CLINICAL AND OCCULT NEUROPATHY AND NEUROPSYCHIATRIC ABNORMALITIES IN CHILDREN AFTER INTRAUTERINE MERCURY EXPOSURE. Introduction: Mercury is an element that is found in several forms. Elemental mercury is the liquid silver- colored metal commonly used in thermometers and widely found in industry. Organic mercury compounds are common contaminants in the environment and are commonly found in seafood. Inorganic mercury salts are widely used in industry and have been used in the past as pharmaceuticals and cosmetics. The toxicity of mercury involves several organ systems, most frequently the nervous system, the kidneys and the oropharynx. Toxicity varies somewhat according to the type of mercury and circumstances of exposure, however all types of mercury are recognized as toxic in the right circumstances. Treatment consists of halting on-going exposures and in some cases, administration of chelators to enhance mercury elimination. However, the appropriate diagnostic workup and treatment is not well delineated for all forms of mercury exposure. In particular, the appropriate workup and treatment of mercury-induced neuropathy is not widely agreed upon. In 1996, a case of sensorimotor neuropathy was detected in a teenage boy in Texas. The cause of his neuropathy was traced to a face cream containing mercurous chloride that was subsequently found to be in wide use along the Border States including New Mexico. Large groups of women have been identified by the state health departments in each border state who have been using this face cream, Crema de Belleza-Manning, and another similar cream, Nutrapiel Cremaning Plus. Many of these women have had elevated urine mercury levels. Initial preliminary screening of these women by the CDC found a high incidence of neuropsychological complaints that may reflect mercury toxicity. Little data describes the toxicity after a dermal exposure to mercury salts in women of childbearing age. To date, there has been no systematic evaluation of these women regarding the presence of hard neurologic findings. The objective of this study is to determine whether women dermally exposed to mercury from face cream during their pregnancy have children with evidence of clinical or subclinical neuropathy or abnormal performance on standard tests of neuropsychological function compared to expected performance. It has been 5-9 years since last use of the mercury cream for most patients. Urine mercury levels have fallen from peak-measured values in all of them. Total body mercury burden is not known. It is felt that much of the mercury body burden after exposure may be stored in the kidney and may be mobilized by chelators. (Molin) The chelation challenge has been used to attempt to assess body burden of other metals including lead and iron. Chelation challenge using DMSA, a chelator not currently available in the US, has shown increases of mercury up to 87 fold in people exposed to mercurous chloride. (Maiorino) It was felt that mercury concentrations in the urine during chelation better reflect body burden. DMSA (dimercaptosuccinic acid) is currently available for use in the US for lead poisoning and animal and human data describe its use in mercury poisoning. Because of its efficacy and availability to practitioners, it will be used to assess body burden of mercury. inary StudiesPatient Selection Twelve (12) patients who are known to have been exposed through their mothers to the use of the face creams Crema de Belleza- Manning or Nutrapiel Cremaning Plus during their intrauterine life will be enrolled. Mercury concentrations in the urine need not be currently elevated. Patients will be recruited through... Inclusion Criteria Patients who are known to have been exposed to the use of the face creams Crema de Belleza- Manning or Nutrapiel Cremaning Plus (mother use) during their intrauterine life for at least two weeks, with or without evidence of clinical or subclinical neuropathy or abnormal performance on standard tests of neuropsychological function compared to expected performance. Mercury concentrations in the urine need not be currently elevated. Exclusion Criteria Patients with polyneuropathy, psychiatric illness or previous heavy metal exposure that would confound the results will be excluded. Patients with allergy or previous adverse reaction to DMSA. will be excluded. Patients will be asked to avoid seafood for 15 days prior to the study. Informed Consent Informed consent must be obtained before subjects can be enrolled. A preliminary example of the consent form is included in appendix A. Research Design and Methods Subjects will be admitted to the CHUH the night prior to the study. On admission, a complete history and physical examination will be performed and blood will be collected for blood mercury