What is Arsenic Toxicity (Arsenic poisoning)?
Arsenic poisoning is a worldwide health problem that impacts millions of people. This can happen through exposure in the environment or workplace, but also through deliberate acts like suicide or murder. While cases of arsenic poisoning related to murder often make the news, the main way that most people come into contact with dangerous levels of arsenic is through things like contaminated water, soil, or food. Arsenic is a type of toxic metal that we can find almost everywhere, but it doesn’t have a taste or smell that would alert us to its presence. Arsenic has several forms – it could be seen in four common states, As(o), As(III), As(V) and as Arsine gas, and generally appears in three forms: inorganic salt, organic salt, and in a gas form.
What Causes Arsenic Toxicity (Arsenic poisoning)?
Arsenic is a natural element that’s widely spread throughout the earth’s crust and groundwater, and it can also be found in the air and in food, especially in seafood. This element gets released into the environment through natural means like weather conditions and mining processes, as well as events like volcanic activity. Additionally, Arsenic is a byproduct in the smelting process when dealing with certain metals like gold, lead, cobalt, nickel, and zinc.
In the past, arsenic was used in herbicides, wood preservative products, certain traditional remedies, and in the distillation process for some alcoholic beverages like beer, wine and whiskey.
The gas form of arsenic, known as Arsine gas, is used in the production of a material called gallium arsenide. This material is a crucial part of semiconductors, lasers, LED lights, photoelectric chemical cells, and microwave devices. Unfortunately, one of the biggest causes of long-term arsenic poisoning is drinking water contamination, which can occur due to soil erosion and contaminated wells and underground water sources.
Risk Factors and Frequency for Arsenic Toxicity (Arsenic poisoning)
Chronic exposure to arsenic through tainted drinking water is a global health issue. However, the contamination rates heavily depend on the geographical location. For instance, India and Bangladesh experience high exposure rates, with an estimated 27 million people in Bangladesh alone consuming water with arsenic levels exceeding the safe limit. The World Health Organization defines the safe arsenic level in drinking water to be less than 10ppb. Contaminated water has also been discovered in private wells around the world, including the United States.
On the other hand, people may also be exposed to arsenic at work. Jobs that include the making of pesticides, herbicides, smelting, mining, glass and semiconductor manufacturing, as well as jobs like carpentry that involve the burning, removal, or handling of materials treated with arsenate wood preservatives, can lead to arsenic exposure.
Although the dominant factor affecting arsenic toxicity appears to be regional distribution, there’s another thing to consider. It seems that the effects of arsenic toxicity may not be the same for everyone. Some studies suggest that men may be more impacted by arsenic-related skin conditions than women.
Signs and Symptoms of Arsenic Toxicity (Arsenic poisoning)
Arsenic poisoning can be serious and can present in different ways depending on the timeline follow-up of exposure – acute, sub-acute or chronic.
In the acute stage, symptoms may include:
- Gastrointestinal issues like nausea, vomiting, diarrhea, and abdominal pain, usually appearing minutes to hours after exposure
- Cardiovascular problems like low blood pressure due to dehydration and heart rhythm disorders
- Respiratory issues like cough, shortness of breath, and chest pain
- Renal issues including proteinuria, blood in urine and kidney failure
- Neurologic symptoms like headache, confusion, and seizures
In the subacute stage (1-3 weeks after exposure), symptoms may include:
- Neurological problems like numbness, weakness, and tingling in hands and feet, and gait disturbances
- Hematological problems – reduced white blood cells, platelets, and abnormal red blood cells
Chronic arsenic poisoning comes with long-term symptoms. These may include:
- Skin abnormalities like dark spots, whitened nails, skin conditions, and hair loss
- Possible skin, lung, and bladder cancer
- Liver problems like tumours, enlarged liver, fluid accumulation in the body and abdominal pain
- Gangrene in extremities
Arsine Gas can cause symptoms like bad breath, headache, nausea, loss of balance, rapid heart rate, fever and kidney failure within hours of exposure. More severe symptoms like discolored urine, red conjunctiva, and liver or spleen tenderness can be seen a few days after exposure.
