Envenenamento agudo por mercúrio: relato de caso

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Acute mercury poisoning: a case report
Sezgin Sarikaya, Ozgur Karcioglu, Didem Ay, Aslı Cetin, Can Aktas, Mustafa Serinken
Dept. of Emergency Medicine, Pamukkale University, School of Medicine, Denizli, Turkey
Fonte: http://www.biomedcentral.com/1471-227X/10/7 Acesso em 17 Ago 2014
Abstract
BACKGROUND: Mercury poisoning can occur as a result of occupational hazard or suicide attempt. This
article presents a 36-year-old case admitted to emergency department (ED) due to exposure to metallic
mercury. CASE PRESENTATION: A 36-year-old woman presented to the ED with a three-day history of
abdominal pain, diarrhea and fever. One week ago her daughter had brought mercury in the liquid form from
the school. She had put it on the heating stove. One day later, her 14-month old sister baby got fever and
died before admission to the hospital. Her blood pressure was 134/87 mmHg; temperature, 40.2°C; heart
rate 105 bpm and regular; respiration, 18 bpm; O2 saturation, 96%. Nothing was remarkable on examination
and routine laboratory tests. As serine or urinary mercury levels could not be tested in the city, symptomatic
chelation treatment with N-acetylcysteine (NAC) was instituted with regard to presumptive diagnosis and
history. At the 7th day of admission she was discharged without any sequelae or complaint. At the discharge
day blood was drawn and sent for mercury levels which turned out to be 30 μg/dL (normal range: 0 - 10
μg/dL). CONCLUSION: Publ
Envenenamento agudo por mercúrio: relato de caso
Resumo
ANTECEDENTES: O envenenamento por mercúrio pode ocorrer como resultado de risco ocupacional ou
tentativa de suicídio. Este artigo apresenta um caso de (um paciente) de 36 anos de idade internado em
unidade de emergência (UE) devido a exposição ao mercúrio metálico. APRESENTAÇÃO DO CASO: Uma
mulher de 36 anos apresentou-se na UE com um histórico de três dias de dor abdominal, diarréia e febre.
Há uma semana sua filha tinha trazido mercúrio na forma líquida da escola. Ela tinha colocado no fogão
para aquecimento. Um dia depois, o bebê, irmã mais velha, de 14 meses de idade apresentou febre e
morreu antes da sua admissão ao hospital. A pressão arterial era 134/87 mmHg; temperatura, 40,2 ° C;
freqüência cardíaca de 105 bpm e regular; respiração, 18 bpm; Saturação de O2, 96%. Nada foi notável no
exame e exames laboratoriais de rotina. Como os níveis de serina ou mercúrio na urina não pode ser
testado na cidade, o tratamento sintomático de quelação com N-acetilcisteína (NAC) foi instituída em
relação ao diagnóstico presuntivo e histórico. No sétimo dia de internação, ela recebeu alta sem sequelas
ou reclamação. No dia da alta (do paciente), o sangue recolhido e enviado para (análise) dos níveis de
mercúrio acabou por ser de 30 μg/dL (valor normal: 0 - 10 μg/dL). CONCLUSÃO: A ed
Realização:
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Apoio:
Sarikaya et al. BMC Emergency Medicine 2010, 10:7
http://www.biomedcentral.com/1471-227X/10/7
CASE REPORT
Open Access
Acute mercury poisoning: a case report
Sezgin Sarikaya1, Ozgur Karcioglu2, Didem Ay1, Aslı Cetin1, Can Aktas1, Mustafa Serinken3*
Abstract
Background: Mercury poisoning can occur as a result of occupational hazard or suicide attempt.
This article presents a 36-year-old case admitted to emergency department (ED) due to exposure to metallic
mercury.
Case Presentatıon: A 36-year-old woman presented to the ED with a three-day history of abdominal pain,
diarrhea and fever. One week ago her daughter had brought mercury in the liquid form from the school. She had
put it on the heating stove. One day later, her 14-month old sister baby got fever and died before admission to
the hospital. Her blood pressure was 134/87 mmHg; temperature, 40.2°C; heart rate 105 bpm and regular;
respiration, 18 bpm; O2 saturation, 96%. Nothing was remarkable on examination and routine laboratory tests. As
serine or urinary mercury levels could not be tested in the city, symptomatic chelation treatment with N-acetyl
cysteine (NAC) was instituted with regard to presumptive diagnosis and history. At the 7th day of admission she
was discharged without any sequelae or complaint. At the discharge day blood was drawn and sent for mercury
levels which turned out to be 30 μg/dL (normal range: 0 - 10 μg/dL).
