Mercury poisoning fornesic toxicolgoy.pdf

Mercury poisoning.pdf

1. CLASSIFICATION-METALLIC IRRITANT
POISONS
COMMON
•ARSENIC
•LEAD
•MERCURY (QUICK
SILVER)
•COPPER
UNCOMMON
•ZINC
•TALLIUM
•IRON
•MANGANESE
•POTASSIUM
PERMANGANATE
•BARIUM
•ANTIMONY
•Gold bismuth tin silver

3. Mercury POISONING
Introduction
Properties
Toxic compounds
Absorption, metabolism & excretion.
Action
Acute poisoning
Chronic poisoning
Treatment
Medico legal aspects

4. At the end of the topic student must be able to
understand this-
Learning Outcome Competencies:
Identify the action, signs & symptoms, fatal dose, fatal period, post mortem findings,
Circumstances of poisoning of mercury.
Specific Learning Objectives:
1. Explain the sources of mercury
2. Describe the action, signs and symptoms and treatment of mercury Poisoning.
3. Explain the fatal dose and fatal period mercury.
4. Explain the post mortem findings and circumstances of mercury Poisoning.
5. Explain the term HYDRARGYRISM

5. Mercury was the name of
the Roman’s messengers of
the gods who were believed
to be really fast moving.

7. Mercury-elemental
(quick silver, para, padarsa, liquid metal)
It is heavy metal and bright silvery in appearance
It is liquid and is non poisonous if swallowed and through intact GIT.
Dissolves in fat and oil, insoluble in water
Volatilizes at room temp and inhalation of vapors is toxic
It gets widely distributed throughout the body and causes toxic damage to brain,
kidney, peripheral nervous system, mucous membranes etc
Elemental Hg is lipid soluble and can cross blood-brain barrier. After absorption most of the elemental Hg get
oxidized to mercuric form which is not lipid soluble.
Sources: Batteries, Dental amalgams, Gold and Silver production, Jewelry industry, Paints, thermometers etc.

9. COMPOUNDS OF MERCURY
Itexistinelemental,inorganicandorganicforminenvironment.
OrganicHg:pesticides,fishes,poultry,fungicideinseedcommerce,diuretics
MethylHg,
EthylHg,
Methoxymethylmercurial
InorganicHg:itformtwoseriesofcompounds
MERCURIC Hg
++
:solubleandmoretoxice.g.
a)Mercuricchloride(corrosivesublimate)
b)Mercuricoxide/Redprecipitate(sipichand)
c)Mercuricsulphide
d)Mercuricnitrite,cyanide,ammoniumchloride(whiteprecipitate)etc.
MERCUROUS Hg
+
:lesssoluble,thus,lessactivee.g.
a)Mercurouschloride(calomel)–rasKapoor

10. 1. Mercuric chloride:
(corrosive sublimate):
Perchlorideof mercury:
-Occurs as odorless, white crystalline
powder or tablets
-Nauseous, acrid, burning metallic
taste and soluble in water, alcohol,
ether, glycerin.
-Common cause of Acute Poisoning
-Used in medicines and taxidermy,
germicide, in laboratories,
preservative.
-HIGHLY TOXIC
Parada[Mercury-Hg] &
Khatika[Chalk-CaCO3]

11. Mercurouschloride:
(raskapoor,
calomel) aka
SUBCHLORIDE
of MERCURY
-Heavy amorphous white tasteless
powder, insoluble in water, alcohol
and ether.
-On exposure to light turns to
Mercuric chloride.
-Used in laxatives.
-NON TOXIC for human in
therapeutic dose.

12. Mercuric sulphide: (rassindoor, cinnabar).
-Artificially prepared as red powder-
vermillion.
-Non poisonous but vapourspoisonous.
-Used in dentures, vermillion

13. Mercuric cyanide-medicine
Mercuric oxide & sulphate-industries.
Mercuric oxide
Mercuric
sulphate-

14. CINNABAR ORE OR MERCURY ORE

15. Organic Mercury
Most toxic form of Hg for human consumption.
It primarily targets enzymes.
It readily crosses placenta and is secreted in breast milk
These are extremely toxic to fetus.
Methyl Hg can build up to certain level in aquatic animals.
It is lipid soluble and gets widely distributed throughout the body.
SOURCES: Fungicides, seed preservatives, mercury containing
vaccines, fish consumption etc.

17. Mercurial Diuretics-organic mercury
Can damage kidneys.
I.V. administration
can cause Anaphylaxis
in sensitive persons.
Used in past.

