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Toxic polyneuropathy — Clinical Guidelines

Overview

Toxic polyneuropathy due to mercury exposure encompasses a range of neurological and systemic symptoms resulting from acute or chronic ingestion, inhalation, or dermal contact with mercury in various forms, including elemental, inorganic, and methylmercury. 1 3 15

Diagnosis

Clinical Presentation: Symptoms include tremors, sensory disturbances, muscle weakness, and neuropsychiatric effects. 14 15

Laboratory Tests: Elevated levels of mercury in blood and urine are indicative. 13 17

Specific Tests: Urinary mercury levels correlate with exposure; blood levels may not always reflect recent exposure accurately. 13

Differentiation: Distinguish from other forms of neuropathy and heavy metal poisoning through detailed clinical history and toxicological screening. 1 11

Management

Decontamination: Removal of mercury sources and environmental cleanup, especially in occupational settings. 4 18

Chelation Therapy: Use of chelating agents like dimercaprol or succimer for severe cases; nifedipine may be effective for acrodynia symptoms. 10 21

Supportive Care: Addressing symptoms such as hypertension, sweating, and pain with appropriate medications. 10

Monitoring: Regular follow-up with mercury level assessments in blood and urine to monitor response to treatment. 17

Special Populations

Pediatrics: Children are particularly vulnerable; exposure can lead to acrodynia with characteristic symptoms like extremity pain and desquamation. 10 3

Occupational Exposure: Miners and workers in industries using mercury require stringent monitoring and protective measures to prevent chronic intoxication. 7 18

Key Recommendations

Identify and Remove Exposure Sources: Promptly identify and eliminate sources of mercury exposure in affected individuals and environments. (Evidence: Strong 4 18)

Monitor Mercury Levels: Regularly measure urinary and blood mercury levels to assess exposure and treatment efficacy. (Evidence: Moderate 13 17)

Initiate Chelation Therapy for Elevated Levels: Consider chelation therapy with agents like succimer for patients with significantly elevated mercury levels. (Evidence: Moderate 21)

Provide Supportive Care: Manage symptoms such as neurological and systemic manifestations with appropriate supportive therapies. (Evidence: Expert opinion 10)

References

1 Phan Dinh Q, Addai-Arhin S, Jeong H, Cahya Nugraha W, Viet PH, Tominaga N et al.. Human health risk of mercury in street dust: A case study of children in the vicinity of compact fluorescence lamp factory, Hanoi, Vietnam. Journal of applied toxicology : JAT 2022. link 2 Alam RTM, Abu Zeid EH, Khalifa BA, Arisha AH, Reda RM. Dietary exposure to methyl mercury chloride induces alterations in hematology, biochemical parameters, and mRNA expression of antioxidant enzymes and metallothionein in Nile tilapia. Environmental science and pollution research international 2021. link 3 Güngör O, Özkaya AK, Kirik S, Dalkiran T, Güngör G, Işikay S et al.. Acute Mercury Poisoning in a Group of School Children. Pediatric emergency care 2019. link 4 . Removing mercury, protecting people's health. Bulletin of the World Health Organization 2018. link 5 Tillman K. What every nurse should know about mercury. Home healthcare nurse 2002. link 6 Poulden M. Mercury: is it elemental my dear Watson?. Emergency medicine journal : EMJ 2002. link 7 Slavec ZZ. Occupational medicine in the Idria mercury mine in the 18th century. Vesalius : acta internationales historiae medicinae 1998. link 8 Gebauer K, Connor B. Cutaneous mercury granuloma. The Australasian journal of dermatology 1991. link 9 Taylor JL, Hockey MS, Rhodes A, Smith ME, Hughes S, Braithwaite RA. Disintegration of mercury disc cells in simulated gastric juice: implications for management of disc cell ingestion. Archives of emergency medicine 1990. link 10 Ozsoylu S, Sarikayalar F, Aksoy A. Nifedipine in the treatment of acrodynia. The Turkish journal of pediatrics 1989. link 11 Shamley DJ, Sack JS. Mercury poisoning. A case report and comment on 6 other cases. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 1989. link 12 Curtis HA, Ferguson SD, Kell RL, Samuel AH. Mercury as a health hazard. Archives of disease in childhood 1987. link 13 Yoshida M. Relation of mercury exposure to elemental mercury levels in the urine and blood. Scandinavian journal of work, environment & health 1985. link 14 Yamanaga H. Quantitative analysis of tremor in Minamata disease. The Tohoku journal of experimental medicine 1983. link 15 Tedeschi LG. The Minamata disease. The American journal of forensic medicine and pathology 1982. link 16 Smith DL. Mental effects of mercury poisoning. Southern medical journal 1978. link 17 Richardson RA. Automated method for determination of mercury in urine. Clinical chemistry 1976. link 18 Rossi LC, Clemente GF, Santaroni G. Mercury and selenium distribution in a defined area and in its population. Archives of environmental health 1976. link 19 Littlejohn D, Fell GS, Ottaway JM. Modified determination of total and inorganic mercury in urine by cold vapor atomic absorption sectrometry. Clinical chemistry 1976. link 20 Eastmond CJ, Holt S. A case of acute mercury vapour poisoning. Postgraduate medical journal 1975. link 21 Selye H. Mercury poisoning: prevention by spironolactone. Science (New York, N.Y.) 1970. link 22 Lee WR. The history of the statutory control of mercury poisoning in Great Britain. British journal of industrial medicine 1968. link

Toxic polyneuropathy