Arsenicosis

Arsenicosis is a world wide health problem.
it may be acute poisoning and chronic poisoning.
chronic poisoning show up with rain drop pigmentation, palmoplantar hyperkeratosis, and other skin , hair, nail and systemic treatment. No specific treatment is yet established for chronic arsenic poisoning.

1. Arsenic and Arsenicosis Dr Azmiree

2. What is arsenic? Arsenic is a naturally occurring, metalloid component of the Earth's crust.

3. Symbol: As Atomic number: 33 Atomic weight: 74.92 Specific gravity : 5.73 Valency : 2+, 3+, 5+

4. History of arsenic and arsenicosis Arsenic was known to the ancient Egyptian, Greek and Chinese. The man credited for the identifying of element mined as arsenic was Albertus Magnus, a German alchemist.

5. Arsenic was known as ‘the king of poison’ The suspected cause of death of Napoleon Bonaparte was chronic arsenic poisoning.

6. The Italian House of Borgia acquired considerable wealth and power through their use of arsenic-tainted wines to assassinate influential popes and cardinals during the 15th and 16th centuries.

7. The second Kumar Ramendra Narayan Roy of Bhawals was tried to be killed by acute arsenic posoning

8. Arsenic in cosmetic product

9. In 1917, arsenicosis through ground water was first identified in Cordoba of Argentina (Bell Ville Disease). Arsenicosis was first reported in Chapai Nawabgonj district in year 1993

10. Source of arsenic

11. The concentration of arsenic may be higher in certain geographical regions. This could be a result of human activity, such as metal mining or the use of pesticides. Natural conditions can also lead to a higher concentration.

12. In human body, aresenic accumulation mainly takes place through the intake of arsenic Arsenic contamination in ground water is the outcome of many factors such as anthropogenic activities, geochemical reactions, and biological actions.

13. The desorption and dissolution of arsenic from arsenic rich rocks and minerals are the main sources of groundwater contamination and soil by oxidation and reduction process Volcanic rocks and geothermal fluids are another major sources of arsenic

14. Man-made sources: Agricultural and industrial activities Burning of fossil fuels Mining activities Use of arsenic as herbicides, fungicides and pesticides

15. Wood preservatives Crop dessicants Arsenic additives to livestocks Tannery Painting products

16. Now arsenic in rice is a burning issue

17. Arsenic preparations used in treatment- Arsenic trioxide in acute promyelocytic leukaemia Homeopathic medicine Traditional chinese herbs Fowler’s solution containing potassium arsenite Bell’s asthma mixture in Bronchial asthma Treatment of psoriasis

18. Global arsenic senerio Gold mining is by far the largest single source of world anthropogenic arsenic. If all estimated gold reserves are exploited, then gold mining will release estimated 104 million tonnes of arsenic in the environment With developing of era , industrialization, use of pesticides it has became worldwide problem.

19. Arsenic contamination of ground water is widespread and there are a number of regions where arsenic contamination of drinking-water is significant. It is now recognized that at least 140 million people in 50 countries have been drinking water containing arsenic at levels above the WHO provisional guideline value of 10 g/L 9.

20. Arsenicosis in bangladesh

21. Arsenicosis was first reported in Chapai Nawabgonj district in year 1993. Now, it is estimated that between 35 to 77 million Bangladeshi or 28 to 62% of the total population of 125 million are now at risk of chronic arsenic poisoning

22. 2009

23. Arsenic contamination has been found more commonly in the tubewells which were installed within the depth of 15–50 m. The arsenic contamination in tubewell water of Bangladesh was thought to be in Gangetic delta plain; later, the contamination was detected in almost all the sedimentary areas of Bangladesh, except in Hilly and Pleistocene Uplands areas (Terrace Land)

24. WHO maximum permissible limits The WHO guideline value for arsenic in drinking water is 0.01 mg/L and that is considered a safe dose Bangladesh consider 0.05 mg/L as the maximum permissible limit due to inadequate testing facilities for lower concentrations

25. Presentation of arsenicosis Acute arsenic poisoning Chronic arsenicosis

26. Acute arsenic poisoning Projectile vomiting Dark or bloody stool followed by rice watery stool Severe burning pain in throat Increase salivation and thrist Decreased urine output Muscle cramp Cardiac arrhythmia Convulsion Coma Death