18. ALKYL MERCURIC COMPOUNDS
PHENYL MERCURIC ACETATE
Used for preservation of seed as
fungicidal agent, can cause mass
poisoning.
Such seed consumed by living stock can
cause poisoning.
Eg: Iraq mass poisoning.

19. Methyl mercury content in fish-
sword fish
-Chronic mercurial poisoning
-Bio-magnification

20. Water
Sea
food
Ther
mome
ters.
Batte
ries
Dental
amalgam
s
Jewelry
industry
Neon
lamps
Paints
Cosmetic
s (such as
skin-
lightenin
g
products)
SOURCE OF MERCURY TOXICITY

21. EPIDEMIOLOGY
Minamatadisease in Japan was involved in the first
and most famous epidemic.
Minamatadisease is a poisoning disease that affects
mainly the central nervous system and is caused by
the consumption of large quantities of fish and
shellfish living in MinamataBay and its
surroundings, the major causative agent being some
sort of organic mercury compound.

24. Mercury poisoning in Iraq
One of the most severe mass
poisonings in history occurred in
Iraq, when nearly 95,000 tons of
seed grains treated with a
methylmercury-based fungicide
were accidentally baked into bread
for human consumption.
More than 6000 individuals were
hospitalized, and hundreds died.
Many were hospitalized for weeks
before methylmercuryintoxication
was correctly diagnosed.

25. Age related demographics
Toxicityprobably affects developing fetuses and children
Prenatal exposure through maternal consumption of predominantly fish and whale meat has
been shown to impair development among children in the
Faroe Islands, while maternal mercury exposure from fish consumption alone in the Seychelles
did not result in significant developmental problems among children prenatally exposed.
In a case of a family exposed to methyl-mercury through the ingestion of contaminated pork, the
more severe clinical manifestations were found in the younger children.

26. How might I be exposed to mercury
All humans are exposed to some level of mercury.
Most people are exposed to low levels of mercury, often
through chronic exposure (continuous or intermittent long
term contact).
However, some people are exposed to high levels of
mercury, including acute exposure (exposure occurring
over a short period of time, often less than a day).
An example of acute exposure would be mercury exposure
due to an industrial accident.

28. Routes of Poisoning of toxic and soluble
mercurial compounds
Ingestion-mercuric compounds are soluble in gastric juice.
Inhalation: vapourof mercury and soluble mercury salts through
respiration.
Vaginal-douche
Urinary Bladder-Mercurial antiseptic washing agents.
Skin-microscopic particles of mercury and calomel (not absorbable
through GIT) are absorbed through skin via sebaceous gland, skin
ointments.

29. Action:
Pharmacokinetics
-Absorbed through all routes
-Salts of mercury are lipid
soluble and can cross blood
brain barrier, get secreted
in milk and crosses
placental barrier.
-It gets widely distributed
throughout the body and
causes toxic damage to
brain, kidney, peripheral
nervous system, mucous
membranes etc
-Gets excreted mainly through
kidneys,liverand large
intestine.

30. Action:
Getsdepositedintissueafter
absorption-liver,kidneys,spleenand
bones.
Inhalationcausedmax.concentrationin
brain.
Combineswithsulphydrylgroup
resultinginenzymeinhibitionand
pathologicalalterationofcellular
membranes.
Sulfhydrylgroups(alsoknownasthiol
groups,-SH)
Examplesincludeenzymeswithcysteine
residueslikeglutathionereductase,
thioredoxinreductase,andcertain
dehydrogenases.
Toxicdeaths:2mg/100gm

31. M
•Metallic Taste, Metal Fume Fever, Mad hatter
syndrome
E
•Erethism, Excessive Salivation, Emaciated
Body (PM appearance)
R
•Renal Failure
C
•Colitis , Chorea
U
•Urine Pink Colour, Ulcers, Uraemia.
R
•Reeling gait , rassindoor, rasKapoor.
Y
•Acrodynia, Ptyalism, Danbury tremor
Acrodynia
-Acrodyniais
characterized
byredness of
the lips and
pharynx, loss of
teeth, a
strawberry
tongue,
swelling,
redness, and
desquamation of
the skin, with
pink or red
fingertips,
palms, and
soles.
Ptyalism
-a condition
that causes
excessive saliva
production, also
known as
hypersalivation
Danburytremor
-tremors and
other
neurological
symptoms
caused by
mercury
poisoning,
particularly in
hat factories,
which were
common in
Danbury,
leading to the
nickname "mad
hatter disease".

32. Acute poisoning
INHALATION OF
ELEMENTAL MERCURY
FUMES.
INGESTION OF
INORGANIC
COMPOUNDS
PARENTERAL ROUTES
OF ADMINISTRATION IN
THE FORM OF
MEDICINE, VACCINE OR
OUT OF IGNORANCE.

