Surgical Management of Iatrogenic Mercury Poisoning From Subcutaneous Injection Into the Arm.

BACKGROUND: Mercury, an element with threats of severe toxic insult to humans and no biological function, has a surprisingly extensive record of human exposure. Regardless of hesitancies toward its harmfulness, it has been historically identified with an almost supernatural power to provide protection from evil and sickness, give good fortune, lend aid in athletic undertakings, or even allow one to achieve immortality. Mercury poisoning is an iatrogenic disease even today as people attempt to achieve these effects through volitional injections into their body by practitioners. Although an uncommon practice in the United States, awareness of patient presentation after volitional injections of elemental mercury is necessary for appropriate treatment of these patients. We aim to increase awareness of the cultural practice of subcutaneous injections of mercury, as it is uncommonly seen in the United States, to contribute a broader understanding to the patient's medical presentation and describe an approach and the impact of medical and surgical intervention. METHODS: In this report, we describe a rare case of elemental mercury poisoning secondary to volitional subcutaneous injection to the arm. Initial management of care through chelation therapy and monitoring of renal and serum mercury levels in addition to symptoms of systemic spread was overseen by an internal medicine physician and poison control. Surgical intervention via full-thickness excision of the visible mercury to the right arm followed by local flap and skin grafting reconstruction was performed. CONCLUSIONS: Mercury poisoning from intentional subcutaneous administration is an uncommon patient presentation in the United States; however, knowledge of management of this rare condition is important for effective management of iatrogenic mercury toxicity.

Inyección subcutánea de mercurio elemental. Importancia de la remoción precoz / Subcutaneous injection of metallic mercury. The importance of early removal

La inyección subcutánea o intramuscular de mercurio elemental, sea accidental o intencional, es una forma poco frecuente de intoxicación. Presentamos el caso de un hombre de 22 años de edad, con antecedentes de rasgos psicóticos y lesiones autolíticas, que se inyectó mercurio elemental en el tejido celular subcutáneo del cuello, tórax y abdomen, tres meses antes de su internación. Las áreas afectadas fueron localizadas mediante el examen físico, radiografías y tomografías. Se realizó el dosaje de mercurio en sangre y orina. Se resecó quirúrgicamente el mercurio de las zonas comprometidas. La detección y remoción precoz del mercurio, mediante cirugía y eventual quelación, es necesaria para prevenir complicaciones a corto y largo plazo.

Accidental or intentional subcutaneous or intramuscular injection of metallic mercury is an uncommon form of intoxication. We present the case of a 22 year-old man, who had psychotic disorders and autoaggressive behavior, with a preceding history of self-injection of mercury into the soft tissues of the neck, thorax and abdomen. Clinical examination, radiographs, and computed tomography showed the affected area. Mercury was measured in blood and urine. The mercury was surgically resected from the affected areas. Early detection and removal of mercury from the body by physical removal or chelation is required to prevent short- and long-term toxicity.

Intoxicación por mercurio elemental por inyección intramuscular: presentación de caso y revisión de literatura / Poisoning with elemental mercury by intramuscular injection. Case report and review of literature

Se han reportado en la literatura pocos casos de intoxicación por mercurio por administración en tejidos blandos. No se cuenta con suficiente evidencia acerca del manejo con terapia quelante en este tipo de intoxicación. Se reporta el caso de una mujer de 34 años con antecedente psiquiátrico la cual se administró mercurio intramuscular en fosa cubital izquierda con fines autolíticos. Acudió al servicio de urgencias 24 horas posteriores a su administración, el motivo principal fue el dolor intenso en la zona y la presencia de edema, sin efectos sistémicos. La radiografía mostró depósitos metálicos en 1/3 de brazo, localizados en músculo, y que migraron a través de la fascia hacia 2/3 del antebrazo. La placa de tórax no mostró alteraciones. Fue intervenida quirúrgicamente en 3 ocasiones extrayendo mínimas cantidades de mercurio. La paciente fue manejada con antibióticos por presencia de celulitis. Un mes después presentó temblor mercurial, razón por la cual se tomaron muestras de sangre y orina para la determinación de mercurio, el cual resulto elevado en ambas muestras, por lo que se le administró terapia quelante con D-penicilamina.

