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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 6

“An unusual cause of pain abdomen”: Acute mercury poisoning


1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Gandhi Medical College, Hyderabad, Telangana, India
3 Department of Pulmonary Medicine, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission20-May-2020
Date of Decision26-May-2020
Date of Acceptance04-Jun-2020
Date of Web Publication07-Dec-2021

Correspondence Address:
Soibam Pahel
Department of Pulmonary Medicine, AIIMS, Virbhadra Road, Shivaji Nagar, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/digm.digm_12_20

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  Abstract 


The severity of mercury intoxication depends on the chemical form, dose, and route of exposure. Mercury intoxication has a wide variety of clinical manifestations that may involve the neurological, gastrointestinal, and dermatological systems. After diagnosis is made, prompt treatment is necessary to avoid systemic complications. Here, we report an unusual case of accidental ingestion of mercury and presenting as acute pain abdomen. She was managed conservatively and discharged in hemodynamically stable condition.

Keywords: Chelation, Mercury poisoning, Pain abdomen


How to cite this article:
Tale S, Kolli M, Pahel S, Pudi S, Garbhapu A. “An unusual cause of pain abdomen”: Acute mercury poisoning. Digit Med 2021;7:6

How to cite this URL:
Tale S, Kolli M, Pahel S, Pudi S, Garbhapu A. “An unusual cause of pain abdomen”: Acute mercury poisoning. Digit Med [serial online] 2021 [cited 2022 Dec 7];7:6. Available from: http://www.digitmedicine.com/text.asp?2021/7/1/0/331945




  Introduction Top


Mercury is in liquid form at room temperature, and it is silver colored. There are two forms in the nature, i.e., organic and inorganic forms. Symptoms and signs of the poisoning depend on the route of exposure, dose, and whether it is acute or chronic ingestion.[1] If large doses of mercury are ingested, patients mostly present with acute neurological problems such as encephalopathy, tremors, and visual symptoms;[2] if it was chronic low-dose exposure, they will present with skin (rain drop) pigmentation, renal dysfunction, insomnia, and memory loss.[3] Here, we present a case of acute mercury poisoning in young female patient who present with pain abdomen after accidental ingestion.


  Case Report Top


A 34-year-old female patient who is a known case of hypothyroidism presented to emergency outpatient department with complaints of diffuse dull aching pain abdomen and foreign body sensation in the throat of 2 days duration following consumption of water stored in the water filter. There was no history of shortness of breath, chest pain, fever, vomiting, and loose stools. Her children also had mild pain abdomen following consumption of same water. At presentation, her blood pressure was 110/70 mmHg, pulse rate was 96 bpm, respiratory rate was 16/min, and oxygen saturation was 96% on room air. Nothing was remarkable in her head–neck, respiratory, cardiovascular, or abdominal examinations. Neurological examination did not reveal any tremor, paresthesia, ataxia, spasticity, hearing, and vision loss. Neuropsychiatric abnormalities were not identified.

On routine laboratory investigations, her complete blood count, serum electrolytes, renal function tests, liver function tests, and serum amylase were within chest X-ray, electrocardiogram, and ultrasound abdomen revealed no abnormalities. X-ray abdomen showed metallic (elemental mercury) deposits in the small and large intestine [Figure 1]a and [Figure 1]b. Hence, based on clinical history and X-ray findings, serum mercury levels were sent and the same were found out to be elevated 6.1 μg/dl (normal <2 μg/dl). She was symptomatically treated with intravenous fluids, pantoprazole, and Vitamin C. She was observed for 48 h and discharged in stable condition without any sequelae or complaint. Follow-up was scheduled for 2 weeks later. In follow-up visit, the patient was asymptomatic without any clinical findings. Further follow-up after 1 month, her serum mercury levels were 0.59 μg/dl and she was asymptomatic.
Figure 1: (a) X-ray abdomen showing metallic mercury deposits in the small and large intestine. (b) X-ray abdomen showing metallic mercury deposits in the small and large intestine.

