Published: 2020-09-18

Lighter Fluid Inhalation and Neurological Sequelae as a Forensic Case

Ege Üniversitesi Tıp Fakültesi Adli Tıp Anabilim Dalı, İzmir
Ege Üniversitesi Tıp Fakültesi Adli Tıp Anabilim Dalı, İzmir
Ege Üniversitesi Tıp Fakültesi Adli Tıp Anabilim Dalı, İzmir
Ege Üniversitesi Tıp Fakültesi Adli Tıp Anabilim Dalı, İzmir
lighter gas volatile substance inhalation forensic medicine ventricular fibrillation çakmak gazı uçucu madde inhalasyon adli tıp ventriküler fibrilasyon

Abstract

The use of inhalants, also known as volatile substances, is increasing all over the world. Lighter gas is one of the most frequently used inhalants, because it is easily accessible, can be bought legally and cheaply and has a pleasant effect in a short time.

In this case report, an 18-year-old case that had a cardiac arrest in the street after lighter gas inhalation about three years ago was presented. He had a generalized tonic seizure during his follow-up in intensive care unit, and had changes secondary to hypoxic ischemic damage due to inhalation of butane gas in his cranial MRI and also had severe motor and mental neurological sequelae.

In literature review, there were mostly autopsy studies of sudden death due to lighter gas inhalation. We think that presented case would contribute to the literature because it clearly reveals neurological sequelae as a result of lighter gas inhalation.

Lighter Fluid Inhalation and Neurological Sequelae as a Forensic Case

1. Introduction

The volatile substances, also known as inhalant substances, are defined as substances that can easily evaporate at room temperature (1). Among these substances, butane and propane are the most common substances to be abused because of their pleasurable properties, and these fluids are also used in air freshener sprays, deodorants and lighters (2).

There are different ways of administration in the misuse of inhalant substances. They can be used by breathing through the nose of the container they are in, squeezing aerosol sprays directly into the mouth and/or nose, pouring the substance into plastic or paper bag and then breathing through nose and mouth and pouring the substance onto a piece of cloth and sniffing it (3).

Inhaled substances are increasingly being used all over the world due to their ease of access, being legally and cheaply available, having a pleasurable effect in a short period of time (3). In recent years, there have been studies showing an increase in lighter fluid misuse, especially among adolescents in Turkey (4-6).

Volatile substances cause many problems, including acute and/or chronic, physical and/or mental problems (7). Volatile substances may lead to sudden death due to their effects; such as cardiac arrhythmias, hypoxia, and respiratory depression in the acute period, and often cause neuropsychiatric disorders in the chronic period (7,8).

This case report aims to evaluate the findings and neurological sequelae that arise from lighter fluid inhalation from a forensic-medical perspective.

2. Case

After the lighter fluid inhalation, 18 years old male case consulted our Forensic Medicine outpatient clinic with the request to be arranged the forensic report.

From the examined document, it was noted that the patient smelled lighter fluid about three years ago before he consulted the clinic, he was found in cardiac arrest on a street, intervened by 112 ambulance services, defibrillated upon taking ventricular fibrillation rhythm in cardiopulmonary resuscitation, then, he was taken to a State Hospital Emergency Department. He was intubated, and activated charcoal was applied. The case was defibrillated twice more during follow-up, returned to a normal rhythm. His general medical condition was not good and was transferred to the University Hospital on the same day.

In Child Intensive Care Service documents after referral, it was noted that the case was followed up as intubated, the light reflexes were bilaterally taken, there were the coarse crackles (rales) in the lung auscultation, activated charcoal was present in the tracheal aspiration, and the appearance was consistent with possible charcoal aspiration on the right side of the chest X-ray (Picture 1). It has been observed in Echocardiography (Echo) that there was a minimal smear type of pericardial fluid, and ventricular functions were normal.

Picture 1. Appearance consistent with activated charcoal aspiration in the right lung.

On the fourth day of the follow-up, it was reported that antiepileptic treatment was started due to generalized tonic-clonic seizure lasting 20-30 seconds, contractions increased as a spasm, and he had dystonia in the form of opisthotonos position and the way legs crossed.

