Toilet cake encephalopathy

Paradichlorobenzene (PDB) is an aromatic compound found in several household insect repellents and deodorizers. Paradichlorobenzene may cause dependence and damage when inhaled or ingested. Prior cases of PDB neurotoxicity involved ingestion or inhalation of mothballs or occupational exposure. We report the first case of PDB neurotoxicity from chronic toilet bowl deodorizers ("toilet cake") sniffing. A 19-year-old woman, 4 weeks postpartum, presented with gradual mental status deterioration, lethargy, and general weakness for 2 weeks. On physical examination, the patient was found to have a strong odor of deodorizer and diffuse hyperpigmented skin lesions, with scratch marks in neck, axillae, trunk, and 4 limbs. She was alert but unable to communicate or follow commands. Ataxia, hyporeflexia, cogwheel rigidity, and decreased muscle tone were also noted. Laboratory tests revealed only normocytic anemia. A brain magnetic resonance imaging scan showed enhancement within the splenium of the corpus callosum. Postpartum depression, psychosis, and panhypopituitarism were excluded. Family members reported on further questioning that the patient was a habitual "toilet cake" sniffer for an unknown period. A urine test for 2,5-dichlorophenol (a PDB metabolite) level was 620 mg/L ( 3100 times higher than the average concentration with household exposure). Her clinical condition and body odor remained unchanged during the 30-day hospitalization and the skin findings improved.