Testing for Arsenic Toxicity (Arsenic poisoning)
Doctors should be mindful of signs such as severe repeated stomach illnesses, decreased blood pressure, skin darkening, and nerve damage, especially in people who are at risk from their job or environment. These might indicate a person has been exposed to arsenic for a long time.
If there is a strong suspicion of arsenic poisoning, treatment should start even before lab tests confirm it.
Checking the level of arsenic in a person’s urine over 24 hours can tell if a person has been exposed to arsenic. The presence of arsenic is confirmed if the level is 50 micrograms/L or above 100 micrograms of total arsenic. During an acute exposure, the level of arsenic in 24-hour urine can surge to several thousand micrograms. If the person isn’t treated, the arsenic levels can remain elevated for several weeks.
In urgent situations, a quick urine test can be used.
The urine sample should be collected in a container that doesn’t have any metals.
It is advisable to keep checking the level of arsenic until it decreases to below 50 micrograms/L.
If there’s no immediate danger, the person should be asked to avoid seafood for five days before the 24-hour urine test, as seafood can also increase the level of arsenic in urine. Seafood contains a type of arsenic which is normally safe at the levels we usually consume.
To determine the extent of the poisoning, other tests might be carried out:
– Abdominal X-ray: to check for signs of arsenic in the stomach.
– Blood tests: to check for reduced red and platelet counts and increased levels of white blood cells.
– Kidney and liver tests: to check for proteins in the urine and blood, raised level of creatinine (a waste product), and raised liver enzymes and bilirubin.
– Tests for hemolytic anemia: to see if the person’s red blood cells are being destroyed.
– Tests to check the size and shape of the person’s red blood cells.
– Electrocardiogram (EKG): to check if the person’s heart rhythm is affected.
– Checks for blood group and screening for blood transfusion: in case the person has been exposed to arsine gas and might need a transfusion.
– Nerve conduction studies: to check if the person’s peripheral nerves are affected.
Hair and nail samples can also be collected and sent for lab analysis in cases where it’s unclear if the person has been exposed to arsenic for a long time. The hair sample should be 200mg and should be taken from the back of the head, as close to the scalp as possible.
Treatment Options for Arsenic Toxicity (Arsenic poisoning)
Arsenic poisoning is a very serious condition that requires urgent treatment. This involves a focus on replenishing fluids, stabilizing blood pressure, and monitoring heart conditions. If the patient needs to be admitted to the hospital, they should be placed in the intensive care unit (ICU) for advanced life-monitoring support.
A form of treatment called chelation therapy, which removes arsenic from the body, can improve the patient’s outcome if started soon after exposure. In severe cases, doctors should start this treatment as soon as possible, even without lab confirmation.
There are several medicines used in chelation therapy, including British Anti-Lewisite (BAL), Dimercaptopropanesulfonic acid (DMPS), and Succimer (2,3-Dimercaptosuccinic acid). Each of these needs to be taken on a specific schedule, which can be gradually lessened over time. The goal is to reduce the level of arsenic in the person’s urine to under 50 mcg/L.
If the patient has specific, serious heart issues like ventricular tachycardia or torsades de point, doctors may need to use medications like magnesium sulfate, lidocaine, amiodarone, and even a defibrillation machine to regulate the heartbeat. Some heart medications should be avoided as they could make the situation worse.
Balancing potassium, calcium, and magnesium levels in the body is crucial to prevent further heart complications. If seizures occur, they can be controlled with medicines like benzodiazepine and general anesthesia if needed. If the skin has been in contact with arsenic, washing it with soap and water can remove the toxin.
The benefits of using activated charcoal and a procedure called gastric lavage are still uncertain. Activated charcoal might help if other harmful substances were swallowed at the same time. Gastric lavage, or stomach pumping, could be considered if X-ray imaging shows large amounts of hard-to-digest material.
