Arsenic Toxicity in Emergency Medicine Clinical Presentation

  • Author: Steven Marcus, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 11, 2012
 

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 rapidly and is brought in with the material safety data sheet (MSDS). A recent 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.[16]

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.

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
    • Vital signs - Tachycardia and hypotension, even shock
    • CNS - Altered mental status, delirium, coma, and seizures (acute encephalopathy)
  • Frequently, patients exposed to arsenic have a garlic smell to their breath and tissue fluids.
  • In trivalent arsenic poisoning, clinical effects depend on the chronicity of exposure.
    • Acute exposures generally manifest with the cholera-like gastrointestinal symptoms of vomiting (often times bloody) and severe diarrhea (which may be rice-watery in character and often bloody); these patients will experience acute distress, dehydration (often), and hypovolemic shock.
    • Chronic toxicity is more insidious and may manifest as a classical dermatitis (hyperkeratosis with a classical "dew drops on a dusty road" appearance) or peripheral neuropathy (usually a painful paresthesia that is symmetrical and stocking-glove in distribution).
    • Also, whitish lines (Mees lines) that look much like traumatic injuries are found on the fingernails.
    • Multiple reports of cardiac arrhythmias exist in the literature. Reports of prolongation of the QT and ventricular fibrillation after acute arsenic intoxication make careful attention to cardiac status imperative.
    • Chronic hepatic and renal damage is common with chronic exposure.
  • Arsine gas exposure manifests with an acute hemolytic anemia and striking 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. Black water urine from a patient with massive hemoBlack water urine from a patient with massive hemolysis secondary to arsine exposure 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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Contributor Information and Disclosures
Author

Steven Marcus, MD  Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center

Steven Marcus, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Clinical Toxicology, American Academy of Pediatrics, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Medical Society of New Jersey

Disclosure: Nothing to disclose.

Specialty Editor Board

David C Lee, MD  Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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Black water urine from a patient with massive hemolysis secondary to arsine exposure at a gas tank cleaning operation.
 
 
 
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