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Arsenic encephalopathy — Clinical Guidelines

Overview

Arsenic encephalopathy results from chronic or acute exposure to arsenic, leading to multisystem toxicity affecting hematology, skin, neurology, and other organs. 1 4 10

Diagnosis

Clinical Presentation: Symptoms include gastrointestinal distress, neuropathy, skin lesions, and multisystem failure. 16 14

Laboratory Tests:

- Quantitative measurement of 24-hour urinary arsenic excretion is definitive. 16 - Plasma-aminothiols (L-cysteine, cysteinyl glycine, total homocysteine, glutathione) and B-vitamin levels may indicate arsenic exposure status. 5

Imaging and Biopsy: Muscle biopsy can show characteristic changes in acute cases (e.g., perifascicular hypercontracted fibers). 13

Management

Acute Exposure:

- Dimercaprol (British Anti-Lewisite, BAL) intramuscularly; hemodialysis may be ineffective in severe cases. 16 18

Chronic Exposure:

- Folic acid supplementation to enhance arsenic methylation and facilitate urinary excretion. 2 7 - Consider B-vitamin supplementation to support one-carbon metabolism. 5

Special Populations

Pregnancy: Specific management guidelines are not provided in the abstracts; folic acid supplementation may be beneficial based on general principles. 2

Pediatrics: No specific data provided in the abstracts.

Elderly: Increased susceptibility to multisystem complications; close monitoring and supportive care are crucial. 14

Comorbidities: Patients with existing hematological or neurological conditions may experience exacerbated symptoms; tailored supportive care is essential. 1 11

Key Recommendations

Confirm arsenic exposure through quantitative 24-hour urinary arsenic excretion (Evidence: Strong 16).

Implement folic acid supplementation to enhance arsenic methylation and promote excretion (Evidence: Moderate 2 7).

Use dimercaprol for acute severe cases, though efficacy of hemodialysis remains variable (Evidence: Weak 16 18).

Monitor and manage multisystem complications closely, especially in vulnerable populations like the elderly and those with comorbidities (Evidence: Expert opinion 14).

References

1 Zubair M, Ahmad M, Saleemi MK, Gul ST, Ahmad M, Martyniuk CJ et al.. Sodium arsenite toxicity on hematology indices and reproductive parameters in Teddy goat bucks and their amelioration with vitamin C. Environmental science and pollution research international 2020. link 2 Bozack AK, Hall MN, Liu X, Ilievski V, Lomax-Luu AM, Parvez F et al.. Folic acid supplementation enhances arsenic methylation: results from a folic acid and creatine supplementation randomized controlled trial in Bangladesh. The American journal of clinical nutrition 2019. link 3 Xiao Y, Huang X, Jing D, Huang Y, Zhang X, Shu Z et al.. Assessment of the Dermatology Life Quality Index (DLQI) in a homogeneous population under lifetime arsenic exposure. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 2018. link 4 Baker BA, Cassano VA, Murray C. Arsenic Exposure, Assessment, Toxicity, Diagnosis, and Management: Guidance for Occupational and Environmental Physicians. Journal of occupational and environmental medicine 2018. link 5 Mukherjee AK, Manna SK, Roy SK, Chakraborty M, Das S, Naskar JP. Plasma-aminothiols status and inverse correlation of total homocysteine with B-vitamins in arsenic exposed population of West Bengal, India. Journal of environmental science and health. Part A, Toxic/hazardous substances & environmental engineering 2016. link 6 Tournel G, Houssaye C, Humbert L, Dhorne C, Gnemmi V, Bécart-Robert A et al.. Acute arsenic poisoning: clinical, toxicological, histopathological, and forensic features. Journal of forensic sciences 2011. link 7 Gamble MV, Liu X, Slavkovich V, Pilsner JR, Ilievski V, Factor-Litvak P et al.. Folic acid supplementation lowers blood arsenic. The American journal of clinical nutrition 2007. link 8 Tollestrup K, Frost FJ, Cristiani M, McMillan GP, Calderon RL, Padilla RS. Arsenic-induced skin conditions identified in southwest dermatology practices: an epidemiologic tool?. Environmental geochemistry and health 2005. link 9 Jha S, Dhanuka AK, Singh MN. Arsenic poisoning in a family. Neurology India 2002. link 10 Woollons A, Russell-Jones R. Chronic endemic hydroarsenicism. The British journal of dermatology 1998. link 11 Barton EN, Gilbert DT, Raju K, Morgan OS. Arsenic: the forgotten poison?. The West Indian medical journal 1992. link 12 Jolliffe DM, Budd AJ, Gwilt DJ. Massive acute arsenic poisoning. Anaesthesia 1991. link 13 Fernandez-Sola J, Nogue S, Grau JM, Casademont J, Munne P. Acute arsenical myopathy: morphological description. Journal of toxicology. Clinical toxicology 1991. link 14 Hall D, Beattie D, Grossman S, Campbell C. Multisystem failure of the arsenic-poisoned patient. Dimensions of critical care nursing : DCCN 1991. link 15 Embry JH, Walls HC. Serial arsenic poisoning: two Alabama cases. Alabama medicine : journal of the Medical Association of the State of Alabama 1990. link 16 Campbell JP, Alvarez JA. Acute arsenic intoxication. American family physician 1989. link 17 Gorby MS. Arsenic poisoning. The Western journal of medicine 1988. link 18 Levin-Scherz JK, Patrick JD, Weber FH, Garabedian C. Acute arsenic ingestion. Annals of emergency medicine 1987. link80076-8) 19 Landrigan PJ, Costello RJ, Stringer WT. Occupational exposure to arsine. An epidemiologic reappraisal of current standards. Scandinavian journal of work, environment & health 1982. link 20 Gillies AJ, Taylor AJ. Acute arsenical poisoning in Dunedin. The New Zealand medical journal 1979. link 21 Fernando PR. Atempted homicide with arsenic. Clinical toxicology 1979. link 22 Li KC, Pupp C. The collection of arsenic oxide vapor in water-filled impingers. American Industrial Hygiene Association journal 1979. link

Arsenic encephalopathy