concentration, chemistry panel 20, complete blood count, liver function studies and urine for small molecular weight proteins. There will be an 8 hour overnight fast. Eight- hour urine collection will be instituted beginning at 22:00 that night and ending at 0600. At 0800, volunteers will receive a standard breakfast. Subjects will receive a standard breakfast, lunch and dinner during the course of the study. A structured questionnaire will be administered to their mothers to best estimate use pattern of the face cream and symptom complaints (Appendix B). Patients will then undergo neuropsychological testing administered under the supervision of a clinical neuropsychologist to assess for deficits in intellect, visuoperceptive, constructive and motor skills, attention and concentration, memory and emotional functioning (Appendix C). Neuropsychologic evaluation will include the symbol digit, grooved pegboard, tapping rest (one hand), WAIS-R, trail making test, symptom checklist (SCL-90-R), controlled oral word association test, progressive planning test, Rey-Osterrieth complex figure and selected tests from the Wechsler memory scale-revised. Test results for each patient will be compared to expected performance and normative values for age and sex. After neuropsychological testing, each volunteer will receive 10 mg/kg of DMSA by mouth with 12 ounces of water. An eight-hour urine collection will be started. _ In the afternoon, subjects will undergo neurodiagnostic evaluation. Each subject will have nerve conduction velocitiesmeasured in sensory and motor nerves in the upper and lower extremities (median, ulnar, peroneal, sural) in accordance with the protocol in the UNM Neurodiagnostics laboratory. After completion of 8-hour urine collection for mercury, subjects will be discharged from the CHUH. Patients will be followed up by a social worker for normal results and by a social worker visit and in university hospital for abnormal results with appropriate treatment and referral as needed. Concomitant Medications It is not anticipated that subjects will require medications other than specified by the protocol. In the advent of vomiting requiring treatment, standard measures will be taken including the administration of intravenous fluids and antiemetic agents as indicated. Adverse Experiences Throughout the trial, subjects will be monitored for adverse experiences. Any adverse experiences, either observed or volunteered problems, complaints or symptoms are to be recorded on the adverse drug reaction case report form. The adverse experience should be recorded in standard medical terminology rather than the patient's own words. Included in the description of each adverse event will be the date and time of onset, date and time of resolution, severity, relationship to the trial treatment, the action taken if any, and the outcome. A serious adverse experience is one that is fatal or life threatening, is permanently disabling, requires or prolongs hospitalization, or is a congenital anomaly, cancer or overdose. An unexpected adverse experience is one that is not identified in nature severity or frequency in the current protocol. Data Analysis and Statistical Procedures Sample size calculations done in conjunction with Clifford Qualls indicate that 12 patients would be required to establish an effect size of 0.9 when comparing differences in nerve conduction velocity and action potential using one sample t-test. These calculations were made using the data presented by Albers et al, and assume 80% power and alpha = 0.05. References Bluhm RE, Bobbitt RG, Welch LW, et al. Elemental mercury vapour toxicity, treatment, and prognosis after acute, intensive exposure in chloralkali plant workers. Part 1: history, neuropsychological findings and chelator effects. Human Exp Toxicol 11:201-210, 1992. Albers, JW, Cavender GD, Levine SP, et al. Asymptomatic sensorimotor polyneuropathy in workers exposed to elemental mercury. Neurology 32:1168-1174, 1982. Shapiro IM, Sumner AJ, Spitz LK, et al. Neurophysiological and neuropsychological function in mercury-exposed dentists. Lancet May 22:1147-1150, 1982. lyer K, Goodgold J, Eberstein A, et al. Mercury poisoning in a dentist. Arch Neurot 33:788- 790, 1976.Barber TE. Inorganic mercury intoxication reminiscent of ainyotrophic lateral sclerosis. J Occupat Med 20:667-669, 1978. Vroom FQ and Greer M. Mercury vapour intoxication. Brain 95:305-318, 1972. Singer R, Valciukas JA, Rosenman KD, Peripheral neurotoxicity in workers exposed to inorganic mercury compounds. Arch Environ Health 42:181184, 1987. Appendix A CONSENT FORM I voluntarily agree to consent my son/daughter participation as a subject in a research project entitled "Clinical and Occult Neuropathy and Neuropsychiatric Abnormalities in Children after Intrauterine