Acute Elemental Mercury Poisoning Masquerading as Fever and Rash
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CDC TOXICOLOGY REPORT
Acute Elemental Mercury Poisoning Masquerading as Fever and Rash Amy C. Young 1
&
Paul M. Wax 1 & Sing-Yi Feng 1 & Kurt C. Kleinschmidt 1 & Jhonny E. Ordonez 2
Received: 22 March 2020 / Revised: 26 May 2020 / Accepted: 29 May 2020 # American College of Medical Toxicology 2020
Abstract This is a case series of 3 children from a single family who developed symptomatic elemental mercury poisoning requiring hospitalization and chelation. The mercury exposure primarily occurred in the home but the mercury was also tracked to one of their schools requiring environmental cleanup at both the home and school. The clinical assessment and management, as well as public health investigation and response, are discussed. There are many lessons learned in this difficult, often delayed, diagnosis. Early recognition of this environmental toxic exposure is essential. Communication between the clinicians and public health officials played a critical role. Public education prevented panic. Proper environmental sampling, and assessment and management of those exposed, were a few of the many challenges faced in this complicated case series.
Introduction Mercury is a toxic heavy metal that is found in the elemental, inorganic, and organic forms. Elemental mercury is found in thermometers, dental amalgams, fluorescent light tubes, compact fluorescent lamps, and mercury added to latex paint [1]. Mercury disrupts normal cell physiology by binding to intracellular sulfhydryl-containing enzymes and proteins [2]. Elemental mercury is lipophilic and highly volatile; 70 to 85% of a dose is absorbed through the lungs [2]. Acutely, patients that inhale the mercury vapor can have chemical pneumonitis and flu-like symptoms [2]. Once elemental mercury is inhaled, it crosses the alveolar membrane in the lungs and is rapidly absorbed and distributed in the major organs. The primary target organs of elemental mercury deposition are the brain and kidney [3]. Neurotoxicity presents as a triad of erythrism, tremors, and gingivitis [3, 4]. Patients can also have acrodynia or “pink disease” [1, 5]. Nephrotoxicity includes proteinuria, acute tubular necrosis, and/or renal failure [1, 4]. Because the clinical presentation can vary, the diagnosis of mercury poisoning can be challenging and is oftentimes delayed. Supervising Editor: Mark B. Mycyk, MD * Amy C. Young [email protected] 1
University of Texas Southwestern Medical Center, Dallas, TX, USA
2
Ministry of Public Health of Ecuador, Quito, Ecuador
This case involved three children ages 14, 11, and 9 years old following an exposure to elemental mercury. Two of the children presented to the emergency department (ED). The diagnosis was not initially made when they were sent home with a typical pediatric presentation of a viral-like illness. The third child became symptomatic the next day prompting all three children to return to the same ED. At the second ED visit, the eldest child brought a container of elemental mercury he had found outside. After further questioning, it w
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