In electroencephalography of the case (EEG), it was stated that bilateral synchrony of slow waves at theta frequency was recorded in parietooccipital regions, the basic rhythm was slow, and its clinical movements were thought to be non-epileptic. Deep tendon reflexes decreased, and no pathology was detected in electromyography (EMG).

In the Cranial Magnetic Resonance Imaging (MRI); in the bilateral frontoparietal cortex (Picture 2) and the occipital region, adjacent to calcarine sulcus (Picture 3), there were changes secondary to primarily hypoxic-ischemic damage and in bilateral putamen secondary appearance to inhalation of toxic gas (butane gas) (Picture 4).

Picture 2. Hyperintense in the diffusion sequence (2a) and hypointense regions in the ADC map (2b) in the diffusion MRI examination.

Picture 3. Hyperintense in the diffusion sequence (3a) and hypointense regions in the ADC map (3b) in the diffusion MRI examination.

Anamnesis and examination of the case were taken in our department (approximately three years after the incident), his family described that he had forgetfulness and we determined gait and speech disorders. No external lesions were observed due to the incident. A neurology consultation was requested. As a result of the consultation, the following problems were detected: dysarthria, dystonic posturing of the extremities and the myocloni, sometimes athetoid movements, impairment in fine hand skills, ataxia and dystonic movements, performance decrease in semantic fluency skills, orientation in space and time, complex attention-concentration, complex calculations, mental flexibility, construction, immediate visual memory, abstraction, disorder of naming skills and significant losses in close memory functions.

It is stated that in the forensic report of the case that the injury due to lighter fluid inhalation causes a situation that endangers the person's life, it can’t be cured by a simple medical treatment, it causes an incurable illness and a permanent speech defect.

Picture 4. Hyperintense areas in the bilateral putamen in T2a flair sequences.

3. Discussion and Conclusions

All over the world, hypnotic substances and drugs are a growing public health problem with the physical and mental problems they cause. This is particularly affecting children-young people who are the future of the societies. In this regard, volatile substances have also been added among the substances commonly used, such as heroin, cocaine, ecstasy and synthetic substances. According to the “National Survey on Drug Use and Health”, which evaluated the use of volatile substances in children, adolescent and young adult age groups by the U.S. National Institute on Drug Abuse, since 2017, the rate of volatile substance use at least once in life was 9.3% at the age of 12 and below; 8.6% in the 12-17 age group; 9.5% among the 18-25 age group; 9.3% for individuals aged 26 and over were detected (9).

In another report presenting the prevalence of drug use in American youth, the rate of volatile substance use at least once in life for 2018 was stated as 8.7% in eighth grades, 6.5% in tenth grades, and 4.4% in twelfth grades (10). In a meta-analysis study, which looked at the prevalence of lifelong use of different substances among street children and young people living in low socioeconomic environments, it was reported that once-in-a-lifetime use of inhaled substances was 47% (11). When we look at this situation from the perspective of our country, it is seen that the usage rates are slightly lower. For instance, a study which was conducted in Kocaeli in 2017, found that the rate of volatile, drug and stimulant substance use in high schools was 3.6% (12). Again, in our country, one who used volatile substances at least once in their lifetime was determined to be 8.8% in another study, which investigated the prevalence of volatile substance use among high school students in 15 separate provinces. (13). However, it may be considered that these studies may not reflect the actual usage rate because the population with certain characteristics (such as high schools, patients working in occupational groups with volatile substances, patients applying to clinics for treatment) was selected (12-14).

Volatile substances are commonly used in everyday life products, such as adhesives, gasoline, paint thinner, spray paints, deodorants, hair sprays and lighter fluids (7). People often inhale gas to cheer up or enjoy it, or because of curiosity, they prefer lighter filling tubes that contain butane gas, which are easily supplied and cheap (5, 15). Although the presented case was injured as a result of lighter fluid inhalation, it was not possible to obtain information about the method by which lighter fluid was inhaled and how long it was inhaled.

