toluene ( methylbenzene ) , an aromatic hydrocarbon is a non - corrosive , colorless , volatile , inflammable liquid with a strong pleasant odor . it is commonly used as an additive and solvent in numerous industries for automotive coatings , thinners , reactive diluent , rubber , adhesives , printing - ink , shoe polish , and correction - fluid diluents . unusual methods of suicide by intravenous administration of solvents like kerosene and gasoline are rare . relevant literature was searched via pubmed , pubchem , toxnet , hazardous substances data bank ( hsdb ) , embase , and psycinfo using keywords  toluene  ,  suicide  , and  intravenous  . to our knowledge , this is the first case of suicide by intravenous administration of toluene in the literature . a 24-year - old male with right - hand dominance , paramedical professional , presented to the emergency department at 0200 hours with chest discomfort , breathlessness , and hemoptysis , following intentional intravenous self - administration of  correction - fluid diluent ( 5 ml ) at 0130 hours [ figure 1a ] . misuse by drinking or inhalation can be harmful , even fatal  [ figure 1b ] . on admission , glasgow coma scale ( gcs ) score was e4v5m6 , with blood pressure of 130/80 mmhg , pulse rate of 172 bpm , and oxygen saturation ( spo2 ) of 77% . pupils were 3 mm in size , round , regular , and reactive to light . tachypnea with coarse crepitation in bilateral infrascapular and infraaxillary areas were noted suggestive of chemical pneumonitis . local examination revealed two puncture marks at the left cubital fossa indicating self - administration of toluene intravenously [ figure 1c ] . ( c ) intravenous puncture marks over the left cubital fossa with no remarkable local skin reaction at injection site hematological investigations revealed raised hemoglobin ( 18 g / dl ) , leukocytosis ( 33,850/mm ) , normal platelet count , normocytic , and normochromic peripheral blood picture . renal profile showed raised serum creatinine ( 1.7 mg / dl ) , normal blood urea ( 39 mg / dl ) and serum electrolytes . liver profile revealed increase in total bilirubin ( 2.67 mg / dl ) , direct bilirubin ( 1.11 mg / dl ) , indirect bilirubin ( 1.52 mg / dl ) , serum glutamate ortho - transaminase ( 68 u / l ) , with other enzymes and proteins within normal limits . his random blood glucose was 215 mg / dl , possibly due to stress - induced hyperglycemia . management included conservative treatment with intravenous hydration , antibiotics , pantoprazole , ondansetron , and mucolytics . at 0930 hours , patient had abdominal pain , hematemesis with deterioration of spo2 to 75% with oxygen therapy . endotracheal aspirate was hemorrhagic in nature . at 1500 hours , patient was in state of stupor with gcs score of 4 ( e1cv1tm2 ) . at 1730 hours cardiopulmonary resuscitation including defibrillator efforts were in vain and patient was declared as dead at 1810 hours same day ( 16 h after intravenous toluene administration ) . psychological autopsy revealed pervasive depression , apathy , insomnia , anorexia , and reduced social interactions for the past 4 months , with marital discord and he was diagnosed as severe major depressive disorder with possible inhalant use disorder as per diagnostic and statistical manual of mental disorders ( dsm)-5 criteria . necropsy revealed grossly edematous and congested lungs [ figure 2a ] , epicardial petechial hemorrhages [ figure 2b ] , hepatic congestion , gastric mucosal congestion and petechial hemorrhages with contents of 50 ml blackish - red colored blood [ figure 2c ] , and pale intestines . two puncture marks were noted over the left cubital fossa with no remarkable local skin changes [ figure 1c ] . two puncture marks of intravenous cannula and test - dose ( antibiotics ) were noted in right forearm . histopathological findings were suggestive of chronic distal renal tubular acidosis ( type - ii ) . necropsy findings of congested and edematous lungs ( a ) , epicardial petechial hemorrhages over posterior surface of right ventricle ( b ) , and gastric hemorrhages with reddish - brown blood as contents ( c ) in a case of suicide by intravenous injection of toluene toluene is absorbed into circulation by inhalation , ingestion , and dermal or eye contact . being a hydrocarbon of low viscosity , it has a direct toxic effect on lung tissue  interfering with gas exchange and leading to interstitial pulmonary edema and severe hypoxemia caused by impaired diffusion . inhaling low to moderate doses of toluene can cause tiredness , confusion , ataxia , amnesia , nausea , anorexia , and loss of hearing and color vision that usually disappear when exposure is stopped . inhaling high doses of toluene in a short - time may cause cardiovascular effects ( tachycardia , hypo / hypertension , dysrhythmia ) , pulmonary effects ( acute pulmonary edema , asphyxia , aspiration / chemical pneumonitis , respiratory depression , apnea ) , and central nervous system effects ( tremors , ataxia , euphoria , hallucinations , convulsions , delirium , coma , death ) . fatal dose of toluene by inhalation is 1,800 - 2,000 ppm or with blood levels of 25 mg / l [ table 1 ] . ingestion of toluene may cause irritation of the digestive tract with nausea , vomiting , and abdominal pain , with fatal dose of about 50 ml . on skin and eye contact clinical features of toluene inhalation in relation to the content of toluene in our case , initially cardiorespiratory adverse effects like dyspnea , chest discomfort , tachypnea , tachycardia , and hypoxemia developed within minutes ; acute pulmonary edema and pneumonitis developed within 4 h ; abdominal pain , vomiting , hematemesis , and respiratory failure within 8 h ; stupor by 12 h ; and sudden cardiac arrest following ventricular tachycardia and death occurred 16 h after intravenous toluene . psychological autopsy revealed underlying severe depression , inhalant addiction , and marital discord as the precipitating factor for suicide . renal tubular acidosis as a consequence of toluene sniffing was first reported by taher et al . necropsy and histopathological findings supported the effects of toluene on vital organs like lungs , heart , and kidneys in our case . the mechanisms by which toluene induces renal tubular acidosis and hypophosphatemia remain to be elucidated . further case studies on the toxic renal effects of this aromatic hydrocarbon are necessary . blood and urine toxicology screening during admission in suspected cases of toluene poisoning should be considered in the diagnosis of young patients presenting with unexplained hypokalemic paralysis and a normal anion gap metabolic acidosis . management of toluene poisoning is supportive as no specific antidote is available and depends on the mode of contact . in cases of skin or eye contact , , the subject should immediately be removed to fresh air to wash out the poisonous substance through the lungs . oxygen therapy and bronchodilators are also useful . in cases of ingestion , supportive therapy is recommended and use of emetics , activated charcoal , or cathartics is contraindicated for the risk of aspiration pneumonitis . in summary , volatile solvents are commonly abused inhalants , but its intravenous use as a mode of suicide is uncommon . tissue injury mainly depends on the concentration of toluene and the duration of its presence in circulation . treatment of such cases should focus on cardiopulmonary stabilization , as volatile hydrocarbons cause major injury to the lungs ; the organ being the first capillary bed encountered . early and aggressive supportive care ; early intubation and controlled hyperventilation to accelerate elimination of volatile hydrocarbons ; and use of defibrillator in managing sudden cardiac arrest or cardiac arrhythmias , correction of hypokalemic paralysis , and normal anion gap metabolic acidosis may be conducive to a favorable outcome with minimal residual pulmonary sequelae .
toluene ( methylbenzene ; volatile hydrocarbon ) is an industrial solvent that causes major injury to the lungs ; the organ being the first capillary bed encountered . 
 we report an unusual case of suicide by a 24-year - old male , paramedical professional , with fatal outcome within 16 h of intentional , intravenous self - administration of toluene , with clinical presentation of acute respiratory distress syndrome . 
 psychological autopsy revealed severe depressive disorder and solvent ( inhalant ) abuse , with marital disharmony as the precipitating stressor for suicide . 
 necropsy revealed diffuse congestion of internal organs like lungs and liver , epicardial petechial hemorrhages , and gastric hemorrhages . 
 treatment of toluene poisoning includes supportive care as no specific antidote is available . early and aggressive management may be conducive to a favorable outcome with minimal residual pulmonary sequelae . 
 relevant literature of toluene poisoning was identified via pubmed , pubchem , toxnet , hazardous substances data bank ( hsdb ) , embase , and psycinfo . to our knowledge , this is the first case of suicide by intravenous administration of toluene in the literature .