View source for Chromium toxicity

==Background==
*Blue white metal
*Essential in glucose and fat metabolism
*The predominant forms are trivalent (Cr<sup>3+</sup>) and hexavalent (Cr<sup>6+</sup>)
*Cr<sup>6+</sup> is a carcinogen
*Uses
**Chrome platting
**Component of making stainless steel
**Used to make cement
**Welding
**Joint arthroplasty
**Coronary artery stents
**Tanned leather products

===Toxicokinetics===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Form'''
| align="center" style="background:#f0f0f0;"|'''Toxicity'''
| align="center" style="background:#f0f0f0;"|'''Absorption'''
| align="center" style="background:#f0f0f0;"|'''Distribution'''
| align="center" style="background:#f0f0f0;"|'''Elimination'''
|-
| Cr<sup>3+</sup>||
*Rarely develops toxicity
||
*Limited oral absorption with 98% recovered in feces
||
||
*Urinary excretion
|-
| Cr<sup>6+</sup>||
*Main cause of toxicity 
*Oxidative agent producing oxidative DNA damage
||
*Modestly absorbed 
**10% orally 
**50-85% inhalational
||
*50% total body burden is localized to the kidney and liver 
**With additional stores in bone marrow, lymph nodes, spleen, and testes
||
*Cr6+ is rapidly converted to Cr3+ in the blood
|}

==Clinical Features==
===Acute===
*Similar to corrosive metal ingestions
*[[Gastrointestinal bleeding]]
*[[Vomiting]]
*[[Bowel perforation]]
*Intravascular hemolysis with [[DIC]]
*[[Acute tubular necrosis]] and [[Renal failure]]
*[[Metabolic acidosis]]
*[[Hyperkalemia]]
*[[Acute lung injury]]
*Skin inflammation and ulcerations
**Dermal chromic acid (H<sub>2</sub>CrO<sub>4</sub>) can lead to systemic toxicity with as little as 10% [[BSA]]

===Chronic===
*Most are occupational inhalation exposures
*Chrome holes
**Nasal septal perforation
**Skin ulcerations
*Chronic cough
*Dyspnea and bronchospasm
*Anaphylactoid-like reactions
*Pneumoconicosis
*Increase risk of lung cancer
**Small cell lung cancer, however all types are associated with Cr<sup>6+</sup> exposure
*[[Contact dermatitis]] and [[Type IV hypersensitivity reaction]]

==Differential Diagnosis==
{{Heavy metals list}}

==Evaluation==
*BMP
*LFTs
*CBC
*CPK
*EKG
*If toxicity present add coagulation factors

===Chromium levels===
''Baseline levels have varied over the past 50 years by 5000-fold, additionally it is difficult to establish standard reference range, use caution when interpreting these levels; phlebotomy needles and blood containers for storage can contain chromium''
*Whole blood: 20-30 μg/L (380-580 nmol/L)
*Serum: 0.05-2.86 μg/L (1-56 nmol/L)
*Urine: < 1μg/g creatinine (<19.2 nmol/g creatinine)
**Can reflect acute absorption of chromium over the past 1-2 days, however wide variation in metabolism and total body burden

==Management==
*Decontamination
**[[Activated charcoal]] not indicated
**Consider [[NG lavage]] if Cr<sup>6+</sup> ingestion and presenting within 1-2 hours without signs of vomiting
**Consider oral [[N-acetylcysteine]] 
***Shown to increases renal elimination of chromium in rats
*Supportive care
*Chelation
**Not effective in reducing chromium levels
*[[Dialysis]]
**Not effective in those with normal renal function
**Consider in those on chronic dialysis

==Disposition==
*Acute toxicity likely requires intensive care unit
*Consult Toxicology or [[poison control]]
==See Also==
*[[Toxicology (main)]]
*[[Heavy Metals]]

==External Links==

==References==
<references/>
*Bird, S. Chromium. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1243-1247

[[Category:Toxicology]]