3rd National Congress of Emergency Medicine

MERCURY POISONING:
An Experience in HUSM

Dr. Rashidi Ahmad. MD (USM), Mmed (USM)

Lecturer/Consultant Emergency Physician
School of Medical Sciences
USM Health Campus, Kelantan 1
17th Nov 2007
Mercury the Metal

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 Environmental Sources of Mercury

• Natural Degassing of the earth

• Combustion of fossil fuel
• Industrial Discharges and Wastes
• Incineration & Crematories
• Dental amalgams

Hg0 Hg2+ CH3Hg+

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The Mercury Cycle

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 Mercury pollution in the Amazon

• Gold mining—sediments of a river are

run through sluice boxes with mercury
in them. The gold sticks to the mercury
and then the mercury-gold goop is
cooked over a fire to drive off the
mercury, leaving the gold
• Mercury goes to water and air
• Altered vision in study of children along
Rio Tajapos river in Brazil

? Similarly it can happens at Rusila, Terengganu

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 The many forms of mercury

ORGANIC INORGANIC

SHORT CHAIN ARYL ELEMENTAL MERCURIC

ARKYL COMPOUND SALT

LONG CHAIN
ARKYL

* Methyl mercury (organic) – most toxic

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 Mercury

• Toxic in any forms

• The difference lies in how it is absorbed,
the clinical signs and symptoms, and
the response to treatment modalities.
• Mercury poisoning can result from vapor
inhalation, ingestion, injection, or
absorption through the skin.

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 Historical awareness

“Mad as a Hatter”

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 Outbreaks of MeHg Poisoning

Place Year Cases

Minamata 1953-60 1000
Nigata 1964-65 646
Guatemala 1963-65 45
Ghana 1967 144
Pakistan 1969 100
Iraq 1956 100
Iraq 1960 1,002
Iraq 1971 40,000
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On-going 2001 ???
 Organic Mercury Poisoning

• Minimata, Japan, 50 years

ago…

• Seafood from the bay was

polluted with mercury from an
industrial source

• Neurotoxicity – CP

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 Seed Grain Outbreaks

• Mercury compounds
applied as antifungal
agent to seed grains

• Iraq—made bread directly

from treated seed grain

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Iraq mercury contaminated seed grain – CP

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 Neurobehavioral Effects

• Blindness – Deafness

• Cerebral Palsy – Seizures

• Retarded motor development

• Visual and Auditory Deficits

• Delayed motor development

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 Hg and Heart Attacks

• Case-control study showing higher

mercury in men who had heart attacks
vs. controls

“Mercury, Fish Oils, and the Risk of Myocardial

Infarction”. New England Journal of Medicine. 2002

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 The harmful effects

• Organic mercury - Most devastating to

the CNS
– Short-chained (methylmercury) - Affects the CNS
– Long-chained - Subacute/chronic effects similar to that
of inorganic mercury exposure

• Elemental mercury - Primary neurologic toxicity

• Inorganic mercury salts

– Acute - Severe corrosive gastroenteritis, acute tubular
necrosis
– Subacute or chronic - GI, neurologic, and renal
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dysfunction
 Introduction

• Mercury poisoning is usually

misdiagnosed [insidious onset, nonspecific s/sx & lack
of knowledge within the medical profession]

• Most recently, 2 areas have caused

public concern regarding mercury
toxicity
- the potential risk associated with eating fish, especially
when dealing with pregnancy
- the use of dental amalgams, or fillings, by dentists.

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Mercury poisonong. www.e-medicine.com
 Pathogenesis

• Unclear
• Induce auto-immunity
• High affinity towards sulfur group
– Haemoglobin
– IgG, helper CD4+ cells, NK cells
– Mitochodrial function esp in neurons
– Inhibit transport proteins

The Journal of Immunology, Vol 140, Issue 3 750-754 19

Accidental Mercury Inhalation:
An Experience in HUSM

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 Learning objectives

• To highlight the possible clinical

features and possible complications

• To describe the effects of elemental

mercury vapor

• To highlight salient points from various

literatures pertaining to the
management of mercury poisoning.

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 17th August 2006 – 3 pm at ED HUSM

• 17 employees of pharmaceutical factory

were rushed to HUSM after alleged
inhalational mercury poisoning.
• Mercury contained thermometer broke in
a beaker with boiled water in a closed
laboratory environment.
• Released mercury vapor was inhaled by
the lab staff.
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 Demographic Data

Gender 15 female, 2 male

Mean age 30.6 years
Premorbid PID – 1
Pregnancy – 2 (33/52 & 28/52
POA)
Race Malay
Occupation Lab technicians

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 Symptoms

Sore throat 7
Chest discomfort 1
Dizziness 3
Eye itchiness 1
N&V 2
Metallic taste 2
SOB 1
Asymptomatic 2

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 Physical examination

• Anxious, tachypneic
• No skin manifestation
• 1 patients showed intention tremor
• 1 patient had reddish sclera of the R eye
• 7 patients had injected throat
• Lungs – clear
• CVS – S1S2, no murmur
• Per abdomen – soft non-tender

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 Triage parameters

• Conscious, alert, tachypneic, pink

• Normal blood pressure and heart rate
• SaO2 97 – 99%
• Afebrile

Fast track – assigned isolated

ward
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 Investigations

• FBC – Normal
• BUSE /RFT/ LFT– Normal
• ABG (n = 2) - Normal
• ECG – Normal sinus rhythm
• Whole blood mercury level : 0.5 – 7.3μg/L

