The results of cerebral and spinal magnetic resonance imaging, electroencephalography, and cerebrospinal fluid analysis were normal.

The patient's twin sister had similar but less severe skin lesions in the same distribution, along with an unsteady gait. Her physical examination showed only increased brisk reflexes. There was no family history of neurologic or dermatologic disease or of consanguinity.

After several days, we accidentally discovered a bag of mothballs in the first patient's hospital room. The mothballs contained paradichlorobenzene (PDB) as the only active substance. It turned out that both sisters had been encouraged by classmates to use mothballs as a recreational drug. The first patient had been “bagging” (inhaling mothball fumes) daily for 10 minutes for the previous four to six months. She had also chewed half a mothball per day for two months. PDB was detected in the serum, and 2,5-dichlorophenol in the urine.

The first patient's biologic abnormalities improved after she had been mothball-free for two months. Clinical examination at six months showed a total recovery. At three months, her twin sister, who had sniffed mothballs for 5 to 10 minutes a day for only a few weeks, had completely recovered.

Substance abuse by youths is a major public health concern.1 PDB is derived from aromatic hydrocarbons, which form one of the families of volatile substances that are commonly abused.2 However, we are aware of only three other cases of self-intoxication with PDB.3-5 Nevertheless, as with other forms of self-intoxication involving volatile compounds, it is easy to abuse PDB, since mothballs and other household products containing PDB (e.g., other insect repellents, air fresheners, toilet-bowl and diaper-pail deodorizers, and fungicides) are legally and readily available. Moreover, since young people usually deny practicing self-intoxication, the incidence of this type of recreational activity is probably underestimated. The association of ichthyosis-like dermatosis and neurologic signs should raise the clinician's suspicion of mothball abuse.

Lionel Feuillet, M.D.
Hôpital de la Timone, 13006 Marseille, France
lionel.feuillet@mail.ap-hm.fr

Stéphanie Mallet, M.D.
Hôpital Nord, 13015 Marseille, France

Michel Spadari, M.D.
Hôpital Salvator, 13009 Marseille, France

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Citing Articles (5)

Citing Articles

1. 1

   2012. Naphthalene and para-Dichlorobenzene (Mothballs). , 716-724.
   CrossRef

2. 2

   Victoria Passov, Eric K. Milliner, James R. Rundell. (2011) Partially Reversible Dementia Associated With the Use of Para-Dichlorobenzene in the Case of PICA. Psychosomatics 52:3, 283-285
   CrossRef

3. 3

   Stephanie H. Hernandez, Sage W. Wiener, Silas W. Smith. (2010) Case Files of the New York City Poison Control Center: Paradichlorobenzene-Induced Leukoencephalopathy. Journal of Medical Toxicology 6:2, 217-229
   CrossRef

4. 4

   Suzanne B. Murray, Megan Dwight-Johnson, Mitchell R. Levy. (2010) Mothball induced encephalopathy presenting as depression: it’s all in the history. General Hospital Psychiatry 32:3, 341.e7-341.e9
   CrossRef

5. 5

   J.A. Stockman. (2008) Timing of Initial Exposure to Cereal Grains and the Risk of Wheat Allergy. Yearbook of Pediatrics 2008, 28-30
   CrossRef