eMedicine Specialties > Neurology > Neurotoxicology

Mercury: Differential Diagnoses & Workup

Author: David A Olson, MD, Clinical Neurologist, Dekalb Neurology Associates, Decatur, Georgia
Contributor Information and Disclosures

Updated: Sep 21, 2009

Differential Diagnoses

Acute Disseminated Encephalomyelitis
Huntington Disease
Alzheimer Disease
Low-Grade Astrocytoma
Amyotrophic Lateral Sclerosis
Lyme Disease
Arsenic
Mental Retardation
Ataxia with Identified Genetic and Biochemical Defects
Metastatic Disease to the Brain
Benign Positional Vertigo
Multiple Sclerosis
Brainstem Gliomas
Neuropathy of Friedreich Ataxia
Dementia in Motor Neuron Disease
Nutritional Neuropathy
Diabetic Neuropathy
Organic Solvents
Dizziness, Vertigo, and Imbalance
Paraneoplastic Cerebellar Degeneration
Essential Tremor
Paraneoplastic Encephalomyelitis
Frontal and Temporal Lobe Dementia
Pseudotumor Cerebri
Frontal Lobe Syndromes
Systemic Lupus Erythematosus
Glioblastoma Multiforme
Thyroid Disease
Head Injury
Viral Encephalitis
HIV-1 Associated Acute/Chronic Inflammatory Demyelinating Polyneuropathy
Vitamin B-12 Associated Neurological Diseases
HIV-1 Associated CNS Complications (Overview)
HIV-1 Encephalopathy and AIDS Dementia Complex

Other Problems to Be Considered

Paraproteinemic neuropathy

Workup

Laboratory Studies

  • Laboratory studies are imperative, although exact toxicity levels remain undefined.
    • In the United States, based on the 2003 National Health and Nutrition Examination Survey (NHANES) data, urine mercury levels of 5 mcg/L and blood mercury levels of 7.1 mcg/L encompassed 95% of the sample and have recently been recommended as medically "credible comparison" levels.35 While blood levels are useful for more acute exposures, long-term exposures are best reflected in hair mercury measurements. Because of environmental contamination, hair measurements have been problematic with elemental mercury exposure, but methylmercury hair measurements are considered accurate.36 A hair value of 1.2 mcg/g encompassed 90% of the NHANES sample.35
    • Toenail mercury has also been used as a measure of long-term mercury exposure, with mean levels of 0.25-0.45 mcg/g among Western samples. Toenail mercury has been correlated with fish and shellfish consumption.37,38
    • Cerebrospinal (CSF) mercury concentrations have been measured with mass spectroscopy and normal values vary widely. Nevertheless, increased CSF mercury levels have been found in workers with ongoing exposure to mercury vapors, but these CSF levels, unlike blood levels, normalize several months after such exposures have abated.39
    • Correlations have been found between signs, symptoms, and electrophysiological studies of subjects exposed to mercury with various statistical extrapolations of measures of exposure, such as duration of exposure, peak urinary mercury levels, and estimated cumulative mercury dose.
    • Interestingly, investigators of Minamata disease identified chronic forms of the disease in which hair mercury levels were not elevated. A delayed neurotoxic effect, with symptoms emerging after age-induced neuronal loss, was hypothesized.3 Similarly, some researchers have been unable to correlate the fluctuations of mercury blood levels with signs and symptoms of toxicity in mercury vapor exposure.40

Imaging Studies

  • Neuroimaging is probably more helpful in excluding other diagnoses than in ruling in mercury toxicity.
  • MRI imaging in cases of Minamata disease, nevertheless, confirms the clinical and pathologic findings. Marked atrophy of the calcarine and parietal cortices as well as the cerebellar folia has been visualized.41
  • MRI findings in one patient with inorganic mercury toxicity revealed mild cortical atrophy and T2 hyperintensities in frontal and subcortical regions.42
  • Single-photon emission computed tomography (SPECT) demonstrated right cingulate hypermetabolism in a 38-year-old man with emotional lability and inattention following exposure to inorganic mercury.43

Other Tests

  • Electrophysiological studies have demonstrated a sensorimotor neuropathy, typically axonal, in some workers exposed to elemental mercury or mercury vapors. Abnormalities have been documented in visual-evoked potential studies among workers exposed to mercury vapors as well.40
  • In the Faroe Islands, intrauterine methylmercury exposure (as determined by maternal hair and cord blood measures) was positively correlated with prolonged brainstem evoked potentials (III and V latency peaks) 14 years after initial exposure.44

Histologic Findings

Occasional sural nerve biopsies have been performed on patients with mercury toxicity. Two cases of inorganic mercury poisoning revealed a combination of axonal and demyelinating changes.45 Organic mercury toxicity in Minamata disease resulted in the preferential loss of large myelinated nerve fibers.46

More on Mercury

Overview: Mercury
Differential Diagnoses & Workup: Mercury
Treatment & Medication: Mercury
Follow-up: Mercury
References
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References

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Further Reading

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Keywords

mad hatter's syndrome, metal fume fever, erethism, Minamata disease, methylmercury, methyl mercury, mercury poisoning, mercury toxicity, mercury-induced cognitive impairments, mercury intoxication, mercury exposure, prenatal mercury exposure

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Contributor Information and Disclosures

Author

David A Olson, MD, Clinical Neurologist, Dekalb Neurology Associates, Decatur, Georgia
David A Olson, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Medical Editor

Joseph Quinn, MD, Assistant Professor, Department of Neurology, Portland VA Medical Center, Oregon Health Sciences University
Joseph Quinn, MD is a member of the following medical societies: American Academy of Neurology, Society for Neuroscience, and Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard J Caselli, MD, Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

,, Kathy Roarty Placeholder
Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

 
 
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