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INJMS 178 No. of Pages 3

Indian Journal of Medical Specialities xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Indian Journal of Medical Specialities

journal homepage: www.elsevier.com/locate/injms

Arsenic poisoning- An overview

Nupur Jain* , Srinath Chandramani
K.J. Somaiya Medical College, Mumbai, India

A R T I C L E I N F O A B S T R A C T

Article history:
Received 16 March 2018 Heavy metal poisoning are among the most prevalent health hazards in toxic waste sites. A large
Received in revised form 12 April 2018 population is also exposed to these on a day to day basis. Exposure to heavy metals may be inhalational in
Accepted 13 April 2018 the forms of dust, fumes or vapors; or ingestion through food and water. Arsenic poisoning is third in
Available online xxx terms of prevalence and severity. This article gives an overview of the sources of arsenic poisoning and
the level of arsenic contamination in various substances. It also describes the signs and symptoms of
Keywords: arsenicosis and management of the illness. Preventive measures are more beneficial and cost effective to
Arsenic treatment of the poisoning.
Poisoning
© 2018 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical
Heavy metal
Specialities.
Arsenicosis
Arsenism

Contents

1. Arsenism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

Low level environmental and occupational exposure pose a [4]. In the human body 40% of arsenic is estimated to be from
significant health risk. Among all the hazards present in toxic waste contaminated food. Arsenic intake through food varies from 17 to
sites, arsenic is third in terms of prevalence and severity of toxicity. 291 mcg/day in different countries depending on the contamination
Exposure to heavy metals may be inhalational in the forms of dust, of the soil and further irrigation from contaminated water [5]. In
fumes or vapors, or ingestion through food and water [1]. Cigarette India, rice is a staple food and accounts for 42% of the total food grain
smoking used to be a common inhalational route of arsenic exposure, production. One of the major rice cultivators in India is West Bengal,
with more than 50 mg of arsenic per gram of tobacco present in the which relies on ground water found to be highly contaminated with
cigarettes during the 1950s. This has been gradually reduced to <1 mg arsenic for the irrigation of its fields [6]. The WHO acceptable limit in
per gram of tobacco once the health hazards were understood [2]. various food items including rice is 1–2 mg/kg [7]. The Indian
However, no control is possible over the handmade cigarettes like bidis basmati rice has been found to have arsenic as high as 882 mcg/kg
which are highly prevalent in our country and continue to remain a and this is compounded by further chelation of arsenic with the rice
significant source of arsenic exposure [3]. bran because of cooking with arsenic contaminated water. Thus, rice
The gastrointestinal absorption of the metal varies with the is among the most important source of arsenic intake in our country
specific chemical form of the metal, the nutritional status and genetic [8]. Vegetables high in arsenic are arum lati (1143 mcg/kg), arum root
predisposition of the host [1]. Exposure to arsenic is mainly via and eggplant (893 mcg/kg), whereas ‘low’ arsenic vegetables like
contaminated water and food irrigated with the contaminated water potato (448 mcg/kg) and amaranth leaf (458 mcg/kg) still have
significantly toxic levels [9].
The concentration of oxygen in water along with the prolifera-
* Corresponding author. tion of microorganisms also influences the mobilization of arsenic
E-mail address: dr.nupur03@gmail.com (N. Jain). in water. Drinking water has a maximum permissible limit of

https://doi.org/10.1016/j.injms.2018.04.006
0976-2884/© 2018 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical Specialities.

