Difference between revisions of "Mercury toxicity"

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(Chelation therapy)
 
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==Background==
 
==Background==
*Atomic symbol of Hg from latin name hydrargyros which means silver water
 
===Historical Exposures===
 
*Hat felters (Elemental)
 
**"Mad as a hatter"
 
*Anti-syphilitic agents (Inorganic)
 
**"A night in the arms of venus lead to a lifetime on mercury"
 
*Calomel (Inorganic)
 
**Mercurous Chloride sold as a teething powder
 
**Causes "pink disease"
 
***pain and erythema of the palms and soles, irritability, insomnia, anorexia, diaphoresis, photophobia, and skin rash
 
*Minamata Bay, Japan (Organic)
 
**Massive exposure to methylmercury from contaminated seafood secondary to industrial dumping of mercury containing compounds
 
*Iraq 1971 (Organic)
 
**95,000 tons of methylmercury coated grain sold for human consumption
 
*Miners and smelters (Elemental)
 
**Mostly secondary to exposure to Cinnabar (HgS)
 
*Dental workers through amalgams (Elemental)
 
**Clinical effects secondary to exposure to mercury through amalgams is controversial
 
 
===Common Exposures===
 
===Common Exposures===
 
*Industrial
 
*Industrial
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*Seafood consumption
 
*Seafood consumption
 
**Mostly methylmercury
 
**Mostly methylmercury
 +
 
===Exists as three major forms===
 
===Exists as three major forms===
 
*All disrupt sulfhydryl ezymes leading to impaired cellular function
 
*All disrupt sulfhydryl ezymes leading to impaired cellular function
 +
 
====Elemental====
 
====Elemental====
 
*Liquid metal at room temperature (Think of the Terminator recongealing)
 
*Liquid metal at room temperature (Think of the Terminator recongealing)
 
*14x more dense than water
 
*14x more dense than water
*Volatile and lipid soluble, therefore rapidly absorbed through lungs (approx 70-80%)
+
*Volatile and lipid soluble, therefore rapidly absorbed through lungs (approximately 70-80%)
 
*Oxidized rapidly to inorganic form
 
*Oxidized rapidly to inorganic form
 
*Poorly absorbed from GI tract  
 
*Poorly absorbed from GI tract  
 
**Therefor most ingestions are non-toxic
 
**Therefor most ingestions are non-toxic
 +
 
====Organic====
 
====Organic====
 
*Exists in three major forms:
 
*Exists in three major forms:
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*Short chain forms are highly lipophilic and cross the blood-brain barrier and placenta
 
*Short chain forms are highly lipophilic and cross the blood-brain barrier and placenta
 
**Metabolized in the liver to N-acetyl-homocysteine-methylmercury which undergoes enterohepatic recirculation
 
**Metabolized in the liver to N-acetyl-homocysteine-methylmercury which undergoes enterohepatic recirculation
 +
 
====Inorganic====
 
====Inorganic====
 
*Exists as monovalent and divalent  
 
*Exists as monovalent and divalent  
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*Found in many batteries, little risk of toxicity from the mercury components s/p ingestion
 
*Found in many batteries, little risk of toxicity from the mercury components s/p ingestion
 
**Other dangers exist though!!!
 
**Other dangers exist though!!!
 +
*The California Department of Public Health issued a health alert on May, 2014 noting mercury poisoning linked to use of skin-lightening or acne Creams from Mexico<ref>http://www.ehib.org/papers/Health_Alert%20_Mercury_Poisonings_from_Mexican_creams_5_2014.pdf</ref>
 +
 +
===Historical Exposures===
 +
''Atomic symbol of Hg from latin name hydrargyros which means silver water''
 +
*Hat felters (Elemental)
 +
**"Mad as a hatter"
 +
*'''Anti-syphilitic agents (Inorganic)'''
 +
**"A night in the arms of venus lead to a lifetime on mercury"
 +
*Calomel (Inorganic)
 +
**Mercurous Chloride sold as a teething powder
 +
**Causes "pink disease"
 +
***pain and erythema of the palms and soles, irritability, insomnia, anorexia, diaphoresis, photophobia, and skin rash
 +
*Minamata Bay, Japan (Organic)
 +
**Massive exposure to methylmercury from contaminated seafood secondary to industrial dumping of mercury containing compounds
 +
*Iraq 1971 (Organic)
 +
**95,000 tons of methylmercury coated grain sold for human consumption
 +
*Miners and smelters (Elemental)
 +
**Mostly secondary to exposure to Cinnabar (HgS)
 +
*Dental workers through amalgams (Elemental)
 +
**Clinical effects secondary to exposure to mercury through amalgams is controversial
  
