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Mercury Poisoning
There are three forms of mercury poisoning: elemental, inorganic, and organic. Elemental mercury is found in thermometers and can volatilize easily. Inorganic mercury is found in traditional medicines and gold mining, while organic mercury is used in fungicides and pesticides. Mercury is highly absorbed through inhalation, ingestion, and dermal contact. Symptoms depend on the specific form and can include gastrointestinal, neurological, and renal effects. Diagnosis is made through blood and urine mercury levels. Chelation therapy with DMPS is the treatment of choice. Tetraethyllead poisoning occurs mainly through inhalation and causes ocular, dermal, and systemic effects ranging from mild to severe.
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Mercury Poisoning
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- 2. Mercury poisoningMercury poisoning -elemental- elemental - inorganic- inorganic - organic- organic Each has a different toxicological profileEach has a different toxicological profile There are 3 different forms of mercuryThere are 3 different forms of mercury
- 3. Sources of mercurySourcesof mercury Elemental mercury:Elemental mercury: – Sphygmomanometers, thermometers, barometersSphygmomanometers, thermometers, barometers – Liquid at room temp – volatilises easilyLiquid at room temp – volatilises easily Inorganic mercury:Inorganic mercury: – Traditional remedies (ayurvedic, chinese)Traditional remedies (ayurvedic, chinese) – Used in gold extraction, caustic sodaUsed in gold extraction, caustic soda manufacturingmanufacturing – RodenticidesRodenticides Organic mercury:Organic mercury: – Fungicides, seed dressingsFungicides, seed dressings – Methylmercury in fish …Methylmercury in fish …
- 4. Mercury - AbsorptionMercury- Absorption • Inhalation :Inhalation : 60-80%60-80% • Dermal :Dermal : 3-15%3-15% • GI Tract :GI Tract : Metallic <0.2%Metallic <0.2% Inorganic 15%Inorganic 15% Organic 90Organic 90++ %%
- 5. SponsoredSponsored Medical Lecture Notes–Medical Lecture Notes – All SubjectsAll Subjects USMLE Exam (America) –USMLE Exam (America) – PracticePractice
- 6. Organic mercuryOrganic mercury poisoning:poisoning: Rare… but severeRare … but severe• Exposure: ingestion, topical or inhalationExposure: ingestion, topical or inhalation • CNS Toxicity:CNS Toxicity: • poor concentration, fatigue, ataxia, tremor,poor concentration, fatigue, ataxia, tremor, constricted visual fields,constricted visual fields, • coma & convulsionscoma & convulsions • BM suppressionBM suppression • Renal toxicity - dealkylation to inorganic formRenal toxicity - dealkylation to inorganic form • Poorer response to treatmentPoorer response to treatment
- 7. Inorganic mercuryInorganic mercury poisoningpoisoning Gastrointestinal phaseGastrointestinal phase:: HgHg2+2+ is a potent GI irritantis a potent GI irritant – gingivitis, stomatitisgingivitis, stomatitis - oesophageal, gastric, small and large boweloesophageal, gastric, small and large bowel erosionserosions - haematemesis, bloody diarrhoea, CVS collapsehaematemesis, bloody diarrhoea, CVS collapse Systemic toxicitySystemic toxicity:: HgHg2+2+ inhibits sulphydryl enzymesinhibits sulphydryl enzymes – hypotension, lactic acidosishypotension, lactic acidosis NephrotoxicityNephrotoxicity: Hg: Hg2+2+ deposits in the tubulesdeposits in the tubules →→ ATNATN – acute renal failureacute renal failure - potentially leads to CRF in survivorspotentially leads to CRF in survivors
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- 9. Inhaled Elemental Mercury(1)Inhaled Elemental Mercury (1) ACUTEACUTE Irritant respiratory effects:Irritant respiratory effects: - cough, dyspnoeacough, dyspnoea - pulmonary oedemapulmonary oedema • Metal fume fever:Metal fume fever: - pyrexia, cough, malaise, flu-like symptomspyrexia, cough, malaise, flu-like symptoms • CNS features:CNS features: - confusion, emotional lability, psychosesconfusion, emotional lability, psychoses - convulsions, CNS depression & comaconvulsions, CNS depression & coma • Renal effects:Renal effects: - rarely ARF (oxidation to Hgrarely ARF (oxidation to Hg2+2+ ))
