Antimony toxicity: Difference between revisions
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==Background==
==Background==
*Antimony is a metalloid and will react as a metal and nonmetal
*Antimony is a metalloid and will react as a metal and nonmetal
**Shares many similar properties with arsenic
**Shares many similar properties with [[arsenic]]
*Used to treat leishmaniasis and schistosomiasis
*Used to treat [[leishmaniasis]] and [[schistosomiasis]]
**Most reported cases are due to complication of treatment
**Most reported cases are due to complication of treatment
*Most common forms used for treatment are trivalent and pentavalent compounds
*Most common forms used for treatment are trivalent and pentavalent compounds
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*'''GI'''
*'''GI'''
**Anorexia
**Anorexia
**Nausea/vomiting
**[[Nausea/vomiting]]
***Leading to profound volume depletion
***Leading to profound [[hypovolemia|volume depletion]]
**Abdominal pain
**[[Abdominal pain]]
**Diarrhea
**[[Diarrhea]]
**Hemorrhagic gastritis
**Hemorrhagic [[gastritis]]
**Pancreatitis
**[[Pancreatitis]]
**Can react with water in salvia, producing sufficient hydrochloric acid to cause GI burns
**Can react with water in salvia, producing sufficient hydrochloric acid to cause GI [[burns]]
*'''CV'''
*'''CV'''
**Decreases myocardial contraction
**Decreases myocardial contraction
**Decreased systolic pressure through decreased coronary vasomotor tone
**[[hypotension|Decreased systolic pressure]] through decreased coronary vasomotor tone
**Bradycardia
**[[Bradycardia]]
**EKG changes
**EKG changes
***More common in pentavalent preparations
***More common in pentavalent preparations
***Prolonged QT
***[[Prolonged QT]]
***Inversion or flattening of T waves
***Inversion or flattening of T waves
***Torsades de pointes
***[[Torsades de pointes]]
*'''Pulmonary'''
*'''Pulmonary'''
**Local irritation
**Local irritation
***Laryngitis and Tracheitis
***[[Laryngitis]] and Tracheitis
**Antimony pneumoconiosis
**Antimony [[pneumoconiosis]]
***Chronic exposure
***Chronic exposure
***Cough, wheezing, and exertional dyspnea
***[[Cough]], [[wheezing]], and exertional [[dyspnea]]
***CXR showing diffuse, dense, punctate non-confluent opacities in the middle and lower lobes
***[[CXR]] showing diffuse, dense, punctate non-confluent opacities in the middle and lower lobes
*'''Renal'''
*'''Renal'''
**Proteinuria
**[[Proteinuria]]
**Increased BUN
**Increased BUN
**ATN
**ATN
**Renal failure
**[[Renal failure]]
*'''Hepatic'''
*'''Hepatic'''
**Elevated aminotransferase
**Elevated aminotransferase
**Hepatic necrosis
**Hepatic necrosis
*'''Hematologic'''
*'''Hematologic'''
**Thrombocytopenia
**[[Thrombocytopenia]]
**Leukopenia
**[[Leukopenia]]
**Severe anemia seen in HIV patients being treated for leishmaniasis
**Severe [[anemia]] seen in HIV patients being treated for leishmaniasis
*'''Dermatologic'''
*'''Dermatologic'''
**Antimony Spots
**Antimony Spots
***Papules and pustules around sweat glands
***Papules and pustules around sweat glands
***Can resemble varicella
***Can resemble varicella
**Eczema
**[[Eczema]]
**Lichenification
**Lichenification
*'''Musculoskeletal'''
*'''Musculoskeletal'''
**Myalgias
**[[Myalgia]]s
**Arthralgias
**[[Arthralgia]]s
*'''Reproductive'''
*'''Reproductive'''
**Increased risk of spontaneous abortion and premature labor
**Increased risk of [[spontaneous abortion]] and [[premature labor]]
*'''Ocular'''
*'''Ocular'''
**Local irritation
**Local irritation
**Conjunctivitis
**[[Conjunctivitis]]
**Photophobia
**Photophobia
**Corneal burn
**Corneal burn


