A Story That Changed Quick(silver): Self-Inflicted Mercurialism

Document Type

Conference Proceeding

Publication Date

2-26-2025

Publication Title

J Med Toxicol

Keywords

antibiotic agent, mercury, silver, succimer, unithiol, abdominal pain, artificial embolization, ataxia, case report, catheterization, chelation, clinical article, clinical feature, conference abstract, drug therapy, dysarthria, erythema, flu like syndrome, follow up, forearm, foreign body, human, inhalational exposure, low vision, lung blood vessel, male, mercurialism, neurotoxicity, parenteral drug administration, pneumonia, radiography, recrudescence, subcutaneous tissue, surgery, thorax radiography, tremor, welding

Abstract

Background: Subacute inorganic mercurialism is well described after exposures to elemental mercury (Hg0) vapor but seldom after parenteral injection. Subcutaneous deposits of Hg0 can be absorbed and cause systemic toxicity. Vascular embolization may also occur and can be detected with imaging Hypothesis: Radiography with intracardiac and/or extrathoracic Hg0 emboli should prompt consideration of a subcutaneous/ intravenous exposure Methods: This is a single patient case report. Results: A 40-year-old male had presented to the ED with erythema and pain in his left forearm. A foreign body on radiography was noted, “chronic” per the patient. He was discharged home with antibiotics. He returned three days later with no improvement prompting PICC placement for IV antibiotics. Incidentally, chest radiography revealed innumerable small radiodense opacities scattered bilaterally, presumed to be related to a inhalational exposure during welding. He again returned four days later to the ED for abdominal pain prompting abdominal plain films which showed massive increase in opacities within the thorax but now scattered throughout the abdomen and pelvis. Patient was noted to be emotionally labile with bizarre behavior and was placed on a hold pending psychiatric evaluation. Toxicology recommended chelation with a five day course of 2,3-dimercapto-1-propanesulfonic acid (DMPS); succimer was utilized during the two-day delay in acquisition. The initial 24-hour urine mercury concentration was 2230 mcg/L. Whole blood mercury was > 160 mcg/dL. On day four of DMPS a repeat 24 hour urine mercury concentration was unmeasurably high (> 10,000 mcg/L). Whole blood mercury remained elevated (> 160 mcg/dL) throughout the course of chelation. Surgery was consulted who recommended outpatient followup. After clearance from psychiatry the patient left against medical advice. Over the next twelve years the patient was chelated multiple times for symptomatic recrudescence. Clinical features included ataxia, dysarthria, neuropsychiatric abnormalities, tremor and decreased visual acuity. Conclusions: Inhalation of Hg0 vapor can result in a flu-like syndrome followed by pneumonitis, neurotoxicity, and renal injury. This particular patient had imaging studies inconsistent with his exposure history. Subcutaneous Hg0 can gain access to the vascular space with embolization primarily to the pulmonary vasculature. Systemic embolization, which can occur in the absence of an anatomical shunt, is unique to this route of exposure.

Volume

21

Issue

2

First Page

124

Last Page

125

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