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Ethyl chloride is commercially available as a DVD/VCR cleaner, and can be found as a gasoline additive and topical anesthetic. There is an emerging trend of recreational huffing to enhance sexual relations. Neurotoxicity from repeated abuse is uncommon.
A 36-year-old man with a history of intermittent ethyl chloride use for 15 years presented to the Emergency Department with an inability to walk for 4 days after frequent use for 1 week. The patient reported a rapid titration of inhalation from zero to eight cans of 4.6 oz ethyl chloride aerosol per day over a 1-week period. Initial vital signs were heart rate 88 beats/min, blood pressure 147/60 mm Hg, temperature 37.2°C (99°F), and respiratory rate 16 breaths/min. Physical examination was notable for slurred speech, ptosis, a wide-based and ataxic gait with short strides, inability to stand without support, loss of toe/finger proprioception, horizontal and vertical nystagmus, and dysmetria on coordination testing. Strength and sensation were preserved. His work-up included computed tomography and magnetic resonance imaging of the brain, cervical, thoracic, and lumbar spine that demonstrated no acute abnormalities. On hospital day 9, the patient was able to ambulate with mild difficulty.
Toxicity from excessive ethyl chloride huffing has been rarely reported. The toxicity was characterized with cerebellar findings, no attributable laboratory abnormalities, and no radiographic abnormalities on computed tomography/magnetic resonance imaging. The neurotoxicity resolved with supportive care.
Why Should an Emergency Physician Be Aware of This? This case of excessive huffing of ethyl chloride presenting with neurotoxicity and ataxia further characterizes a rare complication of ethyl chloride toxicity that is gaining popularity.
). Ethyl chloride is also commercially available as a DVD/VCR head cleaner or topical anesthetic, and it is easy to purchase online. There is an emerging trend of recreational use for sexual enhancement within the men-who-have-sex-with-men (MSM) community, like the use of alkylated nitrites (“poppers”) (
A 36-year-old human immunodeficiency virus-negative, homosexual man with history of intermittent ethyl chloride huffing for 15 years presented to the Emergency Department (ED) with an inability to walk for 4 days after more frequent daily use for 1 week leading up to presentation. The patient reported a rapid titration of “ragging” from zero to eight 4.6-oz ethyl chloride aerosol cans per day over a 1-week period. The patient used the brands Maximum Impact® (Lake Worth, Florida) and Amsterdam® obtained from local adult entertainment stores (Fig. 1). He denied use of supplements or prescription medications. He recreationally used marijuana but denied other inhalant or drug use. He denied use of nitrous oxide. He ceased using ethyl chloride 3 days prior to presentation.
A similar episode of ataxia occurred 1 month prior after a similar episode of heavy ethyl chloride use, and symptoms resolved over 2 weeks. He reported a negative magnetic resonance imaging (MRI) scan of the brain during that evaluation, but the records were unobtainable. The patient was abstinent from ethyl chloride use from prior symptom resolution until this recent binge. Initial vital signs were heart rate 88 beats/min, blood pressure 147/60 mm Hg, temperature 37.2°C (99°F), and respiratory rate 16 breaths/min. Physical examination was notable for slurred speech, ptosis, a wide-based and ataxic gait with short strides, inability to stand without support, loss of toe/finger proprioception, horizontal and vertical nystagmus, bilateral finger-to-nose dysmetria, bilateral mild heel-to-shin dysmetria, and normal strength and sensation. Laboratory data were notable for serum bicarbonate of 20 mmol/L, creatinine 1.21 mg/dL, and alkaline phosphatase 35 U/L. Otherwise, laboratory data were normal; other pertinent labs are summarized in Table 1. Computed tomography of the brain and MRI of the brain, cervical, thoracic, and lumbar spine were performed to rule out other pathology such as demyelinating disease and demonstrated no acute abnormalities. Due to the lack of other etiologies being found and his history of ethyl chloride abuse previously with similar symptoms that improved with cessation, this diagnosis seemed the most likely. Further laboratory data were obtained to rule out other possible volatile hydrocarbons, vitamin deficiency, and nitrous oxide as the etiology of his presentation (Table 1). He initially had minimal improvement of his symptoms after admission; however, on symptom day 9 he dramatically improved and was able to ambulate with mild difficulty when using a cane. On 2-week follow-up after discharge, he reported minimal difficulty ambulating with a cane and denied any further ethyl chloride abuse. He had no other neurologic symptoms or complaints. Incidentally, the patient was observed walking normally at a local grocery store 221 days after discharge.
Ethyl chloride (chloroethane, C2H5Cl) is a volatile aliphatic, halogenated hydrocarbon with a pungent ether-like smell. It is noted to be highly lipophilic and is rapidly absorbed by the lungs. Previously, it was used as a general anesthetic, but fell out of favor once safer anesthetics became available. Ethyl chloride is still used in modern medical practice as a topical anesthetic prior to orthopedic joint injections because evaporation from the skin produces a rapid cooling sensation (
). Cardiac dysrhythmias can occur with heavy ethyl chloride use as with other halogenated hydrocarbons. In recent years ethyl chloride has gained popularity as a sexual aide stimulant within the MSM community (
). Ethyl chloride is “ragged,” unlike traditional poppers (alkylated nitrites) where the fumes are directly inhaled from the bottle. Ethyl chloride is commercially available in stores and online as DVD/VCR head cleaner and topical anesthetic. Common brand names include Maximum Impact, Amsterdam, Rush, and Jungle Juice (Fig. 1) (
). Ethyl chloride is eliminated unchanged through respiration and is hepatically metabolized by both the cytochrome P450 system and glutathione-S-transferase-dependent conjugation in rodents. Human metabolism and elimination is not well understood. Ethyl chloride can be measured by blood testing through gas chromatography/mass spectrometry, thus, ethyl testing is impractical, difficult, and not easily accessible (
). The patient had a slow and prolonged recovery, most likely attributable to the significant central nervous system distribution and high lipophilicity. Treatment for ethyl chloride toxicity is supportive; there are no methods to enhance elimination or antidotes. Patients should be monitored for hypoxia, cardiac dysrhythmias, and electrolyte abnormalities. This patient's neurotoxicity was subacute and spontaneously resolved with supportive care. Interestingly, this case also represents an exposure, re-exposure for toxicity after repeated heavy abuse.
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?
Ethyl chloride is widely available, easily obtained, and is used as a sexual enhancement drug and a drug of abuse (