Heavy Metal Toxicity Differential Diagnoses

Author: Samara Soghoian, MD, MA; Chief Editor: Asim Tarabar, MD more...

Updated: May 6, 2011

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Contributor Information and Disclosures

Author

Samara Soghoian, MD, MA Clinical Assistant Professor of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center

Samara Soghoian, MD, MA is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark Louden, MD, FACEP Assistant Medical Director, Emergency Department, Duke Raleigh Hospital

Mark Louden, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart & 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.

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM, Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM, is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

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.

References

Schwartz BS, Hu H. Adult lead exposure: time for change. Environ Health Perspect. Mar 2007;115(3):451-4. [Medline].
Bowler RM, Roels HA, Nakagawa S, et al. Dose-effect relationships between manganese exposure and neurological, neuropsychological and pulmonary function in confined space bridge welders. Occup Environ Med. Mar 2007;64(3):167-77. [Medline].
Roney N, Osier M, Paikoff SJ, et al. ATSDR evaluation of the health effects of zinc and relevance to public health. Toxicol Ind Health. Nov 2006;22(10):423-93. [Medline].
Parry J. Metal smelting plants poison hundreds of Chinese children. BMJ. Aug 24 2009;339:b3433. [Medline].
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Hornung RW, Lanphear BP, Dietrich KN. Age of greatest susceptibility to childhood lead exposure: a new statistical approach. Environ Health Perspect. Aug 2009;117(8):1309-12. [Medline].
Prozialeck WC, Edwards JR, Nebert DW, et al. The vascular system as a target of metal toxicity. Toxicol Sci. Apr 2008;102(2):207-18. [Medline].
[Guideline] Caravati EM, Erdman AR, Christianson G, Nelson LS, Woolf AD, Booze LL, et al. Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). Jan 2008;46(1):1-21. [Medline]. [Full Text].
[Guideline] Manoguerra AS, Erdman AR, Booze LL, Christianson G, Wax PM, Scharman EJ, et al. Iron ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43(6):553-70. [Medline]. [Full Text].
Ball H. Arsenic Poisoning and Napoleon's Death. New Scientist. October 1982;101-104.
Ellenhorn MJ. Ellenhorn's Medical Toxicology. 2^nd ed. Williams & Wilkins: 1997:1532-1613.
Ford M. Arsenic. In: Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS, eds. Goldfrank's Toxicologic Emergencies. 8^th ed. McGraw-Hill; 2006:1251-1264.
Henretig FM. Lead. In: Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS, eds. Goldfrank's Toxicologic Emergencies. 8^th ed. McGraw-Hill; 2006:1308-1324.
Kaye P, Young H, O'Sullivan I. Metal fume fever: a case report and review of the literature. Emerg Med J. May 2002;19(3):268-9. [Medline].
Meulenbelt J, van Zoelen GA, Vries de I. Cadmium intoxication: features and management. J Toxicol Clin Toxicol. Apr 2001;39:223-226.
Petersdorf RG, Martin JB, Fauci AS, et al. Harrison's Principals of Internal Medicine. Vol 2. 12^th ed. McGraw-Hill; 1991:2182-7.
Sue YJ. Mercury. In: Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS, eds. Goldfrank's Toxicologic Emergencies. 8^th ed. McGraw-Hill; 2006:1334-1344.
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Table. Typical Presentation of the Most Commonly Encountered Metals and Their Treatment

Table. Typical Presentation of the Most Commonly Encountered Metals and Their Treatment