For a specific type of arsenic poisoning from a gas called arsine, there is no antidote and chelation therapy is often not effective. Treatment mostly includes replacing red blood cells, maintaining kidney function, replacing electrolytes, and providing advanced support care.
Consideration can be given to dialysis for patients who show signs of failing kidney function, including decreased urine output. The goal should be urine output of 1 to 2 ml per kg per hour. Making the urine more alkaline might prevent the harmful buildup of broken down red blood cell products. An exchange transfusion might also help by removing arsine that cannot be removed by dialysis.
Just like with other severe arsenic poisoning cases, anyone who needs to be hospitalized should be admitted to the ICU for advanced monitoring and care.
What else can Arsenic Toxicity (Arsenic poisoning) be?
Arsenic poisoning can sometimes be misidentified as Guillain-Barre syndrome. This confusion arises because both conditions show common symptoms of nerve damage that progress from the lower to the upper parts of the body.
Like many stomach-related issues, the symptoms of acute arsenic poisoning can mimic those of:
- Certain bacterial infections like Campylobacter, Shigella, Bacillus, E.Coli, Clostridium, and Vibrio Cholerae
- Viral infections caused by Rotavirus
- Parasitic infections such as Giardia, Cryptosporidium, and Entamoeba
In addition, arsenic poisoning can also mimic:
- Stomach or intestinal bleeding
- Appendicitis
- Blockage of blood supply to the small intestine, also known as mesenteric ischemia
- Diverticulitis or inflammation of an abnormal pouch in the intestine
- Adverse reactions to certain drugs
- Poisoning by other heavy metals
What to expect with Arsenic Toxicity (Arsenic poisoning)
The effects of arsenic poisoning can vary greatly. It depends on the type of arsenic, the amount consumed, and how long the exposure lasted. Exposure can cause a range of different health problems. For example, peripheral neuropathy, a condition that causes pain or numbness in the hands and feet, can improve if exposure to arsenic stops. However, exposure to arsenic is also linked to various types of cancer, including skin, lung, bladder, and liver.
The lethal dose of inorganic arsenic, the type often found in pesticides or industrial areas, is estimated to be 0.6 mg per kg of body weight. If a lethal dose is consumed, death can generally occur 1 to 4 days after ingestion.
Possible Complications When Diagnosed with Arsenic Toxicity (Arsenic poisoning)
For a detailed list of complications associated with exposure to arsenic, please refer to the chronic symptomatology part in the history and physical examination section.
Preventing Arsenic Toxicity (Arsenic poisoning)
Arsenic is a natural element that can be found in the Earth’s crust, but it’s also a notable poison worldwide. This element can contaminate drinking water and people can also be exposed to it in their workplaces, especially in industries like mining, farming, and semiconductor production.
Arsenic can be harmful in two forms, both dissolved in water and in gas form. When dissolved in water, it is nearly tasteless. It can pollute our drinking water and has even been used to commit murder or suicide. The first signs of arsenic poisoning include severe diarrhea, often compared to the appearance of ‘rice water’, and can sometimes be bloody. This is also often accompanied by nausea, vomiting and stomach pain.
Arsine gas is a deadly colorless and nearly tasteless gas that might be produced during mining and is used in making semiconductors. It can be lethal in small amounts, and individuals exposed may not detect the poison until hours after exposure. Usual symptoms of arsine gas poisoning include headaches, nausea, vomiting, diarrhea, unusually colored urine, and yellowed skin.
In cases where arsenic exposure is suspected, it’s critical to call 911 right away for immediate transportation to the nearest hospital.
If you’re worried about ongoing exposure to arsenic at your workplace, you can contact the Occupational Safety and Health Administration (OSHA) at 1-800-321-6742 for an investigation.
For additional advice, the American Association of Poison Control Center can be reached at 1-800-222-1222.