It is reported that patients who use volatile substances, begin to use another addictive substance eventually and that it is common to use volatile substances in combination with another addictive substance (15). Our case has a history of inhalation bally in addition to lighter fluid.

In the literature, it is emphasized that volatile substance usage is the most common in males and adolescents (15). The age and sex of the case presented are in line with the literature. In addition to child/adolescent age group and male sex, the presence of family problems, low socioeconomic level, living on the street, working in occupational groups using volatile substances, are among the other risk factors of volatile substance addiction (16).

Volatile substance abuse is a major cause of morbidity and mortality, pathologies that arise from abuse are diverse (1,2), which may cause sudden death by causing suffocation, vagal inhibition, respiratory depression, and cardiac arrhythmias such as ventricular fibrillation (8). It has been stated that more than 50% of sudden deaths are due to direct toxic (especially cardiac) effects (17-19). The case presented was found in cardiac arrest in the street after inhalation of lighter fluid, and defibrillation was performed on ventricular fibrillation rhythm after cardiopulmonary resuscitation.

Neuropsychiatric sequelae are often seen in chronic volatile substance users. Neurological and behavioral findings and symptoms, peripheral neuropathy, headache, paresthesias, cerebellar symptoms, permanent motor dysfunction, Parkinsonism, apathy, lack of concentration, memory loss, visual-spatial dysfunction, distortion in the processing of verbal material and lead encephalopathy can be considered (1,7). In studies brain atrophy have been shown by Computed Tomography (CT) and; white matter degeneration, deterioration in subcortical structures, such as the thalamus, pons, basal ganglia and cerebellum shown by MRI (1,7). Our patient had seizures on the fourth day of follow-up, and cranial MRI showed changes secondary to hypoxic-ischemic damage and toxic gas (butane gas) inhalation. In the examination of our case conducted by the us and Department of Neurology after about three years, severe motor and mental, neurological sequelae were detected. In the literature review, it was noted that mostly studies about lighter fluid inhalation were autopsy studies of sudden death cases (20,21). It was thought that our case would contribute to the literature because it clearly reveals the neurological sequelae that may occur as a result of lighter fluid inhalation.

As in this case, it is thought that the ease of access to addictive substances, such as lighter fluid, especially in the childhood age group, will result in a further increase in the use of such substances. Thus; especially under the age of 18, restriction of access to substances that are or may be abused, controlling the sale of such substances are only a few of the precautions that can be taken. In our country, volatile substances are defined by “TheRegulationon theProtectionofHumanHealthFromTheDamagesofVolatile Substances” published in the Official Gazette dated 05.08.2010 and numbered 27663 and regulations have been made on the sale and possession of volatile substances. Some governorates have also issued resolutions prohibiting the sale of lighters and lighter fluids to children (22-23). It is also considerable importance that families fulfill their obligations of taking attention and care towards their children.

The situation that occurred in the case presented in this study attracts attention with its permanent neurological sequelae; and it has been endangering a person’s life, causing an incurable illness and a permanent speech defect; caused severe damage (24). Simple and small precautions that can be taken, they will prevent situations that may bring about such a severe disability.

References

Williams JF, Storck M; American Academy of Pediatrics Committee on Substance Abuse; American Academy of Pediatrics Committee on Native American Child Health. Inhalant Abuse. Pediatrics 2007;119(5):1009-17. https://doi.org/10.1542/peds.2007-0470

Gökalp G, Berksoy E, Anıl M, Bıcılıoğlu Y, Zengin N, Kamit Can F, Anıl AB. Nadir Görülen Bir Kardiyotoksisite: Bütan İnhalasyonu. J Pediatr Emerg Intensive Care Med 2018;5:132-33. https://doi.org/10.4274/cayd.70883

World Drug Report 2018, Booklet 4 Drugs and Age, Drugs and associate dissues among young people and older people. https://www.unodc.org/wdr2018/prelaunch/WDR18_Booklet_4_YOUTH.pdf. Erişim Tarihi: 10.03.2019

Sen A, Erdivanli B. Cardiac Arrest Following Butane İnhalation. Anesth Essays Res 2015;9:273-5. https://doi.org/10.4103/0259-1162.156366

Öncü SB, Güzel A, Paksu Ş, Şahin S, Suna F, Yüce M. Lighter Gas Inhalation: A Case Report. CAYD 2014;1(2):101-3.

