Acute Mercury Poisoning Presenting as Fever of Unknown Origin
Acute Mercury Poisoning Presenting as Fever of Unknown Origin
As a vapor, elemental mercury is absorbed rapidly through the lungs, reaching the blood and entering the brain. A clinical picture, which can be divided into three phases, evolves. The initial phase manifests itself as metal fume fever, the intermediate phase can be defined as the period during which severe, multiorgan symptoms of the central nervous, respiratory tract, gastrointestinal and urological systems are reported, and the late phase can be described as the period when the central nervous symptoms persist and other organ system complaints are resolved. The description of the earliest symptoms by the patients is consistent with metal fume fever, a syndrome commonly confused with a viral etiology, as was also true for these patients. Our patient had also high fever, lymphadenopathy, and a diffuse maculopapular rash initially. Her liver and kidney function tests were elevated; she had dyspnea, tachycardia and chest pain during the following days.
The exact pathogenesis of metal fume fever is poorly understood. In some instances, allergic mechanisms may be involved. Our case confirms mechanisms of hypersensitivity because she was diagnosed with urticarial vacuities initially and had eosinophilia in her blood smear. Because either our patient or the other family members had similar signs such as fever, diffuse skin rash and multiple lymphadenopathies predominantly, an infectious process was considered initially. Viral, bacterial infections, autoimmune diseases, malignancies and Kawasaki syndrome were evaluated in the differential diagnosis, but there were no findings to confirm these conditions.
Kawasaki syndrome is rarely seen in the adult population since it is primarily a disease of childhood. It can be seen as sporadic cases and in mini-epidemics. It was reported previously that mercury intoxication had presented with elevated urine mercury levels compared to those of the matched controls.
Acrodinia ('pink disease') is a unique syndrome that can occur in children from chronic exposure to elemental mercury. Only a certain subset of exposed patients is affected, suggesting that it represents an idiosyncratic hypersensitivity response. Clinical manifestations include extremity pain, red face, red hands and feet, skin rash, gingivitis, desquamation, tachycardia, hypertension, photophobia and irritability. Our patient had rash, significantly erythematous on her soles and palms; and developed desquamation, muscle pain and hypertension during the following days. We described this clinical presentation as idiosyncratic hypersensitivity due to mercury intoxication.
Elemental mercury is used in manufacturing and industrial processes (mining, smelting), household, medical and electrical devices (for example, thermometers, thermostats, electrical switches, dental amalgam), and in folk remedies. Thus, environmental release of elemental mercury that results in human exposure can occur in many different locations. Sarıkaya et al. reported a case of acute elemental mercury poisoning that they followed presenting with abdominal pain, diarrhea and high fever. The patient's daughter had brought mercury home from school and heated it. One day after the event, the patient's 14-month-old daughter died of mercury poisoning. Seen from this aspect, mercury should be kept under safer conditions and whether it should continue to be held in schools should be discussed.
Rowens et al. reported that four people from the same family died as a result of respiratory failure caused by heated elemental mercury. Glezos et al. reported a patient that was hospitalized and followed up for seven days because of high fever, pneumonia, generalized maculopapular rash, and axillary lymphadenopathy, and it was learned one week after discharge that he had been present in an environment in which mercury had been heated for three hours. Bamonti et al. reported that cracked mercury dental amalgam was a possible cause of fever of unknown origin. The patients do not realize that they have been exposed to the mercury vapor because it is colorless and odorless. Therefore, patients with such symptoms should be questioned about possible exposure to mercury.
Discussion
As a vapor, elemental mercury is absorbed rapidly through the lungs, reaching the blood and entering the brain. A clinical picture, which can be divided into three phases, evolves. The initial phase manifests itself as metal fume fever, the intermediate phase can be defined as the period during which severe, multiorgan symptoms of the central nervous, respiratory tract, gastrointestinal and urological systems are reported, and the late phase can be described as the period when the central nervous symptoms persist and other organ system complaints are resolved. The description of the earliest symptoms by the patients is consistent with metal fume fever, a syndrome commonly confused with a viral etiology, as was also true for these patients. Our patient had also high fever, lymphadenopathy, and a diffuse maculopapular rash initially. Her liver and kidney function tests were elevated; she had dyspnea, tachycardia and chest pain during the following days.
The exact pathogenesis of metal fume fever is poorly understood. In some instances, allergic mechanisms may be involved. Our case confirms mechanisms of hypersensitivity because she was diagnosed with urticarial vacuities initially and had eosinophilia in her blood smear. Because either our patient or the other family members had similar signs such as fever, diffuse skin rash and multiple lymphadenopathies predominantly, an infectious process was considered initially. Viral, bacterial infections, autoimmune diseases, malignancies and Kawasaki syndrome were evaluated in the differential diagnosis, but there were no findings to confirm these conditions.
Kawasaki syndrome is rarely seen in the adult population since it is primarily a disease of childhood. It can be seen as sporadic cases and in mini-epidemics. It was reported previously that mercury intoxication had presented with elevated urine mercury levels compared to those of the matched controls.
Acrodinia ('pink disease') is a unique syndrome that can occur in children from chronic exposure to elemental mercury. Only a certain subset of exposed patients is affected, suggesting that it represents an idiosyncratic hypersensitivity response. Clinical manifestations include extremity pain, red face, red hands and feet, skin rash, gingivitis, desquamation, tachycardia, hypertension, photophobia and irritability. Our patient had rash, significantly erythematous on her soles and palms; and developed desquamation, muscle pain and hypertension during the following days. We described this clinical presentation as idiosyncratic hypersensitivity due to mercury intoxication.
Elemental mercury is used in manufacturing and industrial processes (mining, smelting), household, medical and electrical devices (for example, thermometers, thermostats, electrical switches, dental amalgam), and in folk remedies. Thus, environmental release of elemental mercury that results in human exposure can occur in many different locations. Sarıkaya et al. reported a case of acute elemental mercury poisoning that they followed presenting with abdominal pain, diarrhea and high fever. The patient's daughter had brought mercury home from school and heated it. One day after the event, the patient's 14-month-old daughter died of mercury poisoning. Seen from this aspect, mercury should be kept under safer conditions and whether it should continue to be held in schools should be discussed.
Rowens et al. reported that four people from the same family died as a result of respiratory failure caused by heated elemental mercury. Glezos et al. reported a patient that was hospitalized and followed up for seven days because of high fever, pneumonia, generalized maculopapular rash, and axillary lymphadenopathy, and it was learned one week after discharge that he had been present in an environment in which mercury had been heated for three hours. Bamonti et al. reported that cracked mercury dental amalgam was a possible cause of fever of unknown origin. The patients do not realize that they have been exposed to the mercury vapor because it is colorless and odorless. Therefore, patients with such symptoms should be questioned about possible exposure to mercury.
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