- 10. • ‘‘Erethism’Erethism’ TREMOR,dysarthriaTREMOR, dysarthria peripheral neuropathy, sweatingperipheral neuropathy, sweating personality changepersonality change • Stomatitis, gingivitisStomatitis, gingivitis • Chronic renal impairmentChronic renal impairment Inhaled Elemental Mercury (2)Inhaled Elemental Mercury (2) CHRONICCHRONIC
- 11. AcrodyniaAcrodynia Mercury syndromein childrenMercury syndrome in children – Usually related to elemental mercury exposure,Usually related to elemental mercury exposure, 2 reports secondary to inorganic exposure2 reports secondary to inorganic exposure 6 P’s hands & feet: puffy, pink, painful, peeling,6 P’s hands & feet: puffy, pink, painful, peeling, paraesthetic, perspiringparaesthetic, perspiring Associated with weight loss, anorexia, irritability,Associated with weight loss, anorexia, irritability, behavioural changesbehavioural changes Hypertension – can mimic phaeochromocytomaHypertension – can mimic phaeochromocytoma – Mercury inhibits COMTMercury inhibits COMT (catecholamine-o-(catecholamine-o- methyltransferase)methyltransferase) … NAdr / Adr accumulate… NAdr / Adr accumulate Torres ADTorres AD PediatricsPediatrics 20002000
- 12. IV/IM Elemental MercuryIV/IMElemental Mercury • Results in:Results in: - local complicationslocal complications - embolic complicationsembolic complications - mercuralismmercuralism
- 13. • ThrombophlebitisThrombophlebitis • InfectionInfection •Granuloma formationGranuloma formation Excise large s/c depositsExcise large s/c deposits ? prevents local & systemic? prevents local & systemic effectseffects IV/IM Elemental MercuryIV/IM Elemental Mercury Local ComplicationsLocal Complications
- 15. • PulmonaryPulmonary - usuallyasymptomaticusually asymptomatic - may cause chest painmay cause chest pain - normal spirometry, decreased transfer factornormal spirometry, decreased transfer factor • SystemicSystemic - ? mercury through pulmonary capillary bed? mercury through pulmonary capillary bed - widespread eg. abdomen, intracerebralwidespread eg. abdomen, intracerebral - asymptomaticasymptomatic IV/IM Elemental MercuryIV/IM Elemental Mercury Embolic ComplicationsEmbolic Complications
- 18. • Slow oxidationof metallic HgSlow oxidation of metallic Hg mercuric ions (Hgmercuric ions (Hg2+2+ )) Chronic renal impairmentChronic renal impairment ?? CNS toxicity?? CNS toxicity IV/IM Elemental MercuryIV/IM Elemental Mercury MercuralismMercuralism • Consider chelation therapy: - guided by blood mercury - may require long-term chelation
- 19. Diagnosis of MercuryDiagnosisof Mercury poisoningpoisoning Blood mercury:Blood mercury: – only really useful acutelyonly really useful acutely normal <10µg/lnormal <10µg/l symptoms with blood mercury >150-200µg/lsymptoms with blood mercury >150-200µg/l Urine mercuryUrine mercury – probably the most reliable indicatorprobably the most reliable indicator normal <10µg/lnormal <10µg/l symptoms with urine mercury >100-150µg/lsymptoms with urine mercury >100-150µg/l Radiology:Radiology: for elemental ingestion/aspiration/injectionfor elemental ingestion/aspiration/injection
- 20. Remove fromsourceRemove from source Supportive careSupportive care – particularly important with inhalationparticularly important with inhalation DMPS ChelationDMPS Chelation (2,3-Dimercapto-1-(2,3-Dimercapto-1- propanesulphonate)propanesulphonate) Chelation therapy of choice for mercuryChelation therapy of choice for mercury For both acute and chronic mercury poisoningFor both acute and chronic mercury poisoning For all forms of HgFor all forms of Hg (inorganic > metallic >> organic(inorganic > metallic >> organic)) - Indications:- Indications: symptomatic patientssymptomatic patients blood/urine mercury persistently > 100 - 150blood/urine mercury persistently > 100 - 150µµg/lg/l Treatment of MercuryTreatment of Mercury poisoningpoisoning
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- 22. Clinical Effects ofAcute ExposureClinical Effects of Acute Exposure Ocular exposures:Ocular exposures: Eye exposureEye exposure produces pain, itching, conjunctivitis,produces pain, itching, conjunctivitis, blurred vision and burns.blurred vision and burns. Dermal exposures:Dermal exposures: TetraethylleadTetraethyllead is readily absorbed through intact skin.is readily absorbed through intact skin. ItIt produces itching, burning andproduces itching, burning and transient redness. On occasion, skintransient redness. On occasion, skin may begin to look pale.may begin to look pale.