 
==Clinical Features==
 
==Clinical Features==
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===Elemental Mercury===
 
===Elemental Mercury===
 
====Acute Exposure====
 
====Acute Exposure====
*Metal fume fever
+
*[[Metal fume fever]]
**Usually self limited course of fever, chills, shortness of breath, metallic taste in throat, lethargy, confusion, vomiting
+
**Usually self limited course of [[flu-like illness]]; [[fever]], chills, [[shortness of breath]], metallic taste in throat, [[lethargy]], [[confusion]], [[vomiting]], renal tubular necrosis
***Rarely may progress to respiratory compromise and death
+
***Rarely may progress to [[respiratory distress|respiratory compromise]] and death
 
*Worse presentation in children
 
*Worse presentation in children
**May develop pneumothorax, pneumomediastinum and interstitial emphysema
+
**May develop [[pneumothorax]], pneumomediastinum and interstitial emphysema
*Small airway obstruction 2/2 desquamation
+
*Small airway obstruction secondary to desquamation
 +
 
 
====Chronic Exposure====
 
====Chronic Exposure====
 
*Classic Triad:
 
*Classic Triad:
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#Hyperexcitable state/emotional lability
 
#Hyperexcitable state/emotional lability
 
*Other findings
 
*Other findings
**Headache, visual disturbances, peripheral neuropathy, ataxia
+
**[[Headache]], [[visual disturbances]], peripheral neuropathy, [[ataxia]]
 
===Inorganic Mercury===
 
===Inorganic Mercury===
 
====Acute Exposure====
 
====Acute Exposure====
 
*Primarily toxic through oral route
 
*Primarily toxic through oral route
*Causes caustic burns
+
*Causes caustic [[burns]]
 
**Severity dependent on type [Hg(2)Cl vs Hg(1)Cl] and concentration of mercurial salts
 
**Severity dependent on type [Hg(2)Cl vs Hg(1)Cl] and concentration of mercurial salts
 
***Mercuric forms [Hg(2)] more toxic
 
***Mercuric forms [Hg(2)] more toxic
**Other symptoms include pain, nausea, hematemesis, hypovolemia, ATN
+
**Other symptoms include pain, [[nausea]], [[hematemesis]], [[hypovolemia]], acute tubular necrosis
**Sequelae include renal failure
+
**Sequelae include [[renal failure]]
 +
 
 
====Chronic Exposure====
 
====Chronic Exposure====
 
*Chronic exposures usually secondary to inhalation exposure
 
*Chronic exposures usually secondary to inhalation exposure
*Symptoms include renal failure, dementia, acrodynia
+
*Symptoms include [[renal failure]], [[dementia]], acrodynia
**Acrodynia (AKA pink disease) = painful erythema and edema of hands and feet, rash, tachycardia, hypertension and irritability.
+
**Acrodynia (AKA pink disease) = painful erythema and edema of hands and feet, [[rash]], [[tachycardia]], [[hypertension]] and irritability.
 
*Neuropsychiatric disturbances
 
*Neuropsychiatric disturbances
 
===Organic Mercury===
 
===Organic Mercury===
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**Acute presentations usually show signs days to weeks after exposure
 
**Acute presentations usually show signs days to weeks after exposure
 
*Neuro symptoms predominate
 
*Neuro symptoms predominate
**Tremor, ataxia, paresthesias, memory difficulties, visual disturbances, hearing loss
+
**Tremor, [[ataxia]], [[paresthesias]], memory difficulties, [[visual disturbances]], [[hearing loss]]
*May also cause thrombocytopenia and agranulocytosis
+
*May also cause [[thrombocytopenia]] and [[agranulocytosis]]
 
*Highly '''fetotoxic'''
 
*Highly '''fetotoxic'''
 
**Easily crosses placenta
 
**Easily crosses placenta
**May lead to severe mental retardation (like those with Minamata disease), developmental delay, ataxia and seizures in offspring
+
**May lead to severe intellectual disability (like those with Minamata disease), developmental delay, ataxia and seizures in offspring
 
**Controversy exists over exposure from regular diet
 
**Controversy exists over exposure from regular diet
 
***Albacore tuna may contain up to 0.34ppm of organic mercury
 
***Albacore tuna may contain up to 0.34ppm of organic mercury
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**Thimerosal (mercury containing preservative found in many vaccines) has '''''NOT''''' been linked to developmental delays or autism
 
**Thimerosal (mercury containing preservative found in many vaccines) has '''''NOT''''' been linked to developmental delays or autism
  
