Sunday, July 12, 2015

Anorexia, Hair Loss, and Fingernail Bands

Anorexia, Hair Loss, and Fingernail Bands

Case presentation: A 62-year-old man has been hospitalized 10 times during the previous 5 years. He has been  treated for gastrointestinal disturbances, cardiomyopathy, leucopenia, and paresthesias. He presents again after several days of uncontrollable diarrhea and vomiting. His “glove and sock” paresthesias have rapidly progressed.

He is having significant hair loss and is experiencing weakness of the upper and lower extremities. A picture of his nails is noted below.

Question: What substance is most likely responsible for
his signs and symptoms?
A. Arsenic
B. Barium
C. Aluminum
D. Chromium
E. Bismuth

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 o f the palms and soles, melanosis, and hair loss. Mees ’ lines may be seen and correspond with signifi cant poisonings that have occurred previously.    

Mees’ lines highlighted by arrows.

A metallic taste and garlic odor of the breath and sweat may be noted. Definitive diagnosis is made by an elevated urinary arsenic level. 


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