- 23. Inhalation exposures:Inhalation exposures: InhalationInhalation is the major route ofis the major route of exposure; however, symptoms ofexposure; however, symptoms of tetraethyllead exposure cannot betetraethyllead exposure cannot be separated from the also-toxic solventseparated from the also-toxic solvent mixture it is associated with. Earlymixture it is associated with. Early inhalation effects include sneezing,inhalation effects include sneezing, irritation of the upper respiratory tractirritation of the upper respiratory tract and mild systemic effects.and mild systemic effects.
- 24. Inhalation exposures:Inhalation exposures: Mild systemic effects include anxiety,Mild systemic effects include anxiety, lethargy, irritability, nausea, vomiting,lethargy, irritability, nausea, vomiting, headache, tremors, slurred speech andheadache, tremors, slurred speech and euphoria.euphoria. Moderate effects include disorientation,Moderate effects include disorientation, hyperreflexiahyperreflexia, spasmodic muscular, spasmodic muscular contractions, spasticity, extreme fatigue,contractions, spasticity, extreme fatigue, bradycardia, hypotension and nystagmus.bradycardia, hypotension and nystagmus. Severe systemic effects include completeSevere systemic effects include complete disorientation with hallucinations, facialdisorientation with hallucinations, facial contortions, mania, psychotic behavior,contortions, mania, psychotic behavior, violent seizures which terminate in coma,violent seizures which terminate in coma, and death.and death.
- 25. Ingestion exposures:Ingestion exposures: Poisonings from ingestions are rare.Poisonings from ingestions are rare. Nausea, vomiting and diarrhea wouldNausea, vomiting and diarrhea would be expected. It would be reasonable tobe expected. It would be reasonable to conclude that the systemic effectsconclude that the systemic effects noted in the inhalation exposuresnoted in the inhalation exposures section would occur from ingestion.section would occur from ingestion. Increased intracranial pressure andIncreased intracranial pressure and pulmonary edema also have beenpulmonary edema also have been reportedreported
- 26. Treatment of Exposuresin aTreatment of Exposures in a Health Care FacilityHealth Care Facility Ocular exposures:Ocular exposures: Irrigate exposedIrrigate exposed eyes with lukewarm, low-pressureeyes with lukewarm, low-pressure water or room-temperature 0.9 percentwater or room-temperature 0.9 percent saline solution. Obtain an ophthalmicsaline solution. Obtain an ophthalmic exam after irrigation.exam after irrigation.
- 27. Treatment of ExposuresTreatmentof Exposures in a Health Care Facilityin a Health Care Facility Dermal exposures:Dermal exposures: First, flood theFirst, flood the skin with water. Mandatory soap andskin with water. Mandatory soap and water washings will be necessary towater washings will be necessary to remove the chemical completely fromremove the chemical completely from the skin. Due to the rapid absorption ofthe skin. Due to the rapid absorption of this chemical through intact skin,this chemical through intact skin, patients may require chelation therapypatients may require chelation therapy for increasing blood lead levels.for increasing blood lead levels.