Normal mercury levels are considered to be less

than 10 mcg/L in the blood and less than 20
mcg/L in the urine

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 Management

• All patients were treated symptomatically

• Observed in OW for 24 hours with all
symptoms resolved
• Discharged with TCA 1 week to A&E and
planned ante-natal clinics.
• Rx – T. Prednisolone 50 mg daily x 3/7

All patients were asymptomatic upon 1/52 follow-up without

any clinical signs. Repeated CXR were all normal.
All patients were discharged
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 Elemental mercury

• Inorganic, Quicksilver (exist in liquid)

• Occurs naturally in soil and in the
atmosphere from volcanic emissions
• Mercury is extracted and used in
industry, then enters air or water from
pollution
• 13.6 times the weight of water
• Evaporates at room temperature
• Lipid soluble; excreted in urine
• Bacteria change to Methylmercury

US Department of Health and Human Services, Public Health 32

Service, Agency for Toxic Substances and Disease Registry, 1989;
publication no. ATSDR/TP-89/16
 Elemental Mercury

• Very toxic to the nervous system, also to

kidneys
• But….very poorly absorbed by the GI tract
Inhalation route gives higher exposure
• Mercury in fillings is inorganic
• Alloys with other metal called Amalgam
• Many Industrial uses ( drugs, chemicals,
thermometers, batteries, gold mining)

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 Mercury inhalation

• 80% of inhaled Hg can be absorbed in blood

(~ t1/2 3 days for single exposure)
• 80-100% lung absorption (WHO, 1991); <1%
GI
• Oxidized to Hg2+ easily binds to sulfhydryl
group on enzymes and other proteins and
membrane disulfide bonds
• Concentrated 10 x higher in brain than
equivalent dose of inorganic mercuric salts

Cases of mercury exposure, bioavailability, and absorption

Michael Gochfeld Environmental and Community Medicine,March 2003 34
 Effect of acute inhalational of elemental Hg

Sore throat 7
Shortness of breath
Metallic taste Chest 1
discomfort
Pleuritic chest pain
Dizziness 3
Lethargy
Eye itchiness 1
Confusion
N&V 2
Nausea & vomitting
Metallic taste 2
Tremors
SOB 1
Asymptomatic 2

Young J: Mercury. In: Goldfrank LR, ed. Goldfrank's Toxicology Emergencies.

Vol 74. New York: McGraw-Hill; 1994:1051-62. 35
 Inhalational mercury respiratory toxicity

• Erosive bronchitis and

bronchiolitis with interstitial
pneumonitis
(WHO,1991)

• Atelectasis, emphysema,
haemorrhage and
pneumothorax
(Winship, 1985)

• Mild respiratory symptoms

(Wallach, 1972; Janus and Klein, 1982;
Tsuji et al, 1970)

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 Long term effect- neurotoxicity

Adult Fetus/children

• Memory loss • Cerebral palsy

• Ataxia • Mental retardation
• Dysarthria • Autism
• Hypoasthesia • Late walking
• Finger tremor
• Alzheimer’s disease

Low dose mercury toxicity and human health, March 2005

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 Pathogeneis of mercury neurotoxicity

• Selectively accumulates in hippocampus,

basal ganglia, cerebral cortex
• Prevents presynaptic serotonin release and
inhibits serotonin transport; causes
calcium disruptions
• Causes demylinating neuropathy
• Causes abnormal neuronal
cytoarchitecture; disrupts neuronal
migration, microtubules, and cell division

Clarkson, T. The toxicology of mercury. Crit

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Rev Clin Lab Sci 1997; 34(3): 369-403
 Pregnancy – the risky group

• 117 first term pregnancies in the

mercury exposed group
• Spontaneous abortion (19 cases)
• Stillbirth (3 cases)
• Congenital malformations (5 cases of
spina bifida and 1 case of intra-atrial
defect)

Sikorski et al, 1987

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 Few words on investigation

• Blood mercury is only useful within 3

days of exposure and it is more reliable
in methylmercury (high concentrations
in RBCs)
• A 24-hour urine specimen is a good
indicator for inorganic mercury
poisoning
• Hair mercury level has no role in acute
Hg toxicity
WHO, 2002
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 Treatment of inhalational mercury

• No role of inducing emesis

• Oral steroid is a common practice but

without substantial evidence

• Hemodialysis is used in severe cases of

toxicity when renal function has declined

(ATSDR, 2002)

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• Most inhalational form are self limited –
recovery without sequalae but fibrosis,
empyema and fatal ARDS has been
reported

Taueg C, et al. Acute and chronic poisoning from residential exposures to

elemental mercury-Michigan, 1989-1990. J Toxicol Clin Toxicol 1992; 30(1): 63-7

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• Use chelating agents: symptomatic,
systemic absorption is anticipated,
increased mercury blood or urine levels
– dimercaprol (BAL) d-penicillamine
(DPCN)
– 2,3-dimercaptosuccinic acid
(DMSA)

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 The identification of mercury
Summary
poisoning is difficult due to vague
toxidrome.

Major target organ in inhalational

mercury poisoning is brain and lung

Pregnant ladies are considered high

risk group

Inhalational elementary mercury

poisoning is self-limited with few
sequelae.

The use of oral steroids in mild

inhalational elemental mercury
poisoning is non-substantial

Only manage severe poisoning in

institutes with well fitted 44
decontamination facilities
 Conclusion

Mercury distribution and

exposure is a global problem

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