Aluminum toxicity

Aluminum Metal

• Dusts cause respiratory tract and eye irritation
• Acute exposures can cause bronchoconstriction and asthma-like response
• Chronic exposure can lead to pulmonary fibrosis
• Increased incidence of cancer

Aluminum phosphide

• Used as a fumigant
• Contact with moisture produces phosphine gas
• Respiratory tract irritant

Aluminum oxide

• Physical irritant, nuisance particulate

Systemic aluminum toxicity

• Usually in renal patients on long-term dialysis with aluminum-containing dialysate
• Rarely acute
• Muscle weakness (especially proximal)
• Premature osteoporosis, bone pain, multiple fractures
• Seziures
• Acute or subacute altered mental status

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

• 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
• Phosphorus toxicity
• Platinum toxicity
• Selenium toxicity
• Silver toxicity
• Thallium toxicity
• Tin toxicity
• Zinc toxicity

Evaluation

• Aluminum level > 50 µg/L (mcg/dL) suggests aluminum overload and possible toxicity
  • Symptomatic patients with levels 20-50 may also need treatment

Management

• Stop exposure
• Supportive care is the cornerstone of treatment, particularly in mild cases. This includes respiratory support (e.g., bronchodilators for bronchospasm) and symptomatic treatment of neurological or musculoskeletal manifestations.
• Chelation therapy:
  • Deferoxamine is the chelator of choice for aluminum toxicity. It binds free aluminum, forming a water-soluble complex (aluminoxamine) excreted by the kidneys.
  • Indications include: symptomatic patients with serum aluminum >50 µg/L, or any patient with encephalopathy, bone disease, or anemia attributed to aluminum.
  • Use with caution in patients with renal impairment, as deferoxamine-aluminum complexes require adequate renal clearance; dialysis may be needed to remove the chelated complex.
• Dialysis: Consider hemodialysis in patients with renal failure and aluminum overload, particularly if encephalopathy is present or if chelation is being performed.
• Avoidance of aluminum-containing medications, including phosphate binders, IV fluids, or antacids, is important during and after treatment.

Disposition

Admission Criteria

Symptomatic patients (e.g., altered mental status, seizures, severe bone pain).

Known or suspected aluminum overload in the setting of renal failure.

Patients requiring chelation or dialysis should be admitted for monitoring and treatment.

Outpatient Management

Asymptomatic patients with mild elevations (e.g., <50 µg/L) and no risk factors (e.g., normal renal function) may be monitored closely with repeat labs and exposure cessation.

Follow-up

Patients with chronic exposure or prior toxicity should be referred for occupational medicine or toxicology evaluation.

Renal patients should have their dialysis fluids and medications reviewed for aluminum content.

Bone health monitoring may be warranted in those with chronic exposure or symptoms suggestive of osteomalacia or osteoporosis.

See Also

• Toxicology (main)