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Presentation of a clinical case" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "231" "paginaFinal" => "235" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Gómez Perera, I. Rodríguez Talavera, H.E. Tapia Quijada, M. Guerrero-Mártir, M. Díaz de Aguilar Osona, R. Falcón Roca" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Gómez Perera" "email" => array:1 [ 0 => "sandragomezperera@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Rodríguez Talavera" ] 2 => array:2 [ "nombre" => "H.E." "apellidos" => "Tapia Quijada" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Guerrero-Mártir" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Díaz de Aguilar Osona" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Falcón Roca" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Graduado en Medicina, Servicio de Oftalmología, Hospital Universitario de Canarias, Tenerife, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pérdida visual secundaria a intoxicación inhalatoria y cutánea por metanol y tolueno. A propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1204 "Ancho" => 1305 "Tamanyo" => 217372 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">OCT image of BE ganglion cell layer, top (A) on admission and bottom (B) after 2 weeks of treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Methanol poisoning associated or not with toluene is a medical emergency considering the high morbidity and mortality it entails. Most of the poisonings described in literature are secondary to accidental intake or with autolytic intention.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Transdermal and inhalation routes have also been described, but as less frequent routes of intoxication. A case of inhalation<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> and transdermal poisoning<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> is presented. As will be shown, the ophthalmological and systemic symptoms are the same regardless of the pathway of contact with the toxic.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case</span><p id="par0010" class="elsevierStylePara elsevierViewall">The case of a 50-year-old female patient, with no history of interest, that visited the emergency room referring a 4-day progressive loss of vision, for which reason she was referred to the ophthalmology service, is presented. The patient described an initial visualization of “flashes” with a decrease in bilateral visual acuity (VA) to light perception. In the anamnesis, the patient mentioned the use of a solvent 2 weeks earlier (including components such as methanol, methyl acetate and toluene) mixed with hot water to clean the house, since it had been recently painted, without adequate room ventilation or protection with gloves or mask. Solvent exposure occurred throughout the cleaning day. Two days later the patient experienced nausea, vomiting and drowsiness along with said visual alteration.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ophthalmological exploration produced a VA of light. Pupils were isochoric, mydriatic and hyporeactive, with preserved consensual reflex. Extrinsic eye motility showed no restrictions or pain on mobilization. The anterior chamber was deep in both eyes, without Tyndall, with bilateral phacosclerosis. Intraocular pressure, taken with Goldmann, was 20<span class="elsevierStyleHsp" style=""></span>mmHg in both eyes.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Fundus examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed sharp-edged optic discs. Peripapillary retinal nerve fiber layer (RNFL) thickening and whitening, narrowed venous vessels in the nasal retina, and “coin” hemorrhages were observed in the 4 quadrants, without associated vitritis. The LE also presented upper peripapillary splinter hemorrhage with bloodless vessels in the upper nasal. A papillary optical coherence tomography (OCT) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) was taken, showing RNFL edema in all papillary sectors.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A computed tomography (CT) scan was agreed upon given the presence of bradypsychia reported by the patient, which showed evidence of basal ganglia inflammation compatible with methanol poisoning. A control MRI (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) confirmed symptoms compatible with methanol poisoning. Slight flattening and moderate signal increase were seen on both optical discs.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was admitted to internal medicine for ethanol perfusion treatment for 3 days, dosed at 20<span class="elsevierStyleHsp" style=""></span>mg/h to maintain therapeutic blood ethanol levels between 100 and 200<span class="elsevierStyleHsp" style=""></span>mg/dl. Likewise, folinic acid and corticosteroid bolus of 1<span class="elsevierStyleHsp" style=""></span>g of methylprednisolone were administered for 3 consecutive days, subsequently reduced to 60<span class="elsevierStyleHsp" style=""></span>mg/day of oral prednisone. During admission, the patient reported improvement, presenting a VA of hand movement.