There are just a few cases of mercury toxicity after administration in soft tissue, reported in the literature. There is insufficient evidence about the management with chelation therapy in this type of poisoning. We report the case of a 34 year-old woman with a psychiatric history who administered herself a mercury injection into de muscle in the left cubital fossa, referred as a suicide attempt. She came to the emergency department 24 hours after administration; the main reason was the intense pain in the area and the presence of edema, with no systemic effects. Radiography showed metallic deposits in 1/3 arm, located in muscle, which moved through the fascia to 2/3 of the forearm. Chest radiography was normal. She underwent surgery trhee times extracting trace amounts of mercury. The patient was managed with antibiotics by the presence of cellulite. One month later she had tremor mercuralis, so a blood and urine samples were sent to the laboratory in order to determinate mercury levels, which resulted high in both fluids, therefore chelation therapy with D-penicillamine was administered.

Intraperitoneal elemental mercury exposure from a mercury-weighted bougie.

INTRODUCTION: Significant exposure to elemental mercury can occur if a mercury-weighted medical device is damaged during use. We report a case of an elemental mercury spill into the peritoneum of a patient undergoing laparoscopic gastric bypass surgery. CASE REPORT: A 64-year-old man with multiple comorbidities underwent an elective Roux-en-Y gastric bypass procedure for the treatment of morbid obesity. A mercury-weighted esophageal bougie was inadvertently used during construction of the anastomosis. A suture placed through the distal tip of the device caused elemental mercury to leak into the peritoneum. Two days later, the patient underwent another surgical procedure for removal of the mercury. Intermittent air measurements taken from the laparoscope exhaust showed a peak intraperitoneal mercury concentration of 98,169 ng/m³. Blood mercury levels peaked at 146 µg/L on day 22 after the exposure, and urine mercury concentrations peaked on day 43 at 227 µg/L. The patient had no evidence of acute toxicity, but he was found to have proteinuria on follow-up evaluation. DISCUSSION: Patients can be exposed inadvertently to toxic amounts of elemental mercury when the integrity of medical devices is compromised. We encourage hospitals to discontinue the use of devices that contain mercury. Effective alternatives that do not pose exposure risks to patients or health care workers are readily available.

Auto-aggressive metallic mercury injection around the knee joint: a case report.

BACKGROUND: Accidental or intentional subcutaneous and/or intramuscular injection of metallic mercury is an uncommon form of poisoning. Although it does not carry the same risk as mercury vapour inhalation, it may cause destructive early and late reactions. CASE PRESENTATION: Herein we present the case of a 29-year-old male patient who developed an obsessive-compulsive disorder causing auto-aggressive behaviour with injection of elemental mercury and several other foreign bodies into the soft tissues around the left knee about 15 years before initial presentation. For clinical examination X-rays and a CT-scan of the affected area were performed. Furthermore, blood was taken to determine the mercury concentration in the blood, which showed a concentration 17-fold higher than recommended. As a consequence, the mercury depots and several foreign bodies were resected marginally. CONCLUSION: Blood levels of mercury will decrease rapidly following surgery, especially in combination with chelating therapy. In case of subcutaneous and intramuscular injection of metallic mercury we recommend marginal or wide excision of all contaminated tissue to prevent migration of mercury and chronic inflammation. Nevertheless, prolonged clinical and biochemical monitoring should be performed for several years to screen for chronic intoxication.

Subcutaneous metallic mercury injection: early, massive excision.

The case of a patient who injected 10 cc of metallic mercury subcutaneously into his left forearm through multiple punctures in an attempt at suicide is presented. Diagnosis was made by plain radiography of his left forearm, which exhibited redness, edema, and tenderness on the third day postinjection. Early excision of all affected subcutaneous tissues including metallic mercury deposits was performed on the fifth day postinjection. Blood and urine mercury levels that were initially found in high levels decreased dramatically to normal ranges after the excision and remained unchanged at the follow-up period of 6 months. No renal or hepatic functional impairment was encountered. The patient was free of toxic symptoms and mercury embolism. The local, aseptic lytic property of metallic mercury, which could cause severe damage to vital structures, was observed perioperatively. Early diagnosis and early, massive excision of mercury deposits in affected tissues is the important treatment modality in these rare cases.