History

The signs and symptoms of aluminum toxicity are usually nonspecific. Typical presentations in chronic toxicity 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 kidney disease; most of them have end-stage kidney disease and are on hemodialysis or peritoneal dialysis.

In the past, aluminum toxicity, including osteomalacia, was seen in patients on long-term hemodialysis, due to exposure to dialysate containing high concentrations of aluminum. However, aluminum toxicity is not a concern with modern dialysis protocols, which use water purified with reverse osmosis.

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 constitute the specific group most closely associated with the syndrome.

When obtaining the history, ask specifically about the use of oral aluminum hydroxide antacids, particularly if the patient has diminished kidney function but does not undergo dialysis.

A history of long-term total parenteral nutrition (TPN) is also a risk factor. This especially true in infants, as elevated aluminum levels have been found in infant TPN formula.^[31]

Physical Examination

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.^[36]

In children, bony deformity is more commonly due to the increased rate of growth and remodeling. The areas of deformity in children usually involve the epiphyseal plates (ie, femur, wrist).Children may also demonstrate varying degrees of growth retardation. In adults, thoracic cage abnormalities, lumbar scoliosis, and kyphosis can be present.

Differential Diagnoses

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Author

Jose F Bernardo, MD, MPH, FASN Former Associate Professor of Medicine; University of Pittsburgh School of Medicine

Jose F Bernardo, MD, MPH, FASN is a member of the following medical societies: American Society of Nephrology, American Society of Transplantation

Disclosure: Nothing to disclose.

Coauthor(s)

Michael R Edwards, MD, CPE, FACEP, FAAEM Physician, Department of Emergency Medicine, Beebe Medical Center; Physician, Department of Emergency Medicine, Catholic Medical Center

Michael R Edwards, MD, CPE, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Harold L Manning, MD Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Chief Editor

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Barbara Barnett, MD Associate Program Director, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine

Barbara Barnett, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lisa Kirkland, MD, FACP, FCCM, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; Chair, Department of Critical Care, ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, FCCM, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Aluminum Toxicity Clinical Presentation

History

Physical Examination

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