Which toxic exposure can present with the pictured rash along with hypertension and tachycardia mimicking pheochromocytoma?
- Arsenic
- Lead
- Mercury
- Silver
- Thallium
Answer
3 – Mercury
Background
Mercury poisoning can present as a constellation of symptoms affecting skin, central and peripheral nervous system, cardiovascular, respiratory, musculoskeletal, and genitourinary systems, making diagnosis challenging. Acrodynia, also known as “pink disease”, is a specific syndrome of mercury poisoning causing painful, dusky discoloration of hands and feet which may desquamate. Nonspecific rash resembling viral exanthem is also reported. Mercury inhibits catecholamine-O-methyltransferase (COMT), preventing metabolism of norepinephrine and epinephrine, and causing symptoms similar to pheochromocytoma. Poisoning can also mimic viral illnesses and rheumatologic disorders (1-4). This patient suffered a chronic exposure from an elemental mercury spill on her carpet that had been repeatedly vacuumed.
What are sources of elemental mercury? (1, 5-7)
- Dental amalgams
- Thermometers/manometers
- Fluorescent lights
- Paints
- Complementary medicine
- Industrial exposure such as in electroplating, metal refineries, gold mining, ceramics
What is the clinical presentation of mercury poisoning? (1-7)
- Presentation varies by the type of mercury exposure: elemental, inorganic or organic. Clinical symptomatology is also determined by the route and chronicity of exposure.
- Our patient had elemental mercury exposure which presents as follows:
- Benign if ingested
- Becomes vaporized if vacuumed
- Inhalation of vapor may cause respiratory symptoms within hours, and severe pulmonary toxicity can be progressive and permanent
- Acute inhalation may also present with rash, weakness, headache, visual disturbances, vomiting, and diarrhea
- Chronic inhalation exposure may additionally result in tremor, kidney dysfunction, and gingivostomatitis
- Erethism refers to a syndrome of chronic poisoning resulting in emotional lability, irritability, extreme shyness, delirium, and tremor
How is mercury toxicity treated?
- Remove from exposure and be careful to avoid secondary exposure to providers
- Supportive care
- Decontamination may be indicated depending on the exposure
- Chelation therapy such as with dimercaprol or succimer may be indicated
- Treatment varies by type, route, and chronicity of exposure
Clinical Pearls on Mercury Poisoning
- Never vacuum an elemental mercury spill.
- Poisoning can mimic many other conditions including pheochromocytoma, viral illnesses, or rheumatologic conditions.
- Acrodynia, also known as “pink disease”, is a specific syndrome of mercury poisoning characterized by painful, dusky red rash to hands and feet.
- Erethism refers to neuropsychiatric manifestations of mercury poisoning.
- Chelation therapy may be indicated.
References
- Sue, YJ. Mercury. In: Nelson LW, Howland MA, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS Eds. Goldfrank’s Toxicologic Emergencies. 11th edition. New York: McGraw-Hill Education, 2019, 1324-1332
- Yildiz M, Adrovic A, Gurup A, et al. Mercury intoxication resembling pediatric rheumatic diseases: case series and literature review. Rheumatol Int. 2020;40(8):1333-1342. PMID: 32342181
- Torres AD, Rai AN, Hardiek ML. Mercury intoxication and arterial hypertension: report of two patients and review of the literature. Pediatrics. 2000;105(3):E34. PMID: 10699136
- Henningsson C, Hoffmann S, McGonigle L, Winter JS. Acute mercury poisoning (acrodynia) mimicking pheochromocytoma in an adolescent. J Pediatr. 1993;122(2):252-253. PMID: 8429442
- Torres AD, Rai AN, Hardiek ML. Mercury intoxication and arterial hypertension: report of two patients and review of the literature. Pediatrics. 2000;105(3):E34. PMID: 10699136
- Koirala S, Leinenkugel K. Notes from the Field: Acute Mercury Poisoning After Home Gold and Silver Smelting–Iowa, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(49):1365-1366. Published 2015 Dec 18. PMID: 26678598
- Kanluen S, Gottlieb CA. A clinical pathologic study of four adult cases of acute mercury inhalation toxicity. Arch Pathol Lab Med. 1991;115(1):56-60. PMID: 1987914
The American College of Medical Toxicology hosts this Toxicology Visual Pearls series.
This post has been edited and peer reviewed on behalf of ACMT by Dr. Bryan Judge, Dr. Louise Kao, and Dr. Laura Tormoehlen.
Author information
Michael Semple, DO
Toxicology Fellow
Washington University School of Medicine
The post ACMT Toxicology Visual Pearl: Hypertension and Rash appeared first on ALiEM.
