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Case Reports

Abstract

Acquired ichthyosis has a wide differential which includes metabolic and autoimmune disease, malignancy, nutritional deficiency, and toxin ingestion. With clinical history and laboratory testing, histologic evaluation can aid in determining the underlying cause of acquired hyperkeratotic plaques. A 32-year-old female was admitted for generalized weakness, encephalopathy, and inability to tolerate oral intake due to nausea and vomiting. Her encephalopathy progressed over several weeks into catatonia. Dermatology was consulted to evaluate plate-like hyperkeratotic plaques on the face, trunk, and extremities. Punch biopsy was done for further evaluation and revealed epidermal papillomatosis, thick lamellar hyperorthokeratosis, superficial dyskeratosis, and a sparse perivascular lymphocytic infiltrate. Further history revealed a year-long ingestion of para-dichlorobenzene (PCDB) scented toilet-bowl cleansers supported by elevated PCDB and its metabolites in the patient’s serum and urine. Treatment included supportive care and maintenance of euglycemia, and the patient was discharged in a persistent vegetative state to a skilled nursing facility. Paradichlorobenzene (PCDB; 1,4-dichlorobenzene) is found in many household products including mothballs and toilet-bowl deodorizers. While acute exposure can lead to euphoria and potential dependence, long-term use can result in neurotoxicity, multiorgan dysfunction, and acquired ichthyosis. Histologic features include prominent superficial dyskeratoses, papillomatosis, an intact granular layer, and a sparse perivascular lymphocytic infiltrate as seen in our patient. Other reports also include acanthosis with parakeratosis and follicular plugging. The histopathologic findings when combined with clinical exam and history can aid in the diagnosis of PCDB toxicity.