In this article, we report a glue-sniffing adolescent with various cardiac complications like myocarditis, arrhythmia and coronary vasospasm. Although the dysrhythmias seen in glue sniffers are usually ventricular, we observed atrial flutter, which has not been previously reported. Asking young patients with symptoms of coronary heart disease about substance abuse is very important in order to solve the clinical and social problem of inhalant abuse.
Adhesive glues as well as correction fluids, paint thinners, and aerosol paints contain toluene, n-hexane, methyl ketones, chlorohydrocarbons, and benzene. These substances can be found very easily and used as pleasure-giving inhalants, usually among individuals in low socioeconomic areas. A study from our country reported that the prevalence of paint thinner and adhesive abuse was 73% among homeless children and 5% among students in their second year of high school (3). In the West (e.g. the United Kingdom and United States), 5-20% of children have experimented with inhalants 1-4.
The most common substance in inhalants is toluene. In Turkey, different types of paint thinners and adhesives contain 50-70% and 35-40% toluene 3. It is very difficult to identify inhalant users. Most of the symptoms are nonspecific like dizziness, irritability, tiredness, loss of appetite, headache, photophobia, or cough and can be seen in other illnesses or syndromes 2. Our patient also demonstrated nonspecific complaints at admission. However, during observation the clinical and laboratory findings pointed to myocardial infarction, which is not seen frequently in pediatric patients and led us to suspect substance abuse as a factor.
Cardiac arrhythmias are the most common causes of sudden sniffing death due to the sensitization of the myocardium to catecholamines. Ventricular arrhythmias in particular are attributed to this sensitization 5. In animal studies, some volatile compounds act directly on the heart to reduce sinoatrial node automaticity, prolong PR interval, and induce atrioventricular block 4. Very few cases reported atrial arrhythmia as atrial fibrillation 6. In our patient, we observed atrial flutter which was not reported before.
Although sudden death may be due to its arrhythmogenic effects, glue may also damage the heart by causing chronic myocarditis, which is detected as myocardial edema, irreversible myocarditis, fibrosis, and congestive heart failure in autopsies 1,7,8. In our patient, myocarditis and cardiac failure were reported at admission but the left ventricular ejection fraction returned to normal within a week. Therefore, we thought that myocardial dysfunction, demonstrated by a 45% left ventricular ejection fraction, was due to the acute arrhythmogenic effect and acute coronary vasoconstriction on the basis of chronic myocardial damage.
In conclusion, adolescent patients exhibiting different arrhythmias and myocardial damage should be specifically questioned about substance abuse.