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Papillary OCT after one week of treatment showed a decrease in RNFL edema. Visual field test performed a week after diagnosis showed a marked loss of retinal sensitivity in both eyes, with some islands with partially preserved sensitivity. Two weeks after starting treatment, the patient evidenced improvement in VA, with RE reaching 0.15 and the LE 0.2 including changes in OCT and CV (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Ganglion cell layer study (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) showed decreased thickness despite the visual improvement registered and reported by the patient during admission.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">After 2 weeks the patient was discharged from the hospital with corticosteroid treatment at home, as well as a prescription of group B vitamin complex.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Methanol and toluene are present in many products, such as homemade or adulterated wines and liqueurs, solvents, burning alcohol, cleaning products, glues, etc. Oral intake of high amounts of methanol, both intentional and accidental,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> have been the most frequently described forms of poisoning. There are some isolated publications in which intoxication is produced through transdermal absorption<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> and inhalation.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> The case was caused by mixed absorption through both pathways.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Methanol toxicity is due to its metabolites, formaldehyde and formic acid. Lethal oral doses are estimated around 30–60<span class="elsevierStyleHsp" style=""></span>ml. It is a severe poisoning that usually requires admission to intensive care.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Despite current treatments nowadays, mortality rates are between 26% and 50%, and cases that survive are usually associated to neurological and visual sequelae.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Symptoms of methanol poisoning can appear in the first 72<span class="elsevierStyleHsp" style=""></span>h, with relevant neurological symptoms including headache, agitation, rigidity, seizures, decreased level of consciousness, nausea, vomiting and abdominal pain secondary to systemic metabolic acidosis. The visual symptoms described in different studies range from small scotomas to significant VA losses, even leading to blindness.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3,5</span></a> Pupil motility is decreased probably related to the deterioration of the intrinsic photosensitivity of ganglion cells, a sign of poor prognosis.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> In acute stages of intoxication, optic disk hyperemia and inflammation are frequently observed, although they may remain normal, as was observed in this case. Optic nerve atrophy appears within the first month with evident papillary pallor.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> Particularly, the presence of damage at the myelin level has been histopathologically demonstrated.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In what concerns toluene intoxication, this case could be an intoxication cofactor. Euphoria, hallucinations, ataxia, confusion-coma and optic neuropathy can occur, among other disorders.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Electroretinograms in methanol poisoning may show decrease in the b wave due to Muller cells injury.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Toluene produces an alteration of wave C amplitudes due to injury at the pigment epithelium level.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">At the neurological level, severe methanol poisoning can induce hemorrhagic necrosis of the putamen, responsible for sudden onset Parkinson, not being the present case. Occasionally, CT and MRI show hypodensity at putamen level compatible with necrosis, since it is an area of high metabolic demand sensitive to hypoxia such as the optic nerves.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In chronic exposure, toluene can produce a diffuse symmetric signal increase in periventricular and subcortical white matter, internal capsules, brain stem, cerebellum and superior cervical spinal cord in T2, as well as generalized cerebral atrophy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Treatment for this ailment treatment must be early, possibly requiring hemodialysis and use of inhibitors of enzyme alcohol dehydrogenase responsible for methanol metabolism, such as ethanol and 4-methylirazole (fomepizole) or antizol. Ethanol is administered by infusion to reach blood levels around 150<span class="elsevierStyleHsp" style=""></span>mg/dl. To date, there is no evidence of the benefit of intravenous corticosteroids; however, cases of visual function improvement using prednisone in doses of 1<span class="elsevierStyleHsp" style=""></span>mg/kg/day for a month and intramuscular vitamin B<span class="elsevierStyleInf">1</span> 100<span class="elsevierStyleHsp" style=""></span>mg/day<span class="elsevierStyleSup">2</span> have been described.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the present case, ethanol perfusion was started in the first 3 days of admission, reaching doses of 30<span class="elsevierStyleHsp" style=""></span>mg/h to achieve serum ethanol levels between 100 and 200<span class="elsevierStyleHsp" style=""></span>mg/dl, as well as folinic acid and corticosteroids in 1<span class="elsevierStyleHsp" style=""></span>g of methylprednisolone megabolus during the first 3 days of admission, subsequently substituted with 60<span class="elsevierStyleHsp" style=""></span>mg of oral prednisone during the following 10 days of admission. At discharge, thiamine, pyridoxine and cyanocobalamin were prescribed.