Mercury Exposure" by Hector Lechuga M.D., and Patrick E. McKinney, M_D., as principal investigators and such qualified assistants as they may need. I understand that these assistants will be under the supervision of Drs. Lechuga and McKinney at all times. PURPOSE OF THE RESEARCH: The purpose this study is to determine if your (spouse) exposure to mercury has caused damage to your children nervous system, whether he/she currently have symptoms or not. INTRODUCTION: Mercury is a metal that is found in many forms. It can be a silver liquid like in a thermometer or it can be a powder or liquid in various colors. People can be exposed to mercury by eating contaminated foods or by chemical exposure. Mercury is found in the workplace, in the envirorunent and was even used in many medications in the past. Recently, two popular beauty creams, Crema de Belleza-Manning and Nutrapiel have been found to contain a type of mercury called catomel. Cases of poisoning have been seen in New Mexico and surrounding states and many women have been identified who have elevated mercury levels from using the cream. Mercury is poisonous and can cause brain and nerve damage, kidney damage, and gum disease. When workers are exposed to mercury, some of them develop evidence of nerve damage on special testing even though they do not have symptoms at the time. These people may be at risk for developing nerve problems in the future. We do not know if women using these face creams are at risk for developing brain or nerve damage in the fiuture. My participation in this study will include I overnight stay in the hospital. Approximately 12 people will be enrolled in this study.PROCEDURES: My son/daughter will participate in one 24-hour study. He/she will be admitted to the hospital at 8:00 PM. Starting at 10:00 PM that night he/she will have all of his/her urine collected to measure mercury levels and to check for protein in the urine and pregnancy. The following morning, a sample of blood will be drawn to check his/her kidney function, blood chemistries, liver function, mercury level and blood count. The total amount of blood that will be drawn will not exceed 2 tablespoons (10 ml). Next, he/she will have a complete history and physical examination performed. He/she will be asked questions to check if he/she has other sources of mercury exposure. I will then take a series of tests to check brain function. These tests will take about 3 hours. After the morning tests, my son/daughter will take 10 mg/kg of an oral medication called Succimers or DMSA. This medication is sometimes used to help the body get rid of mercury faster through the urine. My urine will continue to be collected for the next eight hours to check for mercury again. My son/daughter will then have their nerves tested by nerve conduction studies. These tests will take about 45 minutes. Nerve conduction studies involve having small pads pasted over nerves on the arms and legs. A small electric current is applied and the speed it travels down the nerve is measured. The electrical current feels like a flick of a finger or the static electricity you feel when you touch a doorknob after walking on a carpet. These procedures have been explained to me, and my son/daughter meets the requirements for this study. RISKS: I understand that there are risks to my son/daughter health and well being if I agree he/she to be a subject in this research. Dr. Lechuga has discussed these with me and has described them as follows. During the course of withdrawing blood samples, pain and/or bruising may occur at the site of the needle stick up to 10% of the time. Taking samples of blood from my vein is a simple procedure and is generally well tolerated. However, some people (approximately 1%) become weak or faint when a needle is inserted into the skin or vein. To reduce this risk, I will be lying down at the time the needle is inserted into my arm. DMSA is a medication that is has sulfur in it. It may give me bad breath and body odor for 1-2 days. Up to 6-10% of people given DMSA over 5 days will have temporary, mild elevation of their liver tests. Up to 12.7% of people may get drowsiness, dizzy, headache or numbness. Up to 20.9% of people may get abdominal cramps, nausea, vomiting, diarrhea, loss of appetite and a metallic taste in the mouth. Heart rhythm abnormalities have been reported in 2 patients and decreased white blood cells and platelet cells have been seen in 1.5%. Other rare side effects reported once or twice include flu-like symptoms, earache, sore throat, cough, rash, joint pain, and nasal congestion, No permanent or serious symptoms have been reported The nerve conduction studies are mildly uncomfortable. This discomfort is described as similar to a flick of a fingernail.There may be other risks that are