==Diagnosis==
+
==Differential Diagnosis==
*History
+
{{Heavy metals list}}
*Consider in patient's with caustic burns after suicide attempt
+
 
*Urine Hg levels (>25μg/L is elevated) for elemental and organic mercury
+
==Evaluation==
**Levels >300μg/L usually symptommatic
+
===Work-Up===
**Organic mercury poorly excreted
+
*Urine and blood mercury levels
*Blood levels for organic mercury
 
*Hair analysis is not sufficient
 
==Work-Up==
 
*Urine and blood Hg levels
 
 
*CBC
 
*CBC
 
*Chem 7
 
*Chem 7
 
*Type and screen
 
*Type and screen
 
*Radiographs
 
*Radiographs
==Treatment==
+
 
 +
===Evaluation===
 +
*Urine mercury levels (>25μg/L is elevated) for elemental and organic mercury
 +
**Levels >300μg/L usually symptomatic
 +
**Organic mercury poorly excreted
 +
*Blood levels for organic mercury
 +
*Hair analysis is not sufficient
 +
 
 +
==Management==
 
*ABC's
 
*ABC's
 
*Decontaminate
 
*Decontaminate
 +
**Of note, mercury can penetrate through latex and nitrile gloves
 
===Inhalation injuries===
 
===Inhalation injuries===
*O2
+
*[[Oxygen]]
*May require intubation
+
*May require [[intubation]]
===Caustic injuries===
+
===[[Caustic injuries]]===
 
*May consider milk or egg whites
 
*May consider milk or egg whites
**Thought to bind Hg
+
**Thought to bind mercury
 
*WBI
 
*WBI
 +
 
===Chelation therapy===
 
===Chelation therapy===
*Penicillamine 250mg PO QID x 1-2wks
+
The choice of chelating agent is dependent of the type of mercury poisoning.
 +
*[[Penicillamine]] 250mg PO QID x 1-2wks
 
**Avoid in renal failure
 
**Avoid in renal failure
*Dimercaprol (BAL) 2.5-5mg IM Q6-12hr
+
*[[Dimercaprol]] (BAL) 2.5-5mg IM Q6-12hr
*DMSA 10mg/kg TID x 5days then 10mg/kg BID x 14days
+
**Contraindicated in organic mercury poisoning as can paradoxically increase mercury levels
 +
*DMSA (succimer) 10mg/kg TID x 5days then 10mg/kg BID x 14days
 +
 
 +
==Disposition==
  
 
==See Also==
 
==See Also==
 
*[[Heavy Metals]]
 
*[[Heavy Metals]]
 +
 +
==External Links==
 
*The biological monitoring of mercury in the Seychelles study: Methylmercury and human health http://www.ncbi.nlm.nih.gov/pubmed/8714867
 
*The biological monitoring of mercury in the Seychelles study: Methylmercury and human health http://www.ncbi.nlm.nih.gov/pubmed/8714867
 
*Cognitive performance of children prenatally exposed to "safe" level of methylmercury http://www.ncbi.nlm.nih.gov/pubmed/9600810
 
*Cognitive performance of children prenatally exposed to "safe" level of methylmercury http://www.ncbi.nlm.nih.gov/pubmed/9600810
  
==Source==
+
==References==
 
*Haddad and Winchester's Clinical Management of Poisoning and Overdose
 
*Haddad and Winchester's Clinical Management of Poisoning and Overdose
 
*Goldfrank's Toxicology
 
*Goldfrank's Toxicology
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*http://en.wikipedia.org/wiki/Minamata_disease
 
*http://en.wikipedia.org/wiki/Minamata_disease
 
*http://en.wikipedia.org/wiki/1971_Iraq_poison_grain_disaster
 
*http://en.wikipedia.org/wiki/1971_Iraq_poison_grain_disaster
 
+
<references/>
[[Category:Tox]]
+
[[Category:Toxicology]]

Latest revision as of 12:28, 22 February 2020

Background

Common Exposures

  • Industrial
    • Batteries, fungicide
  • Seafood consumption
    • Mostly methylmercury

Exists as three major forms

  • All disrupt sulfhydryl ezymes leading to impaired cellular function

Elemental

  • Liquid metal at room temperature (Think of the Terminator recongealing)
  • 14x more dense than water
  • Volatile and lipid soluble, therefore rapidly absorbed through lungs (approximately 70-80%)
  • Oxidized rapidly to inorganic form
  • Poorly absorbed from GI tract
    • Therefor most ingestions are non-toxic

