Zinc toxicity: Difference between revisions

(Created page with "==Background== *Transition metal *Essential nutrient *Exposure from diet, medicinal uses, nutritional supplements, and occupational exposures **Multiple case reports of zinc t...")
 
 
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*Exposure from diet, medicinal uses, nutritional supplements, and occupational exposures
*Exposure from diet, medicinal uses, nutritional supplements, and occupational exposures
**Multiple case reports of zinc toxicity related to ingestion of United States pennies which contain 97.5% zinc
**Multiple case reports of zinc toxicity related to ingestion of United States pennies which contain 97.5% zinc
==Toxicokinetics==
 
===Toxicokinetics===
*Absorbed primarily in the jejunum
*Absorbed primarily in the jejunum
*Excreted via the GI tract with minimal amounts excreted in the urine
*Excreted via the GI tract with minimal amounts excreted in the urine
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*Inverse relationship with copper
*Inverse relationship with copper
**Excess zinc absorption will cause a counterregulatory response resulting in copper elimination
**Excess zinc absorption will cause a counterregulatory response resulting in copper elimination
==Clinical Features==
==Clinical Features==
*'''Acute'''
===Acute===
**GI distress
*GI distress
***Nausea
**[[Nausea]]
***Vomiting
**[[Vomiting]]
***Abdominal pain
**[[Abdominal pain]]
***GI bleeding
**[[GI bleeding]]
***Partial and full thickness burns causing strictures with zinc chloride solutions with >20% zinc
**Partial and full thickness burns causing strictures with zinc chloride solutions with >20% zinc
**Inhalation
*Inhalation
***Lacrimation
**Lacrimation
***Rhinitis
**Rhinitis
***Dyspnea
**[[Dyspnea]]
***[[Acute Lung Injury]]
**Acute lung injury
***[[Acute Respiratory Distress Syndrome]]
**[[Acute Respiratory Distress Syndrome]]
***[[Metal fume fever]]
**[[Metal fume fever]]
*'''Chronic'''
 
**Zinc induced copper deficiency
===Chronic===
***Reversible [[sideroblastic anemia]]
*Zinc induced copper deficiency
***Reversible [[myelodysplastic syndrome]]
**Reversible sideroblastic [[anemia]]
**Progressive myeloneuropathy
**Reversible [[myelodysplastic syndrome]]
***Spastic gait
*Progressive myeloneuropathy
***Sensory ataxia
**Spastic gait
**Sensory [[ataxia]]
 
==Differential Diagnosis==
==Differential Diagnosis==
===[[Heavy metal]] toxicity===
{{Heavy metals list}}
*[[Aluminum toxicity]]
 
*[[Antimony toxicity]]
*[[Arsenic toxicity]]
*[[Barium toxicity]]
*[[Bismuth toxicity]]
*[[Cadmium toxicity]]
*[[Chromium toxicity]]
*[[Cobalt toxicity]]
*[[Copper toxicity]]
*[[Gold toxicity]]
*[[Iron toxicity]]
*[[Lead toxicity]]
*[[Lithium toxicity]]
*[[Manganese toxicity]]
*[[Mercury toxicity]]
*[[Nickel toxicity]]
*[[Phosphorous toxicity]]
*[[Platinum toxicity]]
*[[Selenium toxicity]]
*[[Silver toxicity]]
*[[Thallium toxicity]]
*[[Tin toxicity]]
*[[Zinc toxicity]]
==Evaluation==
==Evaluation==
*BMP
*BMP
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*Ceruloplasmin level
*Ceruloplasmin level
*Abdominal films to assess for foreign bodies
*Abdominal films to assess for foreign bodies
*MRI
*[[brain MRI|MRI]]
**Will show increase T<sub>2</sub> signal in the dorsal columns of the cervical cord
**Will show increase T<sub>2</sub> signal in the dorsal columns of the cervical cord
==Management==
==Management==
*Oral toxicity
*Oral toxicity
**Supportive Care
**Supportive Care
***Hydration
***[[IVF|Hydration]]
***H<sub>2</sub> receptor antagonists or PPI
***[[H2 blocker|H<sub>2</sub> receptor antagonists]] or [[PPI]]
***Antiemetics
***[[Antiemetics]]
**Consider whole bowel irrigation
**Consider [[whole bowel irrigation]]
*Inhalation
*Inhalation
**Supportive care
**Supportive care
***Oxygen therapy
***[[Oxygen therapy]]
***Bronchodilators
***[[Bronchodilators]]
**Metal fume fever
**[[Metal fume fever]]
***Usually self limiting
***Usually self limiting
***CXR usually normal
***[[CXR]] usually normal
*Chelation
*Chelation
**Limited data on use, and data present is based off of case reports and treatment for lead toxicity <ref>Majlesi, N. Zinc. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1342</ref>
**Limited data on use, and data present is based off of case reports and treatment for lead toxicity <ref>Majlesi, N. Zinc. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1342</ref>
**Consider in patients with hemodynamic compromise
**Consider in patients with hemodynamic compromise
**CaNa<sub>2</sub>EDTA, British anti-Lewisite, DTPA were all successfully used in case reports
**CaNa<sub>2</sub>[[EDTA]], [[British antilewisite]], DTPA were all successfully used in case reports
**1000mg/m<sup>2</sup>/d IV CaNa<sub>2</sub>EDTA every 6 hours
**1000mg/m<sup>2</sup>/d IV CaNa<sub>2</sub>EDTA every 6 hours
***Based on a successful case report, but should be given in conjunction with toxicology or poison control center
***Based on a successful case report, but should be given in conjunction with toxicology or poison control center
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*Copper replacement
*Copper replacement
**Oral copper alone shown to improve hematopoietic effects and prevent further neurological deterioration <ref> Rowin J, Lewis SL. Copper deficiency myeloneuropathy and pancytopenia secondary to overuse of zinc supplementation. J Neurol Neurosurg Psychiatry. 2005;76:750-751. </ref>
**Oral copper alone shown to improve hematopoietic effects and prevent further neurological deterioration <ref> Rowin J, Lewis SL. Copper deficiency myeloneuropathy and pancytopenia secondary to overuse of zinc supplementation. J Neurol Neurosurg Psychiatry. 2005;76:750-751. </ref>
==Disposition==
==Disposition==
*Consult Toxicology or Poison Control Center
*Consult Toxicology or [[poison control]]
 
