Arsine Poisoning Clinical Presentation

Updated: Apr 22, 2015
  • Author: Kermit D Huebner, MD, FACEP; Chief Editor: Robert G Darling, MD, FACEP  more...
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Presentation

History

Most patients report little or no discomfort at the time of exposure. According to the Centers for Disease Control and Prevention (CDC), signs and symptoms generally occur 2-24 hours after exposure and are a result of massive hemolysis. Signs and symptoms include generalized weakness, dark urine, jaundice, and dyspnea. Oliguria and renal failure often occur 1-3 days after exposure.

A case series documenting comprehensive descriptions of the symptoms and clinical course of arsine toxicity was published in 1975. [7] Eight sailors were exposed to arsine gas that had escaped from a cylinder in the cargo hold of the Asiafreighter. Four sailors were exposed from 1 hour 5 minutes to 3 hours 45 minutes (cases 1-4). Four other sailors were exposed for approximately 15 minutes or less (cases 5-8).

All 8 sailors developed fever, headache, myalgia, epigastric pain, nausea, and vomiting between 1 and 12 hours of exposure. Cases 1-4 each developed intravascular hemolysis, renal failure, and marrow suppression with poor reticulocyte response and thrombocytopenia. Case 1 was exposed for the longest amount of time and suffered from anoxia and encephalopathy and was anuric for 5 weeks. Long-term complications for cases 1-4 included peripheral neuropathies, and case 1 was still severely disabled 6 months after the incident. Cases 5-8 developed much milder symptoms. All 8 sailors survived.

The CDC case definition of arsine poisoning includes the following: [8]

  • Suspected: A case in which a potentially exposed person is being evaluated by health care worker or public health officials for poisoning by a particular chemical agent, but no specific credible threat exists.
  • Probable: A clinically compatible case in which a high index of suspicion (credible threat or patient history regarding location and time) exists for arsine exposure, or an epidemiologic link exists between this case and a laboratory-confirmed case.
  • Confirmed: A clinically compatible case in which laboratory tests have confirmed exposure.

The classic triad of symptoms in sublethal arsine exposures includes abdominal pain, hematuria, and jaundice. Symptoms by organ system are as follows:

  • General - Fever, chills, shivering, thirst, malaise
  • Cardiovascular - Long QT syndrome, hypovolemic shock, tachycardia, dysrhythmias
  • Neurologic - Headache; dizziness; sensorimotor peripheral neuropathy (usually 1-3 wk after exposure); neuropsychological symptoms (several days after exposure) including memory loss, restlessness, and confusion
  • Pulmonary - Dyspnea
  • Gastrointestinal - Nausea, vomiting, abdominal pain, anorexia, jaundice
  • Genitourinary - Red or dark-colored urine, flank pain, decreased urine output
  • Muscle - Weakness, cramping
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Physical

Physical signs and their severity depend on the concentration of arsine gas and the duration of the patient's exposure. Findings may include the following:

  • Vital signs - Hyperthermia, tachypnea, tachycardia, hypotension
  • Head, ears, eyes, nose, and throat (HEENT) - Discoloration of conjunctivae (red, orange, brown, or brassy; reportedly distinct from hyperbilirubinemia), scleral icterus, garlic odor to breath (possible)
  • Pulmonary - Rales from acute respiratory distress syndrome (ARDS) in severe exposure
  • Gastrointestinal - Abdominal tenderness, hepatomegaly
  • Genitourinary - Costovertebral angle tenderness, colored urine (red, brown, or green from hemoglobinuria and/or methemoglobinuria)
  • Extremities - Possible paresthesias and Mees lines with chronic arsenic toxicity from arsine exposure
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Causes

See the list below:

  • Arsine gas is used in the semiconductor industry when depositing arsenic on microchips. Exposure also may occur from producing, cleaning, or reclaiming gallium arsenide wafers.
  • Arsine is released during the (usually accidental) production of hydrogen in an acid medium in contact with arsenic-contaminated metals.
  • Arsine may potentially be used as a chemical warfare agent.
    • Suspect arsine exposure if multiple victims present in a delayed fashion with hematuria, abdominal or flank pain, and jaundice.
    • Severe acute arsine exposure may result in sudden death.
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