not yet known. I will be told about any new information that becomes available during this research, which might influence my decision to take part in it. BENEFITS: I realize that there may be no benefits to my son/daughter for participating in this study. However, if nerve damage is found and my son/daughter mercury level is high, this may be an indication to receive medication to cause my mercury level to fall more rapidly. High mercury levels might also be a clue to continued mercury exposure. Other possible benefit will be the possibility of having my son/daughter enrolled in a special education program if the neuropsychiatric tests indicate that there is any learning problem. COMPENSATION: L will be reimbursed for time and expenses during my participation in this study at an amount up to $100.00. OTHER TREATMENT: This is a volunteer study of children exposed to mercury through a mercury-containing face cream used by their mothers during pregnancy I understand that I may ask questions about this research Project at any time from Hector Lechuga, M.D., who can be telephoned at (14) 26-5881. If Dr. Lechuga learns of important new information that might affect my desire to remain in this study, he will tell me. PAYMENTS AND COSTS TO THE PATIENT: I understand that I will not have to pay for any of the medical examinations performed to my son/daughter, study medications, clinic visits, hospital admissions or laboratory tests that are required by this study. VOLUNTARY PARTICIPATION: I voluntarily agree to permit my son/daughter to be a subject in this research. I understand that if I refuse to let him/her take part, or later change my mind and want to stop he/she being a subject, there will be no penalty or loss of benefits or medical care to which I am otherwise entitled. STOPPING THE STUDY: Dr. Lechuga may, at his discretion, stop the study or my son/daughter being a part of the study at any time without my consent. If I decide to stop my son/daughter being part of the study, Dr. Lechuga will talk to me about the process for stopping this study.CONFIDENTIALITY All information about my son/daughter taking part in this research will be kept confidential Records from the study, which identify he/she, may be given to and inspected by the Chihuahua State Health Department, and other applicable government agencies. Otherwise, no information will be released except as required by law. However, because of the need to release information to these parties, absolute confidentiality cannot be guaranteed. The results of this study may be published in scientific journals or be presented at medical meetings; however, I will not be identified by name in any of these publications. CONSENT: Thave read or had read to me all pages of this consent form, and my doctor has explained this study and this consent form to me. All my questions have been answered to my satisfaction. I freely and voluntarily agree to let my son/daughter be part of this research study, and I believe I understand what will happen if I agree to be part of this study. I will receive a signed copy of this form. If my body is injured by the research treatment, more or different from that explained above, I understand that any emergency medical care I need will be given to me. I understand that by signing this paper, I am not giving up my legal rights. State of Chihuahua laws exist which may help people who think they have been treated carelessly, but which require very prompt notice of any claims. Subject's Name (type or print) Subject's Signature WITNESS STATEMENT: I have witnessed the signing of this consent by the subject or patient or his or her parent or guardian whose signature appears hereon. I have been assured by that person that the signing of this consent has been done freely and voluntarily. Witness to SignatureAppendix B MERCURY TOXICITY HISTORY AND PHYSICAL Date of Interview: Check all that apply Address: Length of time at current address: Children(s) Name(s): Age’ Used cream while Has this child had develop pregnant with this child? mental problems? yes[ ] nof ] yes[ ] nof ] yes{ I nof yes{ ] nof ] yes[ ] nof J yes[ ] no yes{ ] nol ] yes[ J nof ] yes{ ] nof ] yes{ ] nof J OTHER HOUSEHOLD CONTACTS: Name(s) Age: Initials ‘Where were these products purchased? [ ] Market [ ] Drug Store [ ] Swap Meet [ ]Gift [ JOther Name of store where purchased In US [ ] or Mexicof J? Where did you learn about this cream?- Why do you use the cream? Acne] lighten skin[ wrinkles{_] other Were your pregnant during use? [ ] Yes[ ] No How did you learn it contained mercury? { ] Newspaper [ Poster Other[ Friend TV[ ] Doctor [ ] Radio[ ]MEDICATIONS PLUS: Include herbal/folk medicines, OTC meds, creams, cosmetics, skin lighteners, topical antiseptics. Retin A, steroid cream, skin bleaching cream