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Acute and Chronic Arsenic Toxicity R N Ratnaike

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Acute and Chronic Arsenic Toxicity R N Ratnaike 391 REVIEW Postgrad Med J: first published as 10.1136/pmj.79.933.391 on 1 July 2003. Downloaded from Acute and chronic arsenic toxicity R N Ratnaike ............................................................................................................................. Postgrad Med J 2003;79:391–396 Arsenic toxicity is a global health problem affecting adjacent districts in West Bengal, 79.9 million and many millions of people. Contamination is caused by 42.7 million people respectively are exposed to groundwater arsenic concentrations that are arsenic from natural geological sources leaching into above the World Health Organisation maximum aquifers, contaminating drinking water and may also permissible limit of 50 µg/l.5 In both these areas, occur from mining and other industrial processes. the source of arsenic is geological in origin, contaminating aquifers which provide water for Arsenic is present as a contaminant in many traditional over one million tube wells.6–8 In West Bengal the remedies. Arsenic trioxide is now used to treat acute arsenic concentration in some tube wells is as promyelocytic leukaemia. Absorption occurs high as 3400 µg/l.9 The mechanism of arsenic accumulation in the predominantly from ingestion from the small intestine, Bengal Delta Plain is thought to have occurred though minimal absorption occurs from skin contact and during the late Quaternary age (Holocene age) inhalation. Arsenic exerts its toxicity by inactivating up with arsenic-containing alluvial sediments de- to 200 enzymes, especially those involved in cellular posited by the Ganges, Brahmaputra, Meghna, and other smaller rivers that flow across the Ben- energy pathways and DNA synthesis and repair. Acute gal Delta Plain into the Bay of Bengal.8 In the arsenic poisoning is associated initially with nausea, Bengal Delta Plain, the arsenic is adsorbed as vomiting, abdominal pain, and severe diarrhoea. arsenic oxyanions onto oxyhydroxides of iron, aluminium, and manganese and then mobilised Encephalopathy and peripheral neuropathy are in the alluvial aquifers where, due to the reducing reported. Chronic arsenic toxicity results in multisystem environment, the oxyhydroxides are dissolved by disease. Arsenic is a well documented human biogeochemical processes, releasing the arsenic into the groundwater.8 carcinogen affecting numerous organs. There are no Over the centuries, arsenic has been used for a evidence based treatment regimens to treat chronic variety of purposes. Arsenic was a constituent in arsenic poisoning but antioxidants have been cosmetics, and used more extensively than at present in agriculture to protect crops from pests. http://pmj.bmj.com/ advocated, though benefit is not proven. The focus of Arsenic as copper acetoarsenite was a pigment in management is to reduce arsenic ingestion from paints, the best known being “Paris green”. drinking water and there is increasing emphasis on Before electricity was used for illumination, using alternative supplies of water. hydrogen liberated from coal fires and from gas for lighting combined with arsenic in the Paris .......................................................................... green used in wallpaper to form arsine, a toxic gas. A fungus Scopulariopsis breviculis present in on September 28, 2021 by guest. Protected copyright. rsenic is one of the most toxic metals derived damp wallpaper also metabolised the arsenic in from the natural environment. The major Paris green to arsine. Acause of human arsenic toxicity is from In industry, arsenic is used to manufacture contamination of drinking water from natural paints, fungicides, insecticides, pesticides, herbi- geological sources rather than from mining, cides, wood preservatives, and cotton desiccants. smelting, or agricultural sources (pesticides or As it is an essential trace element for some animals, fertilisers).1 Many industrialised and less industr- arsenic is an additive in animal feed. Gallium arse- ialised countries have drinking water contami- nide or aluminium gallium arsenide crystals are nated with arsenic.23 The problem is of major components of semiconductors, light emitting concern in the USA—for example, the arsenic diodes, lasers, and a variety of transistors. content of drinking water from public and private Arsenic is a popular murder weapon. Many sources in Millard County ranges from 14 parts arsenic compounds resemble white sugar and this per billion (ppb) to 166 ppb.4 The Environment ....................... apparent innocuousness is enhanced by being Protection Agency lowered the permissible level tasteless and odourless and was publicised by of arsenic in drinking water in the USA in 2001 Correspondence to: Frank Capra’s film Arsenic and Old Lace, in which Professor Ranjit N from 50 ppb to 10 ppb. Prolonged ingestion of two elderly ladies use arsenic in elderberry wine Ratnaike, Queen Elizabeth water contaminated with arsenic may result in Hospital, Woodville, South to murder their male suitors. Australia 5011, Australia; the manifestations of toxicity in practically all ranjit.ratnaike@ systems of the body as subsequently discussed. adelaide.edu.au The most serious concern is the potential of arsenic to act as a carcinogen. ................................................. Submitted 14 November 2002 The two worst affected areas in the world are Abbreviations: AIF, apoptosis-inducing factor; Bangladesh and West Bengal, India. In 42 Accepted 31 March 2003 As2O5,/As V, arsenate; As2O3,/As III, arsenite; ppb, parts ....................... districts in southern Bangladesh and in nine per billion; ppm, parts per million www.postgradmedj.com 392 Ratnaike replication and repair, and is substituted for phosphate in high Postgrad Med J: first published as 10.1136/pmj.79.933.391 on 1 July 2003. Downloaded from Box 1: Industrial sources energy compounds such as ATP. Unbound arsenic also exerts its toxicity by generating reac- • Agricultural pesticides and herbicides. tive oxygen intermediates during their redox cycling and • Paints, fungicides, insecticides, wood preservatives, and cotton desiccants. metabolic activation processes that cause lipid peroxidation 29 • Manufacture of semiconductors, light emitting diodes, and and DNA damage. As III, especially, binds thiol or sulfhydryl components of lasers and microwave circuits. groups in tissue proteins of the liver, lungs, kidney, spleen, gastrointestinal mucosa, and keratin-rich tissues (skin, hair, and nails). Many other toxic effects due to arsenic are being HISTORICAL THERAPEUTIC USES OF ARSENIC 30 Arsenic was used as a healing agent after Greek physicians such determined and are detailed by Abernathy et al in 1999. as Hippocrates and Galen popularised its use. Arsenic com- ARSENIC EXPOSURE pounds became available as solutions, tablets, pastes, and in Arsenic exposure occurs from inhalation, absorption through injectable forms. Fowler’s solution, a 1% arsenic trioxide prepa- the skin and, primarily, by ingestion of, for example, contami- ration, was widely used during the 19th century. As recently as nated drinking water. Arsenic in food occurs as relatively non- 1958, the British Pharmaceutical and Therapeutic Products hand- toxic organic compounds (arsenobentaine and arseno- book edited by Martindale, listed the indications for Fowler’s choline). Seafood, fