Pulmonary injury after intravenous hydrocarbon injection

Abstract

This report describes the case of a young man in whom an intravenous injection of a hydrocarbon led to reversible pulmonary edema. An 18-year-old male presented with chest pain, a cough and progressive dyspnea at a multidisciplinary paediatric intensive care unit in a tertiary care university hospital. Six hours after oxygen was given, blood gases were pH 7.16, partial pressure of carbon dioxide 43 torr (5.7 kPa), partial pressure of arterial oxygen 149 torr (19.9 kPa) and bicarbonate concentration 15 mEq/L. A chest radiograph suggested pulmonary edema. On day 3, the patient stated that he had injected himself with Varsol (Imperial Oil, Canada) – a mixture of straight and branched-chain hydrocarbons, naphthenes and alkyl derivatives of benzene – several hours before his admission. On day 5, the patient’s respiratory rate returned to 20 breaths/min, and his chest radiograph was normal by day 7. The present case report suggests that the intravenous injection of hydrocarbons may lead to reversible pulmonary injury.

The case of a young man in whom an intravenous injection of a hydrocarbon led to reversible pulmonary edema is presented.

CASE PRESENTATION

An 18-year-old male with a history of self-inflicted hematuria presented with chest pain, a cough and progressive dyspnea. Physical examination was normal, except for puncture sites in the antecubital fossa. Arterial blood gases on room air were pH 7.37, partial pressure of carbon dioxide 32 torr (4.3 kilopascal [kPa]), partial pressure of arterial oxygen 74 torr (9.9 kPa), and bicarbonate concentration 15 mEq/L. A chest radiograph showed increased vascular markings. Oxygen (fraction of inspired oxygen 0.60) was given by face mask. Six hours later, the patient became agitated, confused and experienced tachypnea; arterial blood gases were pH 7.16, partial pressure of carbon dioxide 43 torr (5.7 kPa), partial pressure of arterial oxygen 149 torr (19.9 kPa) and bicarbonate concentration 15 mEq/L. A chest radiograph showed pulmonary edema. Meperidine, promethazine, furosemide (40 mg) and 100% oxygen were prescribed. The patient’s clinical condition and his blood gases improved.

On day 2, a pulmonary examination showed bibasilar rales and tachypnea (57 breaths/min; otherwise, the patient’s physical examination was normal. More furosemide was given. An echocardiogram, an electrocardiogram and creatine kinase levels were normal. A pulmonary ventilation-perfusion scan revealed no signs of embolism, but small, peripheral defects that were compatible with parenchymatous lesions were observed. The patient was gradually weaned from supplemental oxygen.

On day 3, the patient stated that he had attempted suicide by injecting himself with Varsol (Imperial Oil, Canada) on the day of admission. The patient had used an intravenous line and needle kit. Hydrocarbons were identified in the tubing found in his apartment. It was not possible to determine the exact quantity of hydrocarbons injected.

On day 5, the patient’s respiratory returned to 20 breaths/min, and a radiograph of his chest was normal by day 7. On day 9, the patient agreed to pulmonary function testing. Although he was clinically asymptomatic, he had a moderate restrictive syndrome, with a low carbon monoxide diffusing capacity of the lungs. By day 12, the pulmonary function tests had improved but they still showed a slight restrictive syndrome. On day 15, the tests were completely normal.

An extensive workup was performed to find another cause of the lung injury; none was identified. Urine and blood toxicological screening by thin layer chromatography were negative. Creatinine clearance, urinalysis, and hepatic and pancreatic enzyme levels were normal, as were hematological and immunological investigations (complete blood count, coagulation profile, protein electrophoresis, immunoglobulins, sedimentation rate and C-reactive protein, autoimmune antibodies). The patient was discharged on day 15 with psychiatric counselling and medical follow-up.

DISCUSSION

Varsol is a trademark name for mineral spirits that are often used as paint thinners. Also known as Stoddard solvents, they are a mixture of straight and branched-chain hydrocarbons, naphthenes and alkyl derivatives of benzene (1). It is well known that hydrocarbons cause lung injury by local toxicity (2) in both humans (3) and animals (4); the pathological injury is an immediate effect that is secondary to the aspiration of these substances. That hydrocarbons cause lung injury by systemic toxicity is less well established.

We report a case that strongly suggests that intravenous injection of a hydrocarbon can induce severe, reversible pulmonary damage. Our patient and three cases reported in the literature (5–7) confirm that intravenous hydrocarbons, including Varsol, can cause a severe, acute pulmonary edema suggestive of an acute lung injury; therefore, intravenous hydrocarbons should be considered as a possible cause of acute lung injury. Our case also showed that a return to normal pulmonary function is possible after several weeks. We suspect that the pathological injury resembles the damage described after the injection of naphtha into the tail vein of rats (4). The mechanisms that underlie the higher vulnerability of lungs are unknown.

CONCLUSION

Intravenous injection of hydrocarbons may lead to reversible pulmonary injury. Treatment of this injury may only need be symptomatic.