33. Chemical pneumonia,
Corrosive, interstitial
bronchitis, cough
Headache, blurred vision
Fever, chills and dyspnea.
Progression to pulmonary
odema and fibrosis.
GIT: tongue swelling,
loosening of teeth,
SALIVATION,
METALLIC taste,
gingivitis, strawberry
tongue.
Circumstances of
exposure:
Gold refining in a
closed room. Inhaling
fumes of mercury.
D/d: Kawasaki disease
(muco-cutaneous
lymph node syndrome)
usually seen in
children. Scarlet fever
Inhalation of elemental mercury vapors

34. Swallowing the Poison
The signs and symptoms start immediately after swallowing the
poison:
PHASE 1:
Corrosionandirritationwithburningpain.
Acridmetallictasteinmouth.
Feelingofconstrictionorchokingofthroat.
Vomiting:mucus,alteredblood&shredsofgastricmucosa.
Hoarsenessofvoice,thereisdifficultyinbreathingand
mouthandtonguearecorrodedandswollenwithgrey
whitecoating.
Hotburningpaininmouth,stomachandabdomen.
Stoolsarebloodstained,urineissuppressedandscanty,
containbloodandalbuminisaccompaniedbynecrosisof
renaltubulesanddamagetotheglomeruli.

35. Mucosaofmouth,tongueandgumappearsgreyishwhiteandnecrosis.
Pulseisquicksmallandirregular,thereiscirculatoryfailure.
Thrombocytopeniaandbonemarrowdepression.
Renalfailure,oliguria,albuminuria,andhematuria.
Afteraday,bloodstainedstoolswithpresenceofnecrosismucousshreds.
Generalizedsymptoms:Lossofappetite,headache,tremor,fatigue,ataxia.
CAUSEOFDEATH:renalfailure,depressionofheart,colitisandstarvation.
Incaseofphenylmercuricacetate:CNScauseofdeath.

36. PHASE 2:
If death is not rapid, or the patient survives, second phase begins.
Glossitisand ulcerative gingivitis-24 to 36 hours.
Severe infection
Loosening of teeth and necrosis of the jaw-2 to 3 days
Renal tubules shows necrosis, polyuria, albuminuria, uraemiaand acidosis-Nephrotoxicity
of mercury.
Recovery may occur-10 to14 days.
After many days, membranous colitis develops and produces dysentery, ulceration of
colonic mucosa and hemorrhage.

37. Parenteral injection
The signs and symptoms start immediately after i.v.drip.
Intramuscular:abscess with ulceration.
Intravenous:
MERCURALISM -thrombophlebitis, granuloma formation,
pulmonary embolism and repeated hemoptysis is seen.
Wheninjectedintravenously,itproducesdyspnea,cyanosis,hypotensionand
convulsions,deathmaybeduetoananaphylacticshockorventricularfibrillation.
DEATHmayberapidduetoanaphylacticreaction.
After1-3days-renaltubularnecrosisl/tpolyuria,albuminuria,uremiaandacidosis
andinGITmembranouscolitisl/tdysenterymaydevelop.

38. Diagnosis:
F.D.
0.5 gm -4 gm of mercuric chloride,
10-60 mg/kg of methyl mercury
10 mg/ m
3
of Hg vapor.
F.P. : 12 hours to 7 days-ingestion
Rapid death: with I.V. mercurial diuretics
Blood Hg level -< 3.6 µg/L
Urine Hg level-<15 µg/L
24 hrurine excretion should be <50 µg/dl.
Assessed by atomic absorption spectrophotometer.
Symptoms develop with blood and urine levels
exceed 20µg/L & 60µg/L
Normal

39. ORGANIC MERCURY POISONING
PHENYL MERCYRY, METHOXYMETHYL MERCURY, ETHYL MERCURY AND
METHYL MERCURY (most hazardous) are toxic.
Symptoms are mainly CNS and Nephrotoxic .
Ataxia
Dysarthria
Paresthesias
Neuropathies
Mental deterioration
chorea
High stability
Lipid solubility
High ability to penetrate the membranes
HAZARDOUS

40. Treatment: In case of Inorganic mercurial compound poisoning
Removalofpatientfromexposure
Diet:Proteinacioussubstancelikeeggalbumin,skimmedmilk,vegetableglutens,toprecipitateHg
withdemulcents.Highsulphurcontainingdiet.VitaminC.
Emetics:ipecauanha,leukewarmsodiumbicarbonatesoulution.
Gastriclavagewith250mlofsodiumformaldehydesulphoxylate
Antidote:Sodiumformaldehydesulphoxylateisthechemicalantidotethatreducestheperchlorideto
metallicmercury.
Absorbedpoison:BALorPenicillamine.
3-5mg/kg 4 hourly for 2 days.
2.5 mg/kg 6 hourly for1 day.
2.5 mg/kg twice daily according to the severity.
If colitis has developed, high colonic lavage as 1:1000 solution is to be given with 1: 1000 solution of
sulphoxylateBD.
Fordiuresis5-10%glucoseisusedinnormalsaline.