Please cite this article in press as: N. Jain, S. Chandramani, Arsenic poisoning- An overview, Indian J Med Spec. (2018), https://doi.org/10.1016/j.
injms.2018.04.006
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arsenic as 10 mcg/L [10] but drinking water especially ground
water remains among the greatest menace to human health in
India. Groundwater in West Bengal, Bihar, Jharkhand, Assam, Uttar
Pradesh, Manipur and Chattisgarh are among the most contami-
nated, with levels above 50 mcg/L [11]. Arsenic is adsorbed by iron
hydroxides in the soil and subsequently released into the soil.
These hydroxides occur due to an increase in the dissolved iron
concentration of the water. Domestic wells in arsenic
contaminated areas need disinfection with low dose chlorine to
prevent further arsenic leaching by maintaining oxidizing con-
ditions [12].
Occupational exposure is seen in workers from the arsenic
based pesticide, pigment and drug industries. Workers involved in
smelting and mining of various metals, as well as, the population
close to these mines and industries have an increased arsenic
exposure. Other industries with high level arsenic exposure
include wood preservation, desiccant and chemical warfare
industries. Arsenic is both a carcinogen and a mutagenic agent.
Arsenic is mobilized in the environment through environmental
factors like weathering of rocks and anthropogenic activities in the
form of burning of fossil fuels, mining, hydrothermal and
geothermal activities, use of arsenical pesticides, herbicides and
arsenic as an additive in poultry feed [13].
Ayurvedic medicines, part of India’s indigenous health care
system also contribute to arsenic toxicity. Ayurveda has herbal,
mineral and animal origin medicines. The herbal based medicines
are usually safe but the mineral origin medicines may lead to heavy
metal toxicity in the form of lead or arsenic poisoning [14]. More
than 20% of ayurvedic medications have been found to exceed
permissible levels of heavy metals like lead, arsenic, mercury in
various studies. [15,16].
1. Arsenism
Arsenic causes toxic effects in all body systems. Acute arsenism
takes a short time to manifest, with 8 months being the minimum
duration from ingestion to symptom manifestation. Chronic
arsenism may be asymptomatic for more than a decade but when
it presents it is a great mimicker of a multisystem systemic
disorder. The chemical and physical form of arsenic, the route of
entry, the dose and duration of exposure, age and sex of the
individual affect the severity of toxicity [17].
Acute arsenic poisoning causes projectile vomiting, rice water
diarrhea, facial edema, muscular cramps and cardiac abnormali-
ties. Chronic arsenic poisoning is associated with non specific
symptoms like lethargy, anorexia, abdominal pain and altered
bowel habits in the form of either diarrhea or constipation. Brown
pigmentation and keratosis of palms and soles, leukomelanosis
(rain drop pigmentation) are characteristically seen in chronic
arsenism. Melanosis and keratosis present together herald arsenic
toxicity. These skin manifestations can lead to severe social
discrimination and a sense of isolation from the society. The
spectrum of illness in arsenic poisoning is as in Table 1.
Arsenic also causes chronic illness like vascular disease, liver
disease, neurotoxicity, chronic cough and diabetes mellitus. This
Table 1
Clinical features of Arsenic Poisoning.
First Phase Middle Phase
Melanosis (spotted/diffuse) Rain drop pigmentation (leukomelanosis)
Keratosis (spotted/diffuse) Hyperkeratosis
Conjunctivitis Non-pitting pedal edema
Acute Bronchitis Sensorimotor distal neuropathy
Gastroenteritis Proteinuria
Hepatomegaly and deranged Liver Function Tests
Please cite this article in press as: N. Jain, S. Chandramani, Arsenic poisoning- An overview, Indian J Med Spec. (2018), https://doi.org/10.1016/j.
injms.2018.04.006
may be attributed to dipstick proteinuria associated with increased
arsenic exposure [18]. It also causes adverse pregnancy outcome in
the form of spontaneous abortions, still births and preterm births.
Long term effects like impaired child development and increased
risk of infections during infancy have also been seen [19]. Chronic
poisoning also carries the additional risk of skin, lung, liver, colon,
bladder and kidney cancer. The carcinogenic risk also persists for
years after initial exposure and withdrawal [20].
As defined by WHO, Arsenicosis is the chronic health condition
arising from prolonged ingestion of arsenic above the safe dose for
atleast 6 months. Characteristic skin lesions of melanosis and
keratosis, occurring alone or in combination, with or without the
involvement of internal organs are the usual manifestations. Two
major criteria used for diagnosis are - (1) the presence of
pigmentory and/ or keratotic skin lesions and (2) evidence
of exposure to elevated levels of arsenic established by history
of intake of arsenic- contaminated water or by significant arsenic
concentrations in urine, hair or nails [21].
2. Treatment
The lethal dose of arsenic is 120–200 mg in adults and 2 mg per
kg in children. In acute ingestion, ipecac to induce vomiting, gastric
lavage and use of activated charcoal help reduce further absorption
of arsenic. Dimercaprol 3-5 mg/ kg intramuscular injection every 4
h for initial 48 h followed by every 6 h for next 24 h has been found
beneficial. This is followed by a maintenance dose every 12 h for
the next 10 days. The patient is symptomatically managed in the
intensive care setting [1]. Chronic arsenism which is more
commonly seen due to long term ingestion of contaminated food
and water has no specific treatment. Safe drinking water and
cooking water is most crucial to prevent further exposure. A high
protein diet with food rich in Vitamin A, E and C help recovery from
early symptoms. Medical supplements in the form of antioxidants
with Vitamin A, E and C are beneficial. Patients with severe
arsenicosis who have complications at presentation require longer
duration of treatment and the recovery is prolonged. Keratolytic
ointments give symptomatic relief from the keratotic skin lesions.
Symptomatic treatment is the mainstay of treatment till the
toxicity gradually reduces [22].
3. Prevention
Reducing exposure to arsenic is more cost effective than
treatment of the toxicity. Arsenic concentration may be reduced in
groundwater used for drinking by using natural products like
activated charcoal for adsorption of arsenic. A common household
method of decontamination is the three pitcher filtration system
which uses iron fillings and activated charcoal. Iron fillings in the
upper pitcher reduce arsenate to arsenite and activated charcoal in
the middle pitcher adsorbs the arsenic compounds. The lowest
pitcher collects the arsenic water. Natural red earth adsorbs all the
arsenic compounds and may be used in a similar two pitcher
system [23]. Technologies removing arsenic using co-precipitation
with ferric chloride, lime softening and filtration using exchange
Terminal Phase
Chronic Kidney Disease and Kidney failure
Chronic Liver Disease and Liver failure
Peripheral vascular disease and gangrene
Skin, Lung, Bladder Malignancy
Chronic Bronchitis
s
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resin can also be used in small scale plants to ensure affordable
arsenic free water [24].
Extraction of arsenic from polluted soil is neither economical
nor environmental friendly. Phyto-remediation, a technique in
which hyperaccumulator plants are grown, which extract huge
amount of soil pollutants and accumulate them in above ground
tissues is promising [25]. The Chinese brake fern (Pteris vittata),
other ferns (Pityrogramma calomelanos, Pteris longifolia, Pteris
cretica), Indian mustard and tomatoes are some common arsenic
hyperaccumulators [26,27].
4. Conclusions
Arsenic toxicity affects millions of people but is often over-
lookedsince it mimics common systemic diseases. Places with a
high level of soil and water arsenic contamination, it is imperative
to have a high degree of suspicion to diagnose and successfully
treat the disease in its early stages. It is also important to spread
awareness of the disease to prevent the occurrence of disease.
Prevention at individual and state level is essential for successful
reduction of the disease burden.
Conflict of interest
None.
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