==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
*CBC
*CBC
*UA
*[[Urinalysis]]
*EKG to look for cardiac affects of antimony
*[[EKG]] to look for cardiac affects of antimony
*Cardiac monitor to assess for arrhythmia
*Cardiac monitor to assess for arrhythmia
*CXR
*[[CXR]]
*Cases of stibine
*Cases of stibine
**Add type and cross, and coagulation factors as transfusions are likely required
**Add type and cross, and coagulation factors as transfusions are likely required
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==Management==
==Management==
*Consult Toxicology or [[poison control]]
*Decontamination
*Decontamination
**Gastric lavage may be of benefit
**[[Gastric lavage]] may be of benefit
**Activated charcoal
**[[Activated charcoal]]
***Additionally may use multi-dose activated charcoal due to enterohepatic circulation
***Additionally may use multi-dose activated charcoal due to enterohepatic circulation
**Dermal exposure
**Dermal exposure
***Irrigation with soap and water
***Irrigation with soap and water
*Supportive Care
*Supportive Care
**Fluid resuscitation
**[[Fluid resuscitation]]
**Electrolyte repletion
**[[Electrolyte repletion]]
**Monitor I/Os
**Monitor I/Os
**Antiemetics
**[[Antiemetics]]
**Blood transfusions based on institutional criteria
**[[pRBCs|Blood transfusions]] based on institutional criteria
*Chelation
*Chelation
**Dimercaprol
**[[Dimercaprol]]
***200-600mg/d IM shown in a case series to increase urinary excretion of antimony<sub>1</sub>
***200-600mg/d IM shown in a case series to increase urinary excretion of antimony<sub>1</sub>
**Succimer
**[[Succimer]]
**Dimercaptopropane-sulfonic acid (DMPS)
**Dimercaptopropane-sulfonic acid (DMPS)
**All have shown improved survival in animal models
**All have shown improved survival in animal models


===Stibine===
===Stibine===
*Place on high flow oxygen
*Place on high flow [[oxygen]]
*Consider need for exchange transfusion to remove stibine-hemoglobin complexes
*Consider need for [[exchange transfusion]] to remove stibine-hemoglobin complexes


==Disposition==
==Disposition==
* Will require admission to a monitored bed, likely ICU.
* Will require admission to a monitored bed, likely ICU.
*Consult Toxicology or Poison Control Center


==References==
==References==

Revision as of 17:57, 16 October 2019

Background

  • Antimony is a metalloid and will react as a metal and nonmetal
    • Shares many similar properties with arsenic
  • Used to treat leishmaniasis and schistosomiasis
    • Most reported cases are due to complication of treatment
  • Most common forms used for treatment are trivalent and pentavalent compounds
  • Additional exposure occur from industrial exposures as inhalation of antimony dusts or fumes during processing
  • Antimony is thought to exert its toxic effects due to inactivation of various thiol-containing proteins and enzymes

Stibine

  • Most toxic form of antimony
  • Colorless gas that is formed when antimony reacts with hydrogen
    • Can result when mixing drain cleaners containing sodium hydroxide in areas with antimony ore
  • Can result in massive hemolysis

Toxicokinetics

  • Absorption
    • Inhalation
    • Ingestion
    • Transcutaneous
    • Bioavailability is 15-50%
  • Distribution
    • Predominately in highly vascular organs
    • Trivalent form seen in red blood cells
    • Pentavalent form accumulates in the liver
  • Metabolism
    • Pentavalent form is converted to trivalent form in the liver
  • Excretion
    • Trivalent form undergoes enterohepatic recirculation
    • Renal
      • Trivalent has a slow elimination with approximately 10% cleared within the first 24 hours
      • Pentavalent will have approximately 50-60% cleared within the first 24 hours

Clinical Features

Clinical features can range from mild local irritation to organ dysfunction

Differential Diagnosis

Heavy metal toxicity

Evaluation

  • BMP
  • CBC
  • Urinalysis
  • EKG to look for cardiac affects of antimony
  • Cardiac monitor to assess for arrhythmia
  • CXR
  • Cases of stibine
    • Add type and cross, and coagulation factors as transfusions are likely required
  • Serum level 0.8 - 3 μg/L (6.6-24.6 nmol/L)
  • Urine level (24 hr) 0.5-6.2 μg/L (4.1-50.1 nmol/L)

Management

Stibine

Disposition

  • Will require admission to a monitored bed, likely ICU.

References

Tarabar, A. Antimony. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1207-1213

  1. 1. Lauwers LF, Roelants A, Rosseel PM, et al. Oral antimony intoxications in man. Crit Care Med. 1990;18:324-326.
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