Tekelioglu U, Ocak T, Demirhan A, Erdem A, Tekelioglu V, Kocoglu H. Sudden Death due to Voluntary Lighter Fluid İnhalation: A Case Report. Int J Med Sci Public Health 2013;2(4):1128-30. https://doi.org/10.5455/ijmsph.2013.220820133

Boztaş MH, Arısoy Ö. Uçucu Madde Bağımlılığı ve Tıbbi Sonuçları. Current Approaches in Psychiatry 2010;2(4):516­31.

Sugie H, Sasaki C, Hashimoto C, Takeshita H, Nagai T, Nakamura S, et al. Three Cases of Sudden Death due to Butane or Propane Gas Inhalation: Analysis of Tissues for Gas Components. Forensic Sci Int 2004;143:211–4.DOI: https://doi.org/10.1016/j.forsciint.2004.02.038

National Survey on Drug Use and Health: Trends in Prevalence of Various Drugs for Ages 12 or Older, Ages 12 to 17, Ages 18 to 25, and Ages 26 or Older; 2015-2017 (in percent)*, https://www.drugabuse.gov/national-survey-drug-use-health, Erişim tarihi: 09.06.2019.

Monitoring the Future Study: Trends in Prevalence of Various Drugs for 8th Graders, 10th Graders, and 12th Graders; 2015-2018 (in percent)*, https://www.drugabuse.gov/trends-statistics/monitoring-future/monitoring-future-study-trends-in-prevalence-various-drugs, Erişim tarihi: 09.06.2019.

Embleton L, Mwangi A, Vreeman R, Ayuku D, Braitstein P. The Epidemiology of Substance Use among Street Children in Resource constrained Settings: A Systematic Review and Meta-analysis. Addiction 2013;108(10):1722-33. https://doi.org/10.1111/add.12252

Taylan HH, Genç Y. Liselerde Sigara, Alkol ve Uyuşturucu/Uçucu/Uyarıcı Madde Kullanım Eğilimleri: Kocaeli Örneği. ASOS 2017;47:180-99. https://doi.org/10.16992/ASOS.12367

Ögel K, Tamar D, Evren C, Çakmak D. The Prevalence of Volatile Substance Abuse: Evaluation of Data In Multi-Center Study. Anadolu Psikiyatri Derg 2000;1(4):220-24

Kuğu N, Akyüz G, Erşan E, Doğan O. Sanayi Bölgesinde Çalışan Çıraklarda Madde Kullanımı ve Etkileyen Etkenlerin Araştırılması. Anadolu Psikiyatri Derg 2000;1(1):19-25.

Evren C, Ögel K, Tamar D, Çakmak D. Uçucu Madde Kullanıcılarının Özellikleri. Bağımlılık Dergisi 2001;2(2):57-60.

Kaya B, Özcan ME. Uçucu Bağımlılığı ve Kötüye Kullanımı: Epidemiyoloji, Risk Grupları ve Önleme Programlarının Gerekliliği. Turkish J Clinical Psychiatry 1999;2(3):189-96.

Williams DR, Cole SJ. Ventricular Fibrillation Following Butane Gas Inhalation. Resuscitation 1998;37(1):43-5. https://doi.org/10.1016/S0300-9572(98)00030-6

Pfeiffer H, Al Khaddam M, Brinkmann B, Köhler H, Beike J. Sudden Death After İsobutane Sniffing: A Report of Two Forensic Cases. Int J Legal Med 2006;120(3):168-73. https://doi.org/10.1007/s00414-005-0062-x

Fuke C, Miyazaki T, Arao T, Morinaga Y, Takaesu H, Takeda T, et all. A Fatal Case Considered to be due to Cardiac Arrhythmia Associated with Butane Inhalation. Legal Med 2002;4:134-8. https://doi.org/10.1016/S1344-6223(02)00004-4

Akcan R, Çekin N, Hilal A, Arslan MM. Gençlerde Uçucu Madde Soluma Sonucu Ani Ölüm: Olgu sunumu. Dicle Med J 2010;37(2):154-6.