==References==
==References==
<references/>
<references/>
Majlesi, N. Zinc. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1339-1344
 
[[Category:Toxicology]]

Latest revision as of 18:26, 28 September 2021

Background

  • Transition metal
  • Essential nutrient
  • Exposure from diet, medicinal uses, nutritional supplements, and occupational exposures
    • Multiple case reports of zinc toxicity related to ingestion of United States pennies which contain 97.5% zinc

Toxicokinetics

  • Absorbed primarily in the jejunum
  • Excreted via the GI tract with minimal amounts excreted in the urine
  • Accumulates in erythrocytes
    • Whole blood concentrations are 6-7x higher than in the serum
  • Inverse relationship with copper
    • Excess zinc absorption will cause a counterregulatory response resulting in copper elimination

Clinical Features

Acute

Chronic

Differential Diagnosis

Background

Heavy metal toxicity results from exposure to metals like lead, mercury, arsenic, or cadmium, which interfere with cellular function. Exposure may occur occupationally, environmentally, through ingestion, or from alternative medicines. Chronic toxicity can present insidiously, while acute toxicity may mimic sepsis or encephalopathy. Diagnosis is often delayed due to nonspecific symptoms.

Clinical Features

Symptoms depend on the metal and exposure duration but may include:

Neurologic: Peripheral neuropathy, confusion, tremor, encephalopathy

GI: Abdominal pain, nausea, vomiting, diarrhea, anorexia

Heme: Anemia (especially microcytic or hemolytic), basophilic stippling (lead)

Renal: Tubular dysfunction, proteinuria, Fanconi syndrome

Dermatologic: Mees’ lines (arsenic), hyperpigmentation, hair loss

Others: Fatigue, weight loss, hypertension (cadmium), immunosuppression

Differential Diagnosis

Sepsis or systemic inflammatory response

Drug toxicity or overdose

Metabolic disorders (e.g., porphyria, uremia)

Psychiatric illness (if symptoms are vague or bizarre)

Neurologic diseases (e.g., Guillain-Barré, MS, Parkinson’s)

Vitamin deficiencies (e.g., B12, thiamine)

Evaluation

Workup

History: Occupational exposures, home remedies, hobbies (e.g., jewelry making, battery recycling), diet, water source, imported goods

Labs:

  • CBC, CMP, urinalysis
  • Blood lead level, serum/urine arsenic, mercury, or cadmium (based on suspicion)
  • Urine heavy metal screen (note: spot testing may require creatinine correction)

Imaging: Abdominal X-ray (radiopaque material in GI tract, especially with lead)

EKG: Evaluate for QT prolongation or arrhythmias in severe cases

Diagnosis

Confirmed by elevated blood or urine levels of the specific metal in the context of clinical findings. Hair and nail testing are unreliable for acute toxicity. Interpret results with toxicologist input if possible.

Management

Remove the source of exposure (e.g., occupational control, GI decontamination if recent ingestion)

Supportive care: IV fluids, seizure control, electrolyte repletion

Chelation therapy (in consultation with toxicology or Poison Control):

Lead: EDTA, dimercaprol (BAL), succimer

Mercury/arsenic: Dimercaprol or DMSA

Cadmium: No effective chelation—focus on supportive care

Notify local public health authorities if exposure source is environmental or occupational

Disposition

Admit if symptomatic, unstable, or requiring chelation

Discharge may be appropriate for asymptomatic patients with low-level exposure and outpatient follow-up

Arrange toxicology or environmental medicine follow-up for source control and serial testing

See Also

Evaluation

  • BMP
  • CBC
  • Copper level
  • Ceruloplasmin level
  • Abdominal films to assess for foreign bodies
  • MRI
    • Will show increase T2 signal in the dorsal columns of the cervical cord

Management

  • Oral toxicity
  • Inhalation
  • Chelation
    • Limited data on use, and data present is based off of case reports and treatment for lead toxicity [1]
    • Consider in patients with hemodynamic compromise
    • CaNa2EDTA, British antilewisite, DTPA were all successfully used in case reports
    • 1000mg/m2/d IV CaNa2EDTA every 6 hours
      • Based on a successful case report, but should be given in conjunction with toxicology or poison control center
  • Dermal Exposures
    • Do not use water in metallic zinc exposures
      • Concern metal will ignite
    • Remove zinc with forceps and apply mineral oil to affected skin
  • Copper replacement
    • Oral copper alone shown to improve hematopoietic effects and prevent further neurological deterioration [2]

Disposition

References

  1. ↑ Majlesi, N. Zinc. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1342
  2. ↑ Rowin J, Lewis SL. Copper deficiency myeloneuropathy and pancytopenia secondary to overuse of zinc supplementation. J Neurol Neurosurg Psychiatry. 2005;76:750-751.
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