Organic

  • Exists in three major forms:
  1. Long chain
  2. Short chain
  3. Aryl
  • Long chain and Aryl forms are rapidly converted to inorganic forms
  • Short chain forms are highly lipophilic and cross the blood-brain barrier and placenta
    • Metabolized in the liver to N-acetyl-homocysteine-methylmercury which undergoes enterohepatic recirculation

Inorganic

  • Exists as monovalent and divalent
  • Corrosive
  • Chronic exposures lead to accumulation in brain and CNS
  • Found in many batteries, little risk of toxicity from the mercury components s/p ingestion
    • Other dangers exist though!!!
  • The California Department of Public Health issued a health alert on May, 2014 noting mercury poisoning linked to use of skin-lightening or acne Creams from Mexico[1]

Historical Exposures

Atomic symbol of Hg from latin name hydrargyros which means silver water

  • Hat felters (Elemental)
    • "Mad as a hatter"
  • Anti-syphilitic agents (Inorganic)
    • "A night in the arms of venus lead to a lifetime on mercury"
  • Calomel (Inorganic)
    • Mercurous Chloride sold as a teething powder
    • Causes "pink disease"
      • pain and erythema of the palms and soles, irritability, insomnia, anorexia, diaphoresis, photophobia, and skin rash
  • Minamata Bay, Japan (Organic)
    • Massive exposure to methylmercury from contaminated seafood secondary to industrial dumping of mercury containing compounds
  • Iraq 1971 (Organic)
    • 95,000 tons of methylmercury coated grain sold for human consumption
  • Miners and smelters (Elemental)
    • Mostly secondary to exposure to Cinnabar (HgS)
  • Dental workers through amalgams (Elemental)
    • Clinical effects secondary to exposure to mercury through amalgams is controversial

Clinical Features

  • Clinical presentation highly dependent on form, concentration and duration of exposure
    • Inhalation of elemental mercury and ingestion of inorganic can cause acute or subacute toxicity
    • Organic mercury more likely causes chronic toxicity

Elemental Mercury

Acute Exposure

Chronic Exposure

  • Classic Triad:
  1. Tremor
  2. Gingivitis/stomatitis
  3. Hyperexcitable state/emotional lability

Inorganic Mercury

Acute Exposure

  • Primarily toxic through oral route
  • Causes caustic burns
    • Severity dependent on type [Hg(2)Cl vs Hg(1)Cl] and concentration of mercurial salts
      • Mercuric forms [Hg(2)] more toxic
    • Other symptoms include pain, nausea, hematemesis, hypovolemia, acute tubular necrosis
    • Sequelae include renal failure

Chronic Exposure

  • Chronic exposures usually secondary to inhalation exposure
  • Symptoms include renal failure, dementia, acrodynia
  • Neuropsychiatric disturbances

Organic Mercury

  • Acute and chronic exposures present similarly
    • Acute presentations usually show signs days to weeks after exposure
  • Neuro symptoms predominate
  • May also cause thrombocytopenia and agranulocytosis
  • Highly fetotoxic
    • Easily crosses placenta
    • May lead to severe intellectual disability (like those with Minamata disease), developmental delay, ataxia and seizures in offspring
    • Controversy exists over exposure from regular diet
      • Albacore tuna may contain up to 0.34ppm of organic mercury
      • Please see Faroe Island and Seychelles studies
    • Thimerosal (mercury containing preservative found in many vaccines) has NOT been linked to developmental delays or autism

Differential Diagnosis

Heavy metal toxicity

Evaluation

Work-Up

  • Urine and blood mercury levels
  • CBC
  • Chem 7
  • Type and screen
  • Radiographs

Evaluation

  • Urine mercury levels (>25μg/L is elevated) for elemental and organic mercury
    • Levels >300μg/L usually symptomatic
    • Organic mercury poorly excreted
  • Blood levels for organic mercury
  • Hair analysis is not sufficient

Management

  • ABC's
  • Decontaminate
    • Of note, mercury can penetrate through latex and nitrile gloves

Inhalation injuries

Caustic injuries

  • May consider milk or egg whites
    • Thought to bind mercury
  • WBI

Chelation therapy

The choice of chelating agent is dependent of the type of mercury poisoning.

  • Penicillamine 250mg PO QID x 1-2wks
    • Avoid in renal failure
  • Dimercaprol (BAL) 2.5-5mg IM Q6-12hr
    • Contraindicated in organic mercury poisoning as can paradoxically increase mercury levels
  • DMSA (succimer) 10mg/kg TID x 5days then 10mg/kg BID x 14days

Disposition

See Also

External Links

References