Ilhan R, Artar A, Butun C, Yucel Beyaztas F. Butane Gas Inhalation Resulting in Death: Two Case Reports. Med-Science 2015;4(4):2938-46. https://doi.org/10.5455/medscience.2015.04.8275

http://www.izmir.gov.tr/cakmak-ve-cakmak-gazinin-cocuklara-satisinin-yasaklanmasi-hakkinda-karar, Erişim tarihi: 05.08.2019.

http://www.konya.gov.tr/18-yasindan-kucuklere-cakmak-ve-cakmak-gazi-satisinin-yasaklanmasi-ile-ilgili-valilik-karari, Erişim tarihi: 05.08.2019.

Türk Ceza Kanunu’nda Tanımlanan Yaralama Suçlarının Adli Tıp Açısından Değerlendirilmesi Rehberi. Güncelleme Editörleri: Prof. Dr. Yasemin Balcı, Prof. Dr. Başar Çolak, Dr. Öğr. Üyesi Kağan Gürpınar, Uz. Dr. Nurettin Nezih Anolay. https://www.atk.gov.tr/tckyaralama24-06-19.pdf, Erişim tarihi: 05.08.2019.

References

Williams JF, Storck M; American Academy of Pediatrics Committee on Substance Abuse; American Academy of Pediatrics Committee on Native American Child Health. Inhalant Abuse. Pediatrics 2007;119(5):1009-17. DOI: https://doi.org/10.1542/peds.2007-0470
Gökalp G, Berksoy E, Anıl M, Bıcılıoğlu Y, Zengin N, Kamit Can F, Anıl AB. Nadir Görülen Bir Kardiyotoksisite: Bütan İnhalasyonu. J Pediatr Emerg Intensive Care Med 2018;5:132-33. DOI: https://doi.org/10.4274/cayd.70883
World Drug Report 2018, Booklet 4 Drugs and Age, Drugs and associate dissues among young people and older people. https://www.unodc.org/wdr2018/prelaunch/WDR18_Booklet_4_YOUTH.pdf. Erişim Tarihi: 10.03.2019
Sen A, Erdivanli B. Cardiac Arrest Following Butane İnhalation. Anesth Essays Res 2015;9:273-5. DOI: https://doi.org/10.4103/0259-1162.156366
Öncü SB, Güzel A, Paksu Ş, Şahin S, Suna F, Yüce M. Lighter Gas Inhalation: A Case Report. CAYD 2014;1(2):101-3.
Tekelioglu U, Ocak T, Demirhan A, Erdem A, Tekelioglu V, Kocoglu H. Sudden Death due to Voluntary Lighter Fluid İnhalation: A Case Report. Int J Med Sci Public Health 2013;2(4):1128-30. DOI: https://doi.org/10.5455/ijmsph.2013.220820133
Boztaş MH, Arısoy Ö. Uçucu Madde Bağımlılığı ve Tıbbi Sonuçları. Current Approaches in Psychiatry 2010;2(4):516­31.
Sugie H, Sasaki C, Hashimoto C, Takeshita H, Nagai T, Nakamura S, et al. Three Cases of Sudden Death due to Butane or Propane Gas Inhalation: Analysis of Tissues for Gas Components. Forensic Sci Int 2004;143:211–4.DOI: https://doi.org/10.1016/j.forsciint.2004.02.038
National Survey on Drug Use and Health: Trends in Prevalence of Various Drugs for Ages 12 or Older, Ages 12 to 17, Ages 18 to 25, and Ages 26 or Older; 2015-2017 (in percent)*, https://www.drugabuse.gov/national-survey-drug-use-health, Erişim tarihi: 09.06.2019.