Metal	Acute	Chronic	Toxic Concentration	Treatment
Arsenic	Nausea, vomiting, "rice-water" diarrhea, encephalopathy, MODS, LoQTS, painful neuropathy	Diabetes, hypopigmentation/ hyperkeratosis, cancer: lung, bladder, skin, encephalopathy	24-h urine: ≥50 µg/L urine, or 100 µg/g creatinine	BAL (acute, symptomatic) Succimer DMPS (Europe)
Bismuth	Renal failure; acute tubular necrosis	Diffuse myoclonic encephalopathy	No clear reference standard	*
Cadmium	Pneumonitis (oxide fumes)	Proteinuria, lung cancer, osteomalacia	Proteinuria and/or ≥15 µg/ g creatinine	*
Chromium	GI hemorrhage, hemolysis, acute renal failure (Cr⁶⁺ ingestion)	Pulmonary fibrosis, lung cancer (inhalation)	No clear reference standard	NAC (experimental)
Cobalt	Beer drinker’s (dilated) cardiomyopathy	Pneumoconiosis (inhaled); goiter	Normal excretion: 0.1-1.2 µg/L (serum) 0.1-2.2 µg/L (urine)	NAC CaNa₂ EDTA
Copper	Blue vomitus, GI irritation/ hemorrhage, hemolysis, MODS (ingested); MFF (inhaled)	vineyard sprayer’s lung (inhaled); Wilson disease (hepatic and basal ganglia degeneration)	Normal excretion: 25 µg/24 h (urine)	BAL D-Penicillamine Succimer
Iron	Vomiting, GI hemorrhage, cardiac depression, metabolic acidosis	Hepatic cirrhosis	Nontoxic: < 300 µg/dL Severe: >500 µg/dL	Deferoxamine
Lead	Nausea, vomiting, encephalopathy (headache, seizures, ataxia, obtundation)	Encephalopathy, anemia, abdominal pain, nephropathy, foot-drop/ wrist-drop	Pediatric: symptoms or [Pb] ≥45 µ/dL (blood); Adult: symptoms or [Pb] ≥70 µ/dL^[1]	BAL CaNa₂ EDTA Succimer
Manganese	MFF (inhaled)	Parkinson-like syndrome, respiratory, neuropsychiatric^[2]	No clear reference standard	*
Mercury	Elemental (inhaled): fever, vomiting, diarrhea, ALI; Inorganic salts (ingestion): caustic gastroenteritis	Nausea, metallic taste, gingivo-stomatitis, tremor, neurasthenia, nephrotic syndrome; hypersensitivity (Pink disease)	Background exposure "normal" limits: 10 µg/L (whole blood); 20 µg/L (24-h urine)	BAL Succimer DMPS (Europe)
Nickel	Dermatitis; nickel carbonyl: myocarditis, ALI, encephalopathy	Occupational (inhaled): pulmonary fibrosis, reduced sperm count, nasopharyngeal tumors	Excessive exposure: ≥8 µg/L (blood) Severe poisoning: ≥500 µg/L (8-h urine)	*
Selenium	Caustic burns, pneumonitis, hypotension	Brittle hair and nails, red skin, paresthesia, hemiplegia	Mild toxicity: [Se] >1mg/L (serum); Serious: >2 mg/L	*
Silver	Very high doses: hemorrhage, bone marrow suppression, pulmonary edema, hepatorenal necrosis	Argyria: blue-grey discoloration of skin, nails, mucosae	Asymptomatic workers have mean [Ag] of 11 µg/L (serum) and 2.6 µg/L (spot urine)	Selenium, vitamin E (experimental)
Thallium	Early: Vomiting, diarrhea, painful neuropathy, coma, autonomic instability, MODS	Late findings: Alopecia, Mees lines, residual neurologic symptoms	Toxic: >3 µg/L (blood)	MDAC Prussian blue
Zinc^[3]	MFF (oxide fumes); vomiting, diarrhea, abdominal pain (ingestion)	Copper deficiency: anemia, neurologic degeneration, osteoporosis	Normal range: 0.6-1.1 mg/L (plasma) 10-14 mg/L (red cells)	*
*No accepted chelation regimen; contact a medical toxicologist regarding treatment plan. MODS, multi-organ dysfunction syndrome; LoQTS, long QT syndrome; ALI, acute lung injury; ATN, acute tubular necrosis; ARF, acute renal failure; DMPS, 2,3-dimercapto-1-propane-sulfonic acid; CaNa₂ EDTA, edetate calcium disodium; MDAC, multi-dose activated charcoal; NAC, N -acetylcysteine.

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