27. Chronic arsenicosis

28. Pigmentary change: Diffuse hyperpigmentation localized or generalized associated with hypopigmentation giving an appearance of rain drop( rain drop pigmentation) Localized pigmentation Spotty hypopigmentation

29. Hyperkeratosis of palm and sole Stage 1: just palpable thickening and gritty sensation Stage 2: simple hyperkeratosis and discrete warty lesion Stage 3:hyperkeratosis with fissure or crack

30. Hair changes: lusterless, dry , may falloff Nail changes: Brittle nail Mee’s line Pigmentation pitting

31. Mucous membrane: Mucosal pigmentation (Blotchy pigmentation on the undersurface of tongue or buccal mucosa) Conjunctival congestion, swelling, painful eye, lacrimation

32. Perforation of nasal septum Runny nose, crust formation Gum is red and soft Tongue is coated with white silvery fissure

33. Dermatological malignancy and premalignamt conditions: Arsenical keratosis Bowen’s disease Squamous cell carcinoma Basal cell carcinoma

34. Constitutional symptom: Anorexia Weightloss Anaemia Weakness Asthenia

35. Systemic manifestations: Gastrointestinal Abdominal discomfort Anorexia, Nausea, Vomiting Excess salivation Colicky abdominal pain Constipation Diarrhoea

36. Respiratory: Dyspnoea , cough, bronchitis Lung fibrosis. ILD Emphysematous change Hepatic: Hepatomegaly Fatty infiltration Chronic liver disease

37. Renal: Albuminuria ,, hematuria , oliguria Cortical necrosis, tubular necrosis Nephropathy leading to CRF Cancer of- bladder, ureter

38. Cardiovascular Arrhythmia Cardiomegali Conduction defect Heart failure Peripheral vascular disease Black foot disease

39. Nervous system: Symmetrical distal polyneuropathy Peripheral neuropathy Confusion Dimentia Tremor delusion

40. Reproductive: Still birth Sterility Adverse pregnancy outcomes Spontaneous abortion Still birth

41. Hematologic: Anaemia Granulocytopenia Thrombocytopenia Other: Peripheral edema

42. Nondermatological malignancy: Urinary bladder Lungs Liver Gastrointestinal prostate

43. Differential diagnosis Pityriasis versicolor Post kala azar leishmaniasis Xeroderma pigmentosa Addisons disease Dyschromatosis hereditaria universalis

44. Investigations A) Routine Blood for complete blood count Blood urea, s. creatinine Liver function test Chest x ray Fasting blood sugar Urine routine examination

45. B) Specific: Detection of arsenic from hair, nail, urine, blood Skin biopsy for histopathology C) Other investigations according to organ involvement: Ultrasonography of KUB Ultrasonography of whole abdomen Color dopper study of lower limb ECG, echocardiography Serum protein

46. Management: Prevention : Stop further exposure of use of arsenic contaminating water not only for drinking, but also for cooking, washing of food and other household works Ensure safe drinking water

47. Eat vegetable to decrease absorption Eat protein rich diet to eliminate absorbed arsenic

48. Local treatment: Topical keratolytics for palmoplantar hyperkeratosis: Salicylic acid Urea For arsenical keratosis Imiqiumod 5 Flurouracil

49. Nutritional supplement: Spirulina Vitamin A( retinol, beta carotene) Vitamin E Vitamin C Selenium Zinc

50. Treatment of malignancy Simple Excision Mohs micrographic surgery Cryotherapy Electrosurgery For chronic case : oral retinoid

51. Chelation therapy Chelation therapy for chronic arsenic toxicity is thought to be the specific therapy for relief of systemic clinical manifestations and reduction of arsenic stores in the body, reducing subsequent cancer risk.

52. A study evaluating the efficacy of specific chelation therapy with DMSA ( dimercaptosuccinic acid) for patients suffering from chronic arsenic toxicity has not yielded better efficacy than control subjects treated with placebo.

53. But  Therapy with DMPS(2,3-dimercapto-1-propanesulfonic acid, Na salt) chelating agent for arsenic, caused significant improvement of clinical condition of chronic arsenicosis patients. However, the drug is costly, not available locally and reports of long-term clinical trial are not available

54. Thank you