- 28. Treatment of ExposuresTreatmentof Exposures in a Health Care Facilityin a Health Care Facility Inhalation exposures:Inhalation exposures: Maintain theMaintain the patient’s airway. Ventilation may bepatient’s airway. Ventilation may be required. Bronchospasms may berequired. Bronchospasms may be treated with beta2 agonists.treated with beta2 agonists. Chelation therapy will be required forChelation therapy will be required for patients with blood lead levels greaterpatients with blood lead levels greater than 45 mcg/dl. Treat seizures first withthan 45 mcg/dl. Treat seizures first with the benzodiazepines. If not controlled bythe benzodiazepines. If not controlled by the benzodiazepines, second-linethe benzodiazepines, second-line therapy is phenobarbital.therapy is phenobarbital.
- 29. Treatment of Exposuresin aTreatment of Exposures in a Health Care FacilityHealth Care Facility Ingestion exposures:Ingestion exposures: If a large ingestion hasIf a large ingestion has occurred, stomach decontamination should be considered.occurred, stomach decontamination should be considered. These ingestions must be treated as an ingestion ofThese ingestions must be treated as an ingestion of organic solvents, and pulmonary aspiration may occur. Theorganic solvents, and pulmonary aspiration may occur. The airway must be protected.airway must be protected. Aspiration must be avoided. Emesis is not recommended.Aspiration must be avoided. Emesis is not recommended. Whole bowel irrigation should be considered. ChelationWhole bowel irrigation should be considered. Chelation therapy will be required for patients with blood lead levelstherapy will be required for patients with blood lead levels greater than 45 mcg/dl. Chelation therapy is controversial,greater than 45 mcg/dl. Chelation therapy is controversial, as alkylleads are not chelatable, and the therapy probablyas alkylleads are not chelatable, and the therapy probably does not influence central nervous system symptoms.does not influence central nervous system symptoms.
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- 31. Manganese poisoningManganese poisoning Atype of heavy metal poisoning causedA type of heavy metal poisoning caused by excessive exposure to manganese.by excessive exposure to manganese.
- 32. Symptoms of ManganesepoisoningSymptoms of Manganese poisoning Psychiatric disturbancesPsychiatric disturbances Schizophrenic disturbancesSchizophrenic disturbances Neurological disturbancesNeurological disturbances Parkinson-like symptomsParkinson-like symptoms Flu-like symptomsFlu-like symptoms FeverFever Shaking chillsShaking chills HeadacheHeadache CoughCough
- 33. Acute carbonAcute carbon disulphidepoisoningdisulphide poisoning
- 34. Main risks andtargetMain risks and target organsorgans Acute toxic effects include centralAcute toxic effects include central nervous systemnervous system depression, peripheraldepression, peripheral neuropathy and cardiovascularneuropathy and cardiovascular collapse.collapse. Dyspnoea and respiratory failure mayDyspnoea and respiratory failure may occuroccur following exposure to highfollowing exposure to high concentration. Carbonconcentration. Carbon disulphidedisulphide isis irritant to eyes and skin and may causeirritant to eyes and skin and may cause corneal erosionscorneal erosions and chemical burnsand chemical burns respectively. Chronic exposure mayrespectively. Chronic exposure may causecause neuropsychiatric disorders,neuropsychiatric disorders, peripheral neuropathies andperipheral neuropathies and increasedincreased
- 35. Summary of clinicaleffectsSummary of clinical effects Acute carbon disulphide poisoning isAcute carbon disulphide poisoning is rare but very dangerous. Absorptionrare but very dangerous. Absorption occurs through the skin, by ingestionoccurs through the skin, by ingestion or by inhalation. In severe poisoning,or by inhalation. In severe poisoning, the patient rapidly becomes comatosethe patient rapidly becomes comatose and death occurs in a few hours,and death occurs in a few hours, usually due to respiratory depressionusually due to respiratory depression and convulsions.and convulsions.
