Cerebellar infarction following accidental inhalation of toluene-mixed paint

We report a case of atypical cerebellar infarction following accidental inhalation of toluene mixed paint. An unconscious 57-year-old housewife with hypertension arrived at our emergency department by ambulance. She had been rescued from a basement (30 m³) 12 h after exposure to paint containing toluene (34%). On arrival, she was comatose (E₁V₁M₁) with a mild fever (37.4 °C). Physical examination showed chemical burns on her buttocks and rales on the left lung. Initial arterial blood gas with 15 L/min of oxygen showed a pH of 7.142, PCO₂ of 47.3 mmHg, and PaO₂ of 204.7 mmHg. She received endotracheal intubation and mechanical ventilation. Laboratory tests showed elevated white blood cells (26.86 × 10⁹/L), C-reactive protein (0.18 mg/dL), glucose (238 mg/Dl), and CPK (1389 U/L). At 5.5 h after arrival, she became responsive to verbal commands. On day 3, after removal of the endotracheal tube, she began to complain of an occipital headache without neurologic abnormalities. Brain magnetic resonance angiography (MRA) performed on day 6 showed a tiny acute infarction on the right cerebellar hemisphere. We serially measured urinary hippuric acid concentrations (reference range, ≤2.5 g/g creatinine) from 74 h (3.88) after hospital arrival to 218 h (0.5). She was discharged on day 14. Herein we presented a near fatal toluene intoxication (>45,000 mg/m³ estimated based on the basement volume and quantity of paint used) with atypical cerebellar infarction, compared with prior findings of bilateral involvement or reversibility.