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  Discussion Top


Mercury is a highly toxic environmental metal that exists in three different forms: elemental (metallic), inorganic, and organic.[4] It exhibits several patterns of toxicity depending on the chemical form, dose, and route of exposure. Intoxication occurs in either occupational or nonoccupational settings, mainly after inhalation of vapor and fumes in work places, laboratories, or homes.[4] In our patient, the source for mercury ingestion may be due to contamination of the water stored in the filter. Elemental mercury ingestion is generally benign due to the low absorption levels from the gastrointestinal (GI) tract. In fact, elemental mercury has been used traditionally in Hispanic communities as a therapeutic approach in cases of GI symptoms known as “empacho.”[5] Furthermore, in some clinical conditions in which mercury remains for prolonged periods in the GI tract, such as diverticulosis, there is a possibility of conversion of elemental mercury to organic by bacteria leading with that way to systemic toxicosis.[6] Mercury is a toxin that eventually affects cellular physiology and hemostasis. Mercury vapor inhalation mainly affects the brain, while inorganic mercury and methyl mercury primarily affect the intestinal mucosae and kidneys.[4] Acute exposure to elemental mercury vapor can cause severe pneumonitis.[7] Symptoms of low-grade exposure are more subtle and nonspecific such as weakness, fatigue, anorexia, weight loss, and gastrointestinal disturbance have been described.[7] In our case, patient ingested methyl mercury (metallic), so symptoms are predominantly related to gastrointestinal tract. Clinical findings are systemic and more subtle in chronic exposure. Mercury poisoning poses a diagnostic challenge. First, the blood toxicity threshold has been debated. Graeme and Pollack considered that a blood level above 15 g/L indicated mercury toxicity,[8] while Dantzig found that a level as low as 6 g/L or less may be toxic.[9] Hence, symptoms may be present at low levels of exposure. As summarized by Kazantzis, “it has not been possible to set a level for mercury in blood or urine below which mercury-related symptoms will not occur.”[10] The management of elemental mercury poisoning is not well defined. Treatment modalities that may be helpful include specific therapy such as chelation (e.g., dimercaprol, succimer, unithiol, and penicillamine) or nonspecific therapeutic measures such as intravenous hydration and symptomatic treatment.[11] In our case, as the patient was mildly symptomatic, so she received intravenous fluids, Vitamin C, and pantoprazole injection with significant clinical improvement. The role of Vitamin C as an antioxidant in treatment of mercury poisoning is studied in rats by Huq et al.[12] and whether Vitamin C plays a specific role in mercury intoxication treatment or reduces systemic inflammation requires further research and investigation in humans.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gochfeld M. Cases of mercury exposure, bioavailability, and absorption. Ecotoxicol Environ Saf 2003;56:174-9.  Back to cited text no. 1
    
2.
Unverir P, Yuntarali S. General principles of acute poisoning. J Surg Med Sci 2006;2:44-8.  Back to cited text no. 2
    
3.
Malek A, Aouad K, El Khoury R, Halabi-Tawil M, Choucair J. Chronic mercury intoxication masquerading as systemic disease: A case report and review of the literature. Eur J Case Rep Intern Med 2017;4:000632.  Back to cited text no. 3
    
4.
Syversen T, Kaur P. The toxicology of mercury and its compounds. J Trace Elem Med Biol 2012;26:215-26.  Back to cited text no. 4
    
5.
McKinney PE. Elemental mercury in the appendix: An unusual complication of a Mexican-American folk remedy. J Toxicol Clin Toxicol 1999;37:103-7.  Back to cited text no. 5
    
6.
Poulden M. Mercury: Is it elemental my dear Watson? Emerg Med J 2002;19:82-3.  Back to cited text no. 6
    
7.
Friberg L, Nordberg GF. Mercury in the Environment. Boca Raton, Fla, USA: CRC Press; 1972.  Back to cited text no. 7
    
8.
Graeme KA, Pollack CV Jr. Heavy metal toxicity, part II: Lead and metal fume fever. J Emerg Med 1998;16:171-7.  Back to cited text no. 8
    
9.
Dantzig PI. A new cutaneous sign of mercury poisoning? J Am Acad Dermatol 2003;49:1109-11.  Back to cited text no. 9
    
10.
Kazantzis G. Mercury exposure and early effects: An overview. Medicina del Lavoro 2002;93:139-47.  Back to cited text no. 10
    
11.
Caravati EM, Erdman AR, Christianson G, Nelson LS, Woolf AD, Booze LL, et al. Elemental mercury exposure: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2008;46:1-21.  Back to cited text no. 11
    
12.
Huq MA, Awal M, Mostofa M, Ghosh A, Das A. Effects of vitamin E and vitamin C on mercury induced toxicity in mice. Progress. Agric. 2008;19:93-100.  Back to cited text no. 12
    


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