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Recently, methanol poisoning through transdermal and inhalation path ways has earned increased attention. However, recognizing this condition can be complicated given the lack of specificity of symptoms. It should be borne in mind that methanol poisoning through inhalation and transdermal exposure can also cause serious neurological complications, in particular chronic vision loss and poor functional prognosis. It is important to be aware of this etiology as a cause of bilateral amaurosis. Accurate and early diagnosis, as well as a targeted treatment will guarantee a better prognosis not only in vision, but in patient survival.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0095" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1335168" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1229794" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1335167" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1229793" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-11-19" "fechaAceptado" => "2020-02-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1229794" "palabras" => array:5 [ 0 => "Poisoning" 1 => "Methanol" 2 => "Toluene" 3 => "Ethanol" 4 => "Bilateral amaurosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1229793" "palabras" => array:5 [ 0 => "Intoxicación" 1 => "Metanol" 2 => "Tolueno" 3 => "Etanol" 4 => "Amaurosis bilateral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Methanol poisoning is often described in the literature, but not transdermal or inhalational poisoning. It usually involves variable multi-organ damage, among which visual, neurological, and gastrointestinal involvement, as well as the metabolic and electrolyte changes that can lead to death. Contact with toluene by occupational or intentional inhalation may also cause neurological abnormalities. This article describes the case of a female patient who was seen in the Emergency Department due to bilateral visual loss secondary to accidental poisoning (inhalation-transdermal) with a solvent containing methanol and toluene. She had a favorable outcome during admission after treatment with ethanol in perfusion and corticosteroids.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La intoxicación por ingesta de metanol es una entidad frecuentemente descrita en la literatura, no así la intoxicación vía transdérmica o inhalatoria. Suele cursar con daño multiorgánico variable, entre lo que destaca la afectación visual, neurológica y digestiva, así como las alteraciones metabólicas y electrolíticas que pueden llegar a causar la muerte. El contacto con tolueno por inhalación ocupacional o intencional puede producir también alteraciones neurológicas. En este artículo se expone el caso de una paciente mujer que acude al servicio de urgencias por pérdida visual bilateral secundaria a una intoxicación accidental (inhalatoria-transdérmica) con un disolvente que contenía metanol y tolueno, entre otros compuestos, y que durante el ingreso evoluciona favorablemente tras tratamiento con etanol en perfusión y corticoides.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gómez Perera S, Rodríguez Talavera I, Tapia Quijada HE, Guerrero-Mártir M, Díaz de Aguilar Osona M, Falcón Roca R. Pérdida visual secundaria a intoxicación inhalatoria y cutánea por metanol y tolueno. A propósito de un caso. Arch Soc Esp Oftalmol. 2020;95:231–235.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1695 "Ancho" => 1751 "Tamanyo" => 340805 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Retinography. Note RNFL whitening and thickening in its papilla entrance that erases first order vessels. (B) Papilla OCT showing peripapillary fiber thickening. (C) CAT. It shows the size increase secondary to basal ganglia inflammation. (D) NMR with marked hypersignal at putamen level. Signal increase on both optical discs.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 889 "Ancho" => 1755 "Tamanyo" => 250945 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A and B) Papillary OCT of the right and left eye respectively; an edema decrease is observed by showing the RNFL peripapillary regular thickness after 2 weeks of treatment. (C) Campimetry of both eyes showing RE visual field abolition and partial recovery of CV in LE temporal region. (D) Retinography of both eyes after 2 weeks of treatment. Note the RNFL edema decrease and absence of retinal hemorrhage.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1204 "Ancho" => 1305 "Tamanyo" => 217372 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">OCT image of BE ganglion cell layer, top (A) on admission and bottom (B) after 2 weeks of treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A methanol intoxication outbreak from recreational ingestion of fracking fluid" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. 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Secondary visual loss due to inhalation and cutaneous poisoning by methanol and toluene. Presentation of a clinical case
Pérdida visual secundaria a intoxicación inhalatoria y cutánea por metanol y tolueno. A propósito de un caso
S. Gómez Perera
, I. Rodríguez Talavera, H.E. Tapia Quijada, M. Guerrero-Mártir, M. Díaz de Aguilar Osona, R. Falcón Roca
Corresponding author
Graduado en Medicina, Servicio de Oftalmología, Hospital Universitario de Canarias, Tenerife, Spain