41. Treatment: In case of Organic mercurial compound poisoning
Removalofpatientfromexposure
InsteadofBal(lipidbasechelation)DMSA(Succiner)orDMPSisused(watersoluble).
Treatment: In case of Elemental mercurial compound poisoning
PosturaldrainageandETtubesuction.
Surgicalexcision-IMinj.
Environmentaldecontamination:Ifthereisspillage,adsorbonsandandpackintightly
sealedcontained.Adsorbwithcalciumpolysulphideandconvertstocinnabar(HgS)
DonotvacuumcleanHg-itcanvolatilize.

42. Postmortem Findings:
EXTERNALLY:
Bodylookemaciated.
Inflammatoryskinlesion-anaphylaxis.
INTERNALLY:
Mucousmembraneofmouth,tongue,gumsoesophagusappearnecrotic.
Stomachswollen-desquamation,inflammationandulceration.
Necrosisofmucousmembraneofintestine.
Kidneys-swollen.Heart-subendocardialpetechialhemorrhage.
Liver:centralnecrosis.
Histopathology:PCTnecrosis(kidney),neuronalnecrosis(cerebralcortexseenin
Minamatadisease).
DETECTIONofMercury:thetestingmaterialismixedwith½ofitsvol.ofconc.HCLin
atest-tube,inwhichacleancopperfoilisalreadyplacedandthetubeisheated.Ifthe
testingmaterialcontainsmercury,asilverydepositionisseenonthesurfaceofcopperfoil.

43. Chronic poisoning
OCCUPATIONAL
EXPOSURE
THERAPEUTIC
DOSE
EXTERNAL
APPLICATION IN
THE FORM OF
OINTMENT
PROLONGED
EXPOSURE WITH
SMALL DOSE

44. GINGIVITIS
&
SALIVATION
TREMORS
NEURO-
PSYCHIATRIC
CHANGES
Chronic poisoning-triad

45. Chronic Mercury Poisoning/ Hydragyrism
Workers may get poisoned due to vapors or dust(OCCUPATIONAL
EXPOSURE)
External application as OINTMENT
Excessive THERAPEUTIC use of Hg.
When small doses are taken for prolonged time or used as ointment for long period.
Clinical picture are different in Inorganic and Organic mercury poisoning.
The signs and symptoms of chronic mercury start at a blood level 100 mg/ml.
Patient is symptomatic at daily urinary excretion more than 300 mg/ml

46. SIGNS AND SYMPTOMS
1. GENERAL
•Anemia
•Anorexia
•Loss of weight
•Inflammation of gums, foul smelling breath
•BLUE LINE at the junction of teeth and gums. (copper)
•Loosening of teeth, necrosis of jaw
•GIT disturbances
•Chronic nephritis
2. PTYALISM: excessive salivation also seen in Antimony,
Arsenic and Copper poisoning.
•Painful salivary glands

47. 3. Mercurialentisis a peculiar eye
change in chronic mercury poisoning
due to deposition of mercury through
the cornea on to the anterior lens
capsule.
•A brownish reflex from the anterior lens capsule
of both the eyes is seen when observed in slit
lamp in person exposed to mercury vapors for
some years.
•It is bilateral and has no effect on the visual
acuity.

48. 4. DANBURY TREMORS/ MAD HATTER’S SHAKE /
Mercurial tremors / Hatter’s shake or glass blower’s
shake)/ Tetanus mercuralis
•These are moderately coarse tremors interspersed by jerky movements
starting from hands than to the lips and tongue and finally involves arms
and legs.
•Common in persons working in glass -blowing and hat factories.
•These are detected early in the writing.
•The patient then becomes unable to dress himself and at the last stage
(severe form) known as CONCUSSIO MERCURIALIS , the tremors are so
intense that the patient cannot perform daily activities.
•These are excited by voluntary movements and are absent during sleep.
•D/d: These are interspersed with jerky movements, incoordination of
movements, increased deep reflexes, paresis of limbs and peripheral neuritis.
The tremors should be differentiated from thyrotoxicosis in which there is
presence of fine tremors, exophthalmos, raised pulse and goiter.

