Mothball Ingestion in the Setting of G6PD Deficiency Causing Severe Hemolytic Anemia, Methemoglobinemia, and Multiple Organ Failure in a Toddler.

Mothballs containing naphthalene or paradichlorobenzene are known to cause hemolysis and methemoglobinemia. They can also affect the other organs, including the kidneys, liver, lungs, and skeletal muscles. The involvement of 1 or 2 organs at a time has been commonly reported. However, more than 2 organ dysfunction in mothball intoxication is rare and usually indicates severe illness. The intoxication can have more pronounced symptoms in children with glucose-6-phosphate dehydrogenase (G6PD) deficiency. We report this case of a previously healthy 13-month-old patient who presented with severe hemolysis, lactic acidosis, methemoglobinemia, acute renal failure, hepatic dysfunction, and rhabdomyolysis. He required aggressive fluid resuscitation, blood transfusions, and mechanical ventilation. The underlying etiology of his illness was initially unclear; however, upon repeated questioning, the father recalled the patient chewing on a mothball 3-4 days before admission. Hence, mothball intoxication was considered the most plausible clinical diagnosis in this patient. He was given N-acetylcysteine, instead of methylene blue, because of hepatic dysfunction and the fact that G6PD deficiency could not be ruled out in the presence of acute hemolysis. The patient made a full recovery after 2 weeks of intensive care unit management. G6PD testing after 3 months confirmed the deficiency. These mothballs are available in Hawai'i, but this is the first report of such a severe presentation to our knowledge. The presence of methemoglobinemia, severe hemolysis, and thorough history-taking helped us determine the diagnosis of mothball intoxication and enabled definitive treatment.