Monday, February 16, 2015

Arsenic toxicity

Answer: A
Diagnosis: Arsenic toxicity
Discussion: Numerous reports of acute intoxication following criminal poisoning have been published (in the case presented, the patient ’ s wife was placing it into his food). Clinical effects may appear minutes, hours, or days after exposure depending on the dose and type of arsenic
consumed. The earliest manifestations of acute poisoning are severe gastrointestinal symptoms of nausea, vomiting, abdominal pain, and diarrhea. The diarrhea may resemble that seen with cholera and can appear as “ rice water. ” These symptoms occur within minutes to several hours after ingestion. The patient often complains of muscle cramps and thirst. Cardiovascular and respiratory symptoms include hypotension, shock, pulmonary edema, acute respiratory distress syndrome, and heart failure. Prolonged or additional symptoms may occur for days to weeks after an acute exposure. Neurologic symptoms  such as headache, confusion, personality change, irritability, hallucinations, delirium, and seizures may develop or persist. Peripheral neuropathy commonly occurs 1 – 3 weeks after an acute poisoning. The peripheral neuropathy may last for years. Progressive neuropathy
may be misdiagnosed as Guillain – Barr é syndrome. Sensory symptoms may include numbness, tingling, lightheadedness, delirium, encephalopathy, muscle weakness, and severe pain following superfi cial touch of the limbs. An accumulation of arsenic in the skin, hair, and nails causes clinical effects such as hyperpigmentation, keratoses of the palms and soles, melanosis, and hair loss.
Mees ’ lines (Figure )may be seen and correspond with signifi cant poisonings that have occurred previously. A metallic taste and garlic odor of the breath and sweat may  be noted. Defi nitive diagnosis is made by an elevated urinary arsenic level.


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