Perchloroethylene (PCE) is a colorless liquid. It is widely used as a dry cleaner of fabrics and an anti-parasitic agent. The acute intoxication of PCE is very rare amongst adults because of its unique smell and taste. This liquid has a strong and sweet smell which is quite familiar to chloroform and ether. Therefore, perchloroethylene toxication mostly occurs in the pediatric population.
Chronic PCE intoxication can occur in three ways. Firstly, it can occur with chronic inhalation by dry cleaners in the dry-cleaning field. Secondly, substance abuse among young people can cause intoxication. Perchloroethylene (PCE) can cause euphoria by exciting the central nervous system. And third, the ingestion of contaminated water from the dry cleaning field leaks into the underground water sources. It is an environmental hazard because perchloroethylene(PCE) causes bladder cancer according to the International Agency for Research on Cancer [IARC]. Moreover, it produces hepatotoxic metabolites which can chronically damage the liver and kidney.
This case is about an 89-year-old Caucasian woman with a history of accidental ingestion of PCE. The patient comes to the emergency room with a complaint of drowsiness and tachypnea. The patient had no past medical history of surgical aortic valve replacement, triple coronary artery bypass graft surgery, and arterial hypertension.
According to the family, she is an independent woman who works in her dry cleaning shop. While visiting her laundry, she accidentally drank a sip of PCE from the bottle assuming it to be water. Luckily, she only had a small sip of PCE because she immediately realized its different taste. However, the doctors could not confirm the exact amount of ingested PCE due to the high variability of product concentration and variation in formulas.
The doctor checked her vitals immediately which revealed a dropped Glasgow Coma Scale (GCS) of 3, SpO2 96%, tachycardia with a respiratory rate of 34 breaths/minute, heart rate of 51 beats/minute, and blood pressure of 115/55 mmHg. Her ABGs were normal with a PH of 7.38 and lactate of 2.4 mmol/L.
The doctor contacted the poison control centre for information regarding PCE toxicity. The PCE is a fat-soluble liquid that tends to accumulate in the central nervous system. It is a non-caustic agent and its half-life is very uncertain in humans. The estimated half-life of PCE is 144 hours. The PCE manifests life-threatening effects which include CNS and respiratory depression along with cardiac arrhythmias. Moreover, it can also cause liver injury, kidney injury, and skin erythema. There is no antidote or therapy available for PCE.
Management of Perchloroethylene Toxication
Initially, the patient had a sudden central nervous system depression with a GCS scale of 3. This led the whole team to suspect that the patient had ingested a large quantity of PCE and that immediate management should be started. This includes prolonged mechanical ventilation and a long intensive care unit (ICU) stay which could increase the risk of ICU-related complications.
The meeting was held in which the doctors decided to intubate the patient and admit her to the ICU. The patient had no complications during intubation however she developed severe hypoxemia. The doctors corrected this by increasing FiO2 to 1. The oxygenation improved in the following 3-4 hours with an arterial partial pressure of oxygen of 155 mmHg at FiO2 of 0.6 (ratio between partial pressure of oxygen and FiO2 (PaO2:FiO2) of 258).
The patient was hemodynamically unstable initially which was controlled by fluid resuscitation. The doctors infused the patient with 3000 ml of crystalloids in the first 4 hours. The patient had a normal urinary output. However, the doctors rapidly corrected her unbalanced lactate concentration. Also, she experienced two episodes of supraventricular tachycardia five hours after the ingestion.The doctors immediately treated it with adenosine.
The patient’s neurological condition improved in the ICU and she self-extubated at 3 am almost 12 hours after the PCE ingestion. Moreover, she was fully awake with full consciousness and was coughing properly. This indicates her respiratory system was working normally. The doctor checked her vitals at 8 am and it was as follows: SpO2 98% with 2 L/minute nasal oxygen, blood pressure of 145/50 mmHg, respiratory rate of 17 breaths/minute, heart rate of 70 beats/minute, and urinary output of 1400 ml.
The patient was stepped down from the ICU within 24 hours and 4 days later she was sent home. The patient had no severe complications during the hospital stay. However, she noticed a single episode of blood in the sputum. For further evaluation, the doctors sent a blood and urine sample to the forensic toxicology department of the University of Milano to measure the amount of PCE present in it.
The results were as follows: blood concentration 9.45 ng/ml and urine concentration 25.5 ng/mg. However, they were of little clinical importance.
Reference: Journal of Medical Case Reports