Aluminum Toxicity Clinical Presentation

Updated: Jul 10, 2017
  • Author: Jose F Bernardo, MD, MPH; Chief Editor: Sage W Wiener, MD  more...
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Presentation

History

The signs and symptoms of aluminum toxicity are usually nonspecific.

In patients on long-term hemodialysis, osteomalacia is associated with the accumulation of aluminum in bone. Most evidence to support skeletal toxicity is from animal studies.

Studies have also shown that patients on hemodialysis who are exposed to dialysate containing high aluminum concentrations are at increased risk of osteomalacia.

Some of the clinical symptoms of the disease entity reflect the chief complaint. An emergency physician will rarely consider aluminum toxicity as a possible diagnosis in a patient on dialysis who presents with an acute mental status change; however, these patients are the specific group most closely associated with the syndrome.

Typical presentations may include proximal muscle weakness, bone pain, multiple nonhealing fractures, acute or subacute alteration in mental status, and premature osteoporosis. These patients almost always have some degree of renal disease. Most patients are on hemodialysis or peritoneal dialysis.

When obtaining the history, ask specifically about the supplemental use of oral aluminum hydroxide, particularly if the patient does not undergo dialysis.

In children, special awareness must be made in those who require parenteral nutrition so as not to give excessive amounts of aluminum in the nutriitonal formula.

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Physical

Unfortunately, physical findings are often noticeably lacking in patients with aluminum toxicity, and findings usually mimic other disease processes.

Patients can present with multiple fractures (particularly of the ribs and pelvis), proximal muscle weakness, mutism, seizures, and dementia.

Some studies have shown a direct correlation between aluminum levels and intensity of uremic pruritus.

In children, bony deformity is more commonly due to the increased rate of growth and remodeling. Children may also express varying degrees of growth retardation.

The areas of deformity in children usually involve the epiphyseal plates (ie, femur, wrist). In adults, thoracic cage abnormalities, lumbar scoliosis, and kyphosis can be present.

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Causes

Aluminum toxicity is usually found in patients with renal impairment. Acute intoxication is extremely rare; however, in persons in whom aluminum clearance is impaired, it can be a source of significant toxicity.

Intravesical irrigation with aluminum is used as a treatment for hemorrhagic cystitis, a life-threatening complication of bone marrow transplantation, chemotherapy, and radiotherapy. Bogris et al reported a case of aluminum toxicity in a pediatric patient with leukemia who received this treatment. [24]

A number of vaccines contain aluminum salts as adjuvants. As a result, fully vaccinated children are exposed to up to 4 mg of aluminum in the first 2 years of life. [25] Mitkus et al reported that in an infant's first year of life, the body burden of aluminum from vaccines and diet is significantly less than the corresponding safe body burden of aluminum modeled using the regulatory minimal risk levels. [26] However, adjuvant aluminum in vaccines has been reported to cause local inflammatory reactions (eg, erythema, subcutaneous nodules, contact hypersensitivity). [27, 28]

Inbar et al posited that data on vaccine-related aluminum toxicity may have been limited by the use of aluminum adjuvants as placebos in most human vaccine trials, and suggested (on the basis of their study showing behavioral changes in mice) that aluminum adjuvants may trigger neuroinflammation and autoimmune reactions. [29] The study, however, was later withdrawn from the journal where it was originally published, in view of “severely flawed” methodological issues and unjustified claims. [30]

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