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arsenic poisoning

Etiology: - ingestion of arsenical salts often as insect poison - case presentation as chronic ingestion of well water [5] Epidemiology: - worldwide, the greatest threat to public health from arsenic is through contaminated groundwater [6] Pathology: - reversible interaction with multiple sulfhydryl-containing proteins - arsine gas is the most toxic form of arsenic a) can cause intravascular hemolysis & acute renal failure b) > 30 ppm of arsine gas may be fatal - a fatal dose of arsenic trioxide is 120 mg - exposure to inorganic arsenic during infancy can adversely affect some developmental outcomes [3] - infants eating rice have higher urinary levels of arsenic than infants who eat no rice [4] Clinical manifestations: 1) toxicity generally manifested within 1 hours of ingestion - toxicity from chronic exposure also occurs [5] 2) most commonly presents with gastrointestinal symptoms a) dry mouth b) dysphagia c) nausea/vomiting d) abdominal pain e) diarrhea, watery or bloody f) hematemesis[2] 3) odor of garlic on the breath 4) metallic taste 5) cardiovascular manifestations a) hypotension b) tachycardia c) ventricular arrhythmias [2] 6) oliguria, acute renal failure 7) pulmonary edema 8) headache 9) vertigo 10) increased fatigability 11) paralysis of extremities 12) mental impairment 13) painful sensory polyneuropathy a) occurs late, 1-2 weeks after ingestion b) NO upper motor neuron signs 14) mottled brown pigmentation of skin - patchy hyperpigmentation is a pathologic hallmark of chronic exposure [5] - may be found anywhere on the body - occurs particularly on the eyelids, temples, neck, nipples, axillae, & groin - in severe cases, chest, back, & abdomen 15) hyperkeratosis on palms & soles (rsenical keratoses) [5] - generally multiple - typically occur at sites of friction & trauma, especially on palms & soles, dorsum of hands, arms & legs - nontender, horny, hard, yellowish, 0.2-1.0 cm papules - lesions may coalesce into larger verrucous papules or plaques - benign arsenical keratoses may progress to malignancy [5] 16) edema of cutis 17) transverse striate leukonychia; Mees lines [5] 18) perforation of nasal septum 19) edema of eyelids 20) rhinitis 21) decreased deep tendon reflexes Laboratory: 1) urinalysis a) hematuria b) hemoglobinuria 2) arsenic in urine > 50 ug/L 3) arsenic in hair, arsenic in nails 4) arsenic in serum/plasma 5) complete blood count: macrocytic anemia 6) arterial blood gas [5] Special laboratory: - electrocardiogram [5] Radiology: - chest X-ray - abdominal X-ray [5] Complications: - increased risk of several cancers - basal cell carcinoma - Bowen disease - Merkel cell carcinoma [5] - liver cancer - bladder cancer - lung cancer Management: - gastric lavage - irrigate exposed areas, IV hydration as needed [5] - dimercaprol combines with arsenic through sulfhdryl groups to produce water soluble complexes - 2,3-dithioerythritol may be less toxic than dimercaprol - hemodialysis may be used to remove dimercaprol-arsenic complexes [2] - remove from toxic source - limit infant rice consumption [4] Notes: - FDA proposes limit for inorganic arsenic in infant rice cereal of 100 ppb (parts per billion)* * inorganic arsenic levels are higher in rice than in other foods [3] * ~50% of infant rice cereals tested in 2014 were < 100 ppb [3]

Related

arsenic in urine arsenic [As] leukonychia; achromia unguium; canities unguium; leukopathia unguis; white nails

General

heavy metal toxicity

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 866
  2. Henry's Clinical Diagnosis & Management by Laboratory Methods, 21st edition, McPherson RA & Pincus MR (es), W.B. Saunders Co., Philadelphia, PA. 2007, pg 322
  3. FDA News Release. April 1, 2016 FDA proposes limit for inorganic arsenic in infant rice cereal. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm493740.htm
  4. Karagas MR, Punshon T, Sayarath V et al Association of Rice and Rice-Product Consumption With Arsenic Exposure Early in Life. JAMA Pediatr. Published online April 25, 2016 PMID: 27111102 http://archpedi.jamanetwork.com/article.aspx?articleid=2514074
  5. Harmon J, Kapitanyan R Poisoning Clues on the Skin: 10 Cases Medscape. April 6, 2017 http://reference.medscape.com/features/slideshow/acutepoisonings
  6. Lindenmayer G, Hoggett K, Burrow J et al A Sickening Tale. N Engl J Med 2018; 379:75-80. July 5, 2018. PMID: 29972758 https://www.nejm.org/doi/full/10.1056/NEJMcps1716775