- 36. CClinical effectslinical effects Inless severe cases local irritation,In less severe cases local irritation, nausea, vomiting and abdominal painnausea, vomiting and abdominal pain are followed by headache, euphoria,are followed by headache, euphoria, hallucinations, manic delirium,hallucinations, manic delirium, paranoid reactions and suicidalparanoid reactions and suicidal tendencies.tendencies.
- 37. CClinical effectslinical effects Chronicoccupational exposure is more common. After 10 -15Chronic occupational exposure is more common. After 10 -15 years it may cause sensory and motor neuropathy,years it may cause sensory and motor neuropathy, neuropsychiatric changes and parkinsonism. Atherosclerosis,neuropsychiatric changes and parkinsonism. Atherosclerosis, in particular coronary heart disease, impaired visionin particular coronary heart disease, impaired vision (perception of coloured rings around lights and retinal(perception of coloured rings around lights and retinal changes), renal and hepatic damage, and permanentchanges), renal and hepatic damage, and permanent impairment of reproductive function also occur after long-termimpairment of reproductive function also occur after long-term exposures. In addition, sleep disturbance, fatigue, anorexiaexposures. In addition, sleep disturbance, fatigue, anorexia and weight loss are common complaints among exposedand weight loss are common complaints among exposed workers. Local contact may result in irritation, burningworkers. Local contact may result in irritation, burning sensation, blistering or deep burns. Conjunctivitis, pain andsensation, blistering or deep burns. Conjunctivitis, pain and blurred vision result from exposure of the eyes to the vapour,blurred vision result from exposure of the eyes to the vapour, and severe irritation or burns occur after direct contact.and severe irritation or burns occur after direct contact.
- 38. DiagnosisDiagnosis The diagnosisis made on the history of exposureThe diagnosis is made on the history of exposure and the presence of clinical effects. In acuteand the presence of clinical effects. In acute poisoning by ingestion, there may be nausea,poisoning by ingestion, there may be nausea, vomiting and abdominal pain followed by headache,vomiting and abdominal pain followed by headache, euphoria, hallucinations, manic delirium, dyspnoea,euphoria, hallucinations, manic delirium, dyspnoea, cyanosis, peripheral vascular collapse,convulsionscyanosis, peripheral vascular collapse,convulsions and coma.and coma. Carbon disulphide can be measured in blood, urineCarbon disulphide can be measured in blood, urine and breathand breath but this is not useful in the management of poisoning.but this is not useful in the management of poisoning. Dithiocarbamine (DTS) may also be measured inDithiocarbamine (DTS) may also be measured in urine.urine. In chronic occupational exposure, the diagnosis isIn chronic occupational exposure, the diagnosis is made from the presence of sensory and motormade from the presence of sensory and motor neuropathy, neuropsychiatric changes, parkinsonism,neuropathy, neuropsychiatric changes, parkinsonism, renal and hepatic damage, sleep disturbance,renal and hepatic damage, sleep disturbance, fatigue, anorexia and weight loss.fatigue, anorexia and weight loss.
- 39. First-aid measures andFirst-aidmeasures and management principlesmanagement principles Remove patient to fresh air if carbon disulphide isRemove patient to fresh air if carbon disulphide is inhaled. In cases of ingestion do not induceinhaled. In cases of ingestion do not induce vomiting.vomiting. Perform gastric aspiration or lavage if the toxin wasPerform gastric aspiration or lavage if the toxin was recently ingested. Wash contaminated skin withrecently ingested. Wash contaminated skin with soap and water. Irrigate contaminated eyessoap and water. Irrigate contaminated eyes copiously with water.copiously with water. In case of severe poisoning, support respiration,In case of severe poisoning, support respiration, administeradminister oxygen and monitor cardiovascular function.oxygen and monitor cardiovascular function. There is no specific antidote. Give symptomatic andThere is no specific antidote. Give symptomatic and supportive treatment as required.supportive treatment as required.