Arsenic Toxicity Clinical Presentation

Updated: May 30, 2017
  • Author: Adam Blumenberg, MD, MA; Chief Editor: David Vearrier, MD, MPH  more...
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Presentation

History

Arsenic exposure is usually suicidal, malicious, homicidal, or occupational.

To reveal the exposure, record a careful work history on individuals with symptoms of a painful peripheral neuropathy. If the setting is not occupational, a careful epidemiological history of those affected and those unaffected must be undertaken.

Exposure to arsine gas is usually the result of an occupational accident; in most cases, the worker presents promptly and ideally is brought in with the material safety data sheet (MSDS). One case report indicates that the presentation may be more insidious: In this report, a man in his 20s presented to an emergency department complaining of bloody urine and vomiting 34 hours after an apparent exposure to arsine in the workplace. Laboratory evaluation revealed arsenic in his blood and urine, and an industrial hygiene evaluation of his worksite was able to reproduce his exposure. [19]

Determining unusual cases requires a careful history regarding dietary and nutritional habits, particularly the use of nutritional supplements and ayurvedic medicines, hobbies, and alcohol abuse. [20]

Often, patients with neurological symptoms are subjected to "heavy metal screens" by their primary care practitioners or even neurologists. Often, the laboratories used are not the standard medical reference laboratories, and the results are of questionable reliability. In other cases, the results are reported in concentration of total arsenic in urine or blood, and this is not generally accepted as valuable in the determination of possible exposure or toxicity.

 

 

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Physical

Acute severe arsenic poisoning produces the following findings:

  • Hemodynamcs - Tachycardia, hypotension, and shock
  • Central nervous system - Altered mental status, delirium, coma, and seizures (acute encephalopathy)
  • Frequently, patients exposed to arsenic may have a garlic smell to their breath and tissue fluids.

In trivalent arsenic poisoning, clinical effects depend on the chronicity of exposure, as follows:

  • Acute exposures generally feature the cholera-like gastrointestinal symptoms of vomiting (often bloody) and severe diarrhea (which may be rice-watery in character and is often bloody). Dehydration and shock may result.
  • Chronic toxicity is more insidious and may manifest as a classic dermatitis (hyperkeratosis with a classical "dew drops on a dusty road" appearance) [21] or peripheral neuropathy (usually a painful paresthesia that is symmetrical and stocking-glove in distribution). Motor weakness and ascending paralysis similar to Guillain-Barré syndrome may develop.
  • In chronic toxicity, the fingfernails exhibit whitish lines (Mees lines) that look much like traumatic injuries.
  • Multiple reports of cardiac arrhythmias exist in the literature, with abnormalities including prolongation of the QT interval, torsades de pointes, and ventricular fibrillation after acute arsenic intoxication.
  • Chronic hepatic and renal damage is common with chronic exposure.

Arsine gas exposure manifests as an acute hemolytic anemia and chills. Hemoglobinuria causes the urine to appear black (see the image below), and the patient becomes rapidly obtunded and shocky. Shaking chills are often described in these patients.

"Blackwater" urine due to massive hemolysis, from "Blackwater" urine due to massive hemolysis, from a patient exposed to arsine at a gas tank cleaning operation.

 

 

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Causes

Children may encounter arsenic trioxide as a rodenticide or herbicide. Examine for both arsenic and cholinesterase-inhibitor exposure. Possible transdermal absorption from exposure to pressure-treated wood, now banned for use by the US EPA, has been reported.

Adults may be exposed through work in a metal foundry, mining, glass production, or the semiconductor industry.

Arsenic has been found to contaminate such common items as wine, glues, and pigments. Arsenic is commonly found in many foods both in its apparently nontoxic organic form and also in the more toxic inorganic form. Such arsenic has been reported in milk and dairy products, beef, pork, poultry, and cereal. Arsenic is also often found in rice, representing a potentially serious source of exposure in certain at-risk populations.

Arsenic exists in significant concentrations in some shallow wells dug for provision of clean water in some underdeveloped countries.

 

 

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