Conclusion: Public education on poisoning and the potential hazards of mercury are of vital importance for
community health.
Background
Acute and chronic mercury exposure represents a
potential threat to community health. Mercury poisoning can occur as a result of occupational hazard or suicide attempt. Mercury is silver-colored and liquid at
room temperature. Mercury is available in inorganic and
organic forms. All compounds of mercury are toxic but
differ in the routes of absorption, clinical findings, and
responses to therapy. Methylmercury, the soluble form
is neurotoxic. Elemental (organic) mercury is especially
hazardous for children since it is in liquid form and can
easily be found around [1].
The clinical effects of mercury poisoning depend on
the form and the route of entry to the organism. Neurologic, gastrointestinal and renal systems are predominantly affected depending on the route of exposure.
This article presents a 36-year-old case admitted to
emergency department (ED) with nausea, vomiting and
diarrhea caused by accidental inhalation and skin exposure of metallic mercury.
* Correspondence: [email protected]
3
Dept. of Emergency Medicine, Pamukkale University, School of Medicine,
Denizli, Turkey
Case Presentation
A 36-year-old woman presented to the ED with a
three-day history of abdominal pain, diarrhea and
fever. One week ago her daughter had brought mercury in the liquid form from the school without permission from her teacher. She had played with the
mercury, and then put it on the heating stove and
watched its vaporization. Meanwhile, her mother
breast-fed her 14-month old sister. 24 hours after this
event her baby got fever and died before admission to
the hospital, without any specific diagnosis. The
autopsy report disclosed a suspected mercury poisoning which might have led to cardiorespiratory collapse
resulting in death of the infant.
On examination, her blood pressure was 134/87
mmHg; temperature, 40.2°C; heart rate 105 bpm and
regular; respiration, 18 bpm; O2 saturation, 96% with
pulse oximetry at room temperature. The patient had
no past medical history. Her fever relieved after administration of 1 gr paracetamol given via intravenous
route, while arterial oxygen saturation rose to 98% with
supplemental oxygen.
Nothing was remarkable in her head-neck, respiratory,
cardiovascular, or abdominal examinations. Neurological
© 2010 Sarikaya et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Sarikaya et al. BMC Emergency Medicine 2010, 10:7
http://www.biomedcentral.com/1471-227X/10/7
examination did not reveal any tremor, paresthesia,
ataxia, spasticity, hearing and vision loss. Neuropsychiatric abnormalities were not identified.
Complete blood count, urinalysis, sodium, potassium,
blood urea nitrogen (BUN), creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin levels were within normal ranges. Chest X-ray and
cranial computed tomography revealed no findings of
disease.
As serine or urinary mercury levels could not be
tested in the city, symptomatic chelation treatment with
N-acetyl cysteine (NAC) was instituted with regard to
presumptive diagnosis and history. At the 7 th day of
admission she was discharged without any sequelae or
complaint. In the same day, blood was drawn and sent
for mercury levels which turned out to be 30 μg/dL
(normal range: 0 - 10 μg/dL in accord with the hospital
laboratory reference). Her symptoms guided the treatment and her laboratory results took three days to be
officially reported.
A week after the discharge the patient revisited the ED
due to recurrent abdominal pain. Physical examination
and laboratory test results were unremarkable and she
was discharged after 24-hour observation. Follow-up
was scheduled for one week later. In follow-up visit the
patient was asymptomatic without any clinical finding.
Therefore, NAC treatment was terminated after 14
treatment days. The other children did not exhibit any
manifestations of the disease.
Conclusion
Children are always attracted to elemental mercury with
its bright gray appearance [2]. The compound has a short
half-life in the blood due to rapid distribution into body
compartments. Half life in the body is only two months.
Almost all of the absorbed amount is excreted via urination [3]. Mercury is used for the manufacturing of industrial chemicals, paints, explosives, batteries, thermometers,
sphygomanometers, electronic instruments, etc. Different
mercury compounds are used as antiseptic and diuretic in
medicine [1]. It is also an ingredient in the drug Thiomersal which is used to prevent contamination of vaccines.
Page 2 of 3
Acute inhalations of mercury vapors can cause pneumonia, adult respiratory distress syndrome, progressive
pulmonary fibrosis and death. Also elemental (metallic)
mercury can readily pass to systemic circulation via
alveoli present in mercury vapor or directly through the
skin. It is also known to pass directly from nursing
mothers to infants via breast milk [4]. Predominance of
gastrointestinal symptoms and historical findings suggest
intoxication with elemental mercury in the present case.