49. Handwriting of a MercurialisTremors
patient

51. 5. Mental symptoms: (MERCURIAL
ERETHISM):includes the psychological
effects of mercury poisoning.
•Seen in the person working in mirror
manufacturing factory.
•Anxiety, restlessness, irritability, insomnia,
emotional liability, difficulty concentrating, and
impaired memory.
•Feature of insanity such as shyness, timidity,
irritability, loss of confidence, mental depression,
loss of memory, insomnia, hallucinations and
delusion develop in the workers.
•Sometimes suicidal, melancholia or manic
depressive psychosis (Mad hatter) develops.

52. 6. ACRODYNIA (PINK
DISEASE):-
•There is generalized rashes over the body.
•It is an Idiosyncratic hypersensitivity
reaction particularly seen in children.
•This results from chronic exposure to
mercury in any forms.
•Onset is insidious.
•Hands and feet become puffy, pinkish,
painful, paraestheticwith peeling skin rash
and photophobia.
•Erythematous, eczematous (watery and
weeping) papulartype of skin lesion
•Mostly in the hands and feet accompanied
with thickening of skin are produced.
•Teeth may be shed.

53. A man working in hat manufacture with no protective equipment, putting him at risk for
mercury poisoning

54. History: Mad hatter disease, or mad hatter syndrome
Especially in the 19th century, inorganic mercury in the form of mercuric nitrate was commonly used in
the production of feltfor hats.
During a process called carroting, in which furs from small animals such as rabbits, hares or beavers
were separated from their skins and matted together, an orange-coloredsolution containing mercuric
nitrate was used as a smoothing agent.
The resulting felt was then repeatedly shaped into large cones, shrunk in boiling water and dried.
In treated felts, a slow reaction released volatile free mercury.
Hatters (or milliners) who came into contact with vapours from the impregnated felt often worked in
confined areas.

55. Some of the steps in the manufacture of felt hats are illustrated in this image
from 1858.

57. MinamataDisease
Chronicmercuryintoxicationduetoconsumptionofcontaminatedfish.
Symptoms:disturbanceinhandco-ordination,gaitandspeech,chewingandswallowing
difficulty,tremors,rigidity,seizuresandcloudingofconsciousness.

58. Treatment:
Removal of the individual from the source of exposure
Demulcents
Saline purgatives
High Sulphurcontaining food, meat, eggs, legumes
Plenty of milk should be given
Mouth wash by borax, oral hygiene
Vitamin C
Saline purgative to be given
Chelation therapy: D-pencillamine
Periodic medical checkup for workers

59. Precautions for reducing exposure
Increasing protection of sensitive populations, such as
pregnant women;
Providing technical and financial support to developing
countries and to countries with economies in transition;
and
Supporting increased research, monitoring and data-
collection on the health and environmental aspects of
mercury

60. Medicolegal Aspects/ Circumstances of Poisoning
Homicidal and suicidal poisoning is rare
ACCIDENTAL: COMMON
Mercuric chloride causes accidental poisoning when it is widely used as,
disinfectant and antiseptic, contraceptive vaginal, rectal tablets, for anti-
syphilitic treatment. IV administration of organic mercurial or diuretics.
Sometimes it is introduced in vagina as a contraceptive or producing
abortion.-DOUCHE
CHILDREN: accidental poisoning occurs. Bleaching cream, swallowing the
sulphocyanideof mercury stick or tablet popularly known as Pharoah’s
serpents.

61. Medicolegal Aspects/ Circumstances of Poisoning
Inindustrialworkers, chronic poisoning may occur due to
inhalation or mercurial vapours.
It crosses the placental barrier and can cause death of foetusor
anomalies.
Mercury is not a constituent of human body, hence it presence
indicates that it must have been introduced into the system.
5-150 mg/ 100gm is normally present in the tissues like kidney
and liver.

62. MERCURIUS SOLUBILIS
Quicksilver
(MERCURIUS -HYDRARGYRUM)
Every organ and tissue of the body is more or less affected by this powerful drug; it transforms
healthy cells into decrepit, inflamed and necrotic wrecks, decomposes the blood, producing a
profound anemia. This malignant medicinal force is converted into useful life saving and life
preserving service if employed homeopathically, guided by its clear cut symptoms.
Glands
Tremorseverywhere.
Weakness with ebullitions and trembling from least exertion
worse during perspiration
A human "thermometer“
Breath, excretions and body smell foul

64. thanks