mercury poisoning toxicity

Which toxic exposure can present with the pictured rash along with hypertension and tachycardia mimicking pheochromocytoma?

  1. Arsenic
  2. Lead
  3. Mercury
  4. Silver
  5. Thallium

Answer

3 – Mercury

Background

Mercury poisoning can present as a constellation of symptoms affecting skin, central and peripheral nervous system, cardiovascular, respiratory, musculoskeletal, and genitourinary systems, making diagnosis challenging. Acrodynia, also known as “pink disease”, is a specific syndrome of mercury poisoning causing painful, dusky discoloration of hands and feet which may desquamate. Nonspecific rash resembling viral exanthem is also reported. Mercury inhibits catecholamine-O-methyltransferase (COMT), preventing metabolism of norepinephrine and epinephrine, and causing symptoms similar to pheochromocytoma. Poisoning can also mimic viral illnesses and rheumatologic disorders (1-4). This patient suffered a chronic exposure from an elemental mercury spill on her carpet that had been repeatedly vacuumed.

What are sources of elemental mercury? (1, 5-7)

  • Dental amalgams
  • Thermometers/manometers
  • Fluorescent lights
  • Paints
  • Complementary medicine
  • Industrial exposure such as in electroplating, metal refineries, gold mining, ceramics

What is the clinical presentation of mercury poisoning? (1-7)

  • Presentation varies by the type of mercury exposure: elemental, inorganic or organic. Clinical symptomatology is also determined by the route and chronicity of exposure.
  • Our patient had elemental mercury exposure which presents as follows:
    • Benign if ingested
    • Becomes vaporized if vacuumed
    • Inhalation of vapor may cause respiratory symptoms within hours, and severe pulmonary toxicity can be progressive and permanent
    • Acute inhalation may also present with rash, weakness, headache, visual disturbances, vomiting, and diarrhea
    • Chronic inhalation exposure may additionally result in tremor, kidney dysfunction, and gingivostomatitis
    • Erethism refers to a syndrome of chronic poisoning resulting in emotional lability, irritability, extreme shyness, delirium, and tremor

How is mercury toxicity treated?

  • Remove from exposure and be careful to avoid secondary exposure to providers
  • Supportive care
  • Decontamination may be indicated depending on the exposure
  • Chelation therapy such as with dimercaprol or succimer may be indicated
  • Treatment varies by type, route, and chronicity of exposure

Clinical Pearls on Mercury Poisoning

  • Never vacuum an elemental mercury spill.
  • Poisoning can mimic many other conditions including pheochromocytoma, viral illnesses, or rheumatologic conditions.
  • Acrodynia, also known as “pink disease”, is a specific syndrome of mercury poisoning characterized by painful, dusky red rash to hands and feet.
  • Erethism refers to neuropsychiatric manifestations of mercury poisoning.
  • Chelation therapy may be indicated.

References

  1. Sue, YJ. Mercury. In: Nelson LW, Howland MA, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS Eds. Goldfrank’s Toxicologic Emergencies. 11th edition. New York: McGraw-Hill Education, 2019, 1324-1332
  2. Yildiz M, Adrovic A, Gurup A, et al. Mercury intoxication resembling pediatric rheumatic diseases: case series and literature review. Rheumatol Int. 2020;40(8):1333-1342. PMID: 32342181
  3. Torres AD, Rai AN, Hardiek ML. Mercury intoxication and arterial hypertension: report of two patients and review of the literature. Pediatrics. 2000;105(3):E34. PMID: 10699136
  4. Henningsson C, Hoffmann S, McGonigle L, Winter JS. Acute mercury poisoning (acrodynia) mimicking pheochromocytoma in an adolescent. J Pediatr. 1993;122(2):252-253. PMID: 8429442
  5. Torres AD, Rai AN, Hardiek ML. Mercury intoxication and arterial hypertension: report of two patients and review of the literature. Pediatrics. 2000;105(3):E34. PMID: 10699136
  6. Koirala S, Leinenkugel K. Notes from the Field: Acute Mercury Poisoning After Home Gold and Silver Smelting–Iowa, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(49):1365-1366. Published 2015 Dec 18. PMID: 26678598
  7. Kanluen S, Gottlieb CA. A clinical pathologic study of four adult cases of acute mercury inhalation toxicity. Arch Pathol Lab Med. 1991;115(1):56-60. PMID: 1987914
Michael Semple, DO

Michael Semple, DO

Toxicology Fellow
Washington University School of Medicine
Michael Semple, DO

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Johana Lopez, MD

Johana Lopez, MD

EM Resident
Department of Emergency Medicine
Washington University School of Medicine
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Evan Schwarz, MD

Evan Schwarz, MD

Medical Toxicology Fellowship Director
Washington University School of Medicine
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