All kinds of neurological findings can be seen in
chronic mercury exposure. Some effects of high dose
mercury inhalation are shown on Table 1[4,5]. A
recently published recommendation guideline stresses
that “if the elemental mercury was recently heated
(e.g., from stove top, oven, furnace) in an enclosed area,
all people within the exposure area should be evaluated
at a healthcare facility due to the high risk of toxicity
(Grade C)” [1].
Findings in history played a critical role in the diagnosis in the present case. Inquiry for additional acid, alkali,
arsenic, phosphorus or iron ingestion did not yield any
suspicious finding. History of exposure to mercury, gastrointestinal symptoms and suspicious death of breast
fed baby led us to the presumptive diagnosis of acute
mercury poisoning. It can be postulated that in the present case neurotoxicity was prevented by NAC treatment which was instituted empirically based on clinical
symptoms and history although blood and urine mercury levels were not determined at the time of
admission.
Because brain maturation was not completed in young
children and fetuses even a small exposure can be fatal
[6]. Death of the previously healthy baby in 24 hours
prompts consideration of necrotizing bronchitis, pneumonia or respiratory distress syndrome [7]. Inhalation of
mercury by the baby can be thought to be the main
reason of death.
Initial treatment is keeping the patient away from the
environment and toxic agents. NAC is used for chelation of mercury, due to lack of other treatment options.
Basically it binds mercury by its cystein groups [1]. The
chelating drugs with worldwide application are
Table 1 Effects of high dose mercury inhalation [5].
Cardiovascular system
Weakness, unconsciousness, headache, irritability, fatigue, confusion, insomnia, behavioral disorders, tremor,
polyneuropathy, reduction or loss of hearing and vision
Tachycardia, arrhythmia, hypertension, less frequently similar symptoms of pheochromacytoma
Respiratory system
Cough, dyspnea, chest pain, pulmonary edema
Urogenital system
Tubular dysfunction, dysuria
Dermatological
Erythema, rash, itching
Digestive system
Stomatitis, metallic taste in mouth, abdominal pain, nausea, vomiting, diarrhea, colit
Liver
Elevation of liver function tests, hepatomegaly, central lobular vacuolization
Musculoskeletal system
Fasciculation, myoclonus, myalgia, tremor
Central nervous system
Sarikaya et al. BMC Emergency Medicine 2010, 10:7
http://www.biomedcentral.com/1471-227X/10/7
dimercaprol (BAL), dimercaprosuccinic acid (DMSA),
2,3-Dimercapropropane-1-sulphonate (DMPS) British
Anti Lewisite (BAL) (2.5 mg/kg) is also commonly used
in the treatment [1,8].
This case report emphasizes the importance of public
education on poisoning and specifically, potential
hazards of mercury for preventive community health.
Training is recommended for school children and
teachers on poisoning with heavy metal compounds.
Page 3 of 3
8.
Blanusa M, Varnai VM, Piasek M, Kostial K: Chelators as antidotes of metal
toxicity: therapeutic and experimental aspects. Curr Med Chem 2005,
12:2771-94.
Pre-publication history
The pre-publication history for this paper can be accessed here: http://www.
biomedcentral.com/1471-227X/10/7/prepub
doi:10.1186/1471-227X-10-7
Cite this article as: Sarikaya et al.: Acute mercury poisoning: a case
report. BMC Emergency Medicine 2010 10:7.
Consent section
Written informed consent was obtained from the
patients’ relatives for publication of this case report.
Mustafa Serinken, MD
Acknowledgements
All contributors for this study are those included in the authors.
Meanwhile, no source of funding from any third party was utilized in any
phase of study design, writing and publication of the study.
Author details
1
Dept. of Emergency Medicine, Yeditepe Univ, School of Medicine, Istanbul,
Turkey. 2Dept. of Emergency Medicine, Acibadem Univ, School of Medicine,
Istanbul, Turkey. 3Dept. of Emergency Medicine, Pamukkale University, School
of Medicine, Denizli, Turkey.
Authors’ contributions
SS.. Data Collection, Data Interpretation. Manuscript Preparation, Literature
Search. OK... Study Design, Manuscript Preparation, Data Interpretation. DA...
Data Collection. Manuscript Preparation. AC... Data Collection, Literature
Search. CA... Data Collection, Literature Search. MS... Study Design, Literature
Search. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests
No financial arrangements exist which may be interpreted as having the
potential to bias the outcome of this case.
Received: 16 July 2009 Accepted: 19 March 2010
Published: 19 March 2010
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