Heavy Metal Toxicity Follow-up
- Author: Samara Soghoian, MD, MA; Chief Editor: Asim Tarabar, MD more...
Further Inpatient Care
- Arsenic is frequently used for homicidal or suicidal purposes. Thoroughly scrutinize all arsenic toxicity cases for evidence of such activity. Report all cases with possible homicidal association to the proper legal authorities before discharge.
- Patients with suspected suicidal intent should undergo psychiatric evaluation before discharge from hospital.
Further Outpatient Care
- The first priority in managing any patient with detectable serum lead is to determine the source of exposure and to remove the person from it. The finding of any elevated serum or urine metal concentration in an asymptomatic person should prompt a thorough dietary, occupational, and recreational history, and radiographs where indicated to identify any source of ongoing exposure.
- A majority of asymptomatic children and adults with elevated lead levels can be safely managed solely by removing the source of exposure. Contact a medical toxicologist or the local poison control center for specific recommendations.
- All cases of significantly elevated lead levels should be reported to the local health department.
- Report any industry- or workplace-related heavy metal toxicities to OSHA.
- Symptomatic patients with elevated metal concentrations should be treated more aggressively. Please refer to the relevant articles (see Toxicity, Arsenic; Toxicity, Lead; Toxicity, Mercury; Toxicity, Iron) or contact a medical toxicologist for more specific recommendations.
Complications
- Metal toxicity is rarely encountered clinically and may be difficult to recognize.
- If untreated, acute exposures may progress to multiorgan failure and death or permanent organ damage.
- Chronic exposure to metals may present with nonspecific symptoms, but if it is not identified and the exposure is allowed to continue, permanent neurologic damage, organ failure, or cancer may develop.
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| 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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