Monitoring the Future Study: Trends in Prevalence of Various Drugs for 8th Graders, 10th Graders, and 12th Graders; 2015-2018 (in percent)*, https://www.drugabuse.gov/trends-statistics/monitoring-future/monitoring-future-study-trends-in-prevalence-various-drugs, Erişim tarihi: 09.06.2019.
Embleton L, Mwangi A, Vreeman R, Ayuku D, Braitstein P. The Epidemiology of Substance Use among Street Children in Resource constrained Settings: A Systematic Review and Meta-analysis. Addiction 2013;108(10):1722-33. DOI: https://doi.org/10.1111/add.12252
Taylan HH, Genç Y. Liselerde Sigara, Alkol ve Uyuşturucu/Uçucu/Uyarıcı Madde Kullanım Eğilimleri: Kocaeli Örneği. ASOS 2017;47:180-99. DOI: https://doi.org/10.16992/ASOS.12367
Ögel K, Tamar D, Evren C, Çakmak D. The Prevalence of Volatile Substance Abuse: Evaluation of Data In Multi-Center Study. Anadolu Psikiyatri Derg 2000;1(4):220-24
Kuğu N, Akyüz G, Erşan E, Doğan O. Sanayi Bölgesinde Çalışan Çıraklarda Madde Kullanımı ve Etkileyen Etkenlerin Araştırılması. Anadolu Psikiyatri Derg 2000;1(1):19-25.
Evren C, Ögel K, Tamar D, Çakmak D. Uçucu Madde Kullanıcılarının Özellikleri. Bağımlılık Dergisi 2001;2(2):57-60.
Kaya B, Özcan ME. Uçucu Bağımlılığı ve Kötüye Kullanımı: Epidemiyoloji, Risk Grupları ve Önleme Programlarının Gerekliliği. Turkish J Clinical Psychiatry 1999;2(3):189-96.
Williams DR, Cole SJ. Ventricular Fibrillation Following Butane Gas Inhalation. Resuscitation 1998;37(1):43-5. DOI: https://doi.org/10.1016/S0300-9572(98)00030-6
Pfeiffer H, Al Khaddam M, Brinkmann B, Köhler H, Beike J. Sudden Death After İsobutane Sniffing: A Report of Two Forensic Cases. Int J Legal Med 2006;120(3):168-73. DOI: https://doi.org/10.1007/s00414-005-0062-x
Fuke C, Miyazaki T, Arao T, Morinaga Y, Takaesu H, Takeda T, et all. A Fatal Case Considered to be due to Cardiac Arrhythmia Associated with Butane Inhalation. Legal Med 2002;4:134-8. DOI: https://doi.org/10.1016/S1344-6223(02)00004-4
Akcan R, Çekin N, Hilal A, Arslan MM. Gençlerde Uçucu Madde Soluma Sonucu Ani Ölüm: Olgu sunumu. Dicle Med J 2010;37(2):154-6.
Ilhan R, Artar A, Butun C, Yucel Beyaztas F. Butane Gas Inhalation Resulting in Death: Two Case Reports. Med-Science 2015;4(4):2938-46. DOI: https://doi.org/10.5455/medscience.2015.04.8275
http://www.izmir.gov.tr/cakmak-ve-cakmak-gazinin-cocuklara-satisinin-yasaklanmasi-hakkinda-karar, Erişim tarihi: 05.08.2019.
http://www.konya.gov.tr/18-yasindan-kucuklere-cakmak-ve-cakmak-gazi-satisinin-yasaklanmasi-ile-ilgili-valilik-karari, Erişim tarihi: 05.08.2019.
Türk Ceza Kanunu’nda Tanımlanan Yaralama Suçlarının Adli Tıp Açısından Değerlendirilmesi Rehberi. Güncelleme Editörleri: Prof. Dr. Yasemin Balcı, Prof. Dr. Başar Çolak, Dr. Öğr. Üyesi Kağan Gürpınar, Uz. Dr. Nurettin Nezih Anolay. https://www.atk.gov.tr/tckyaralama24-06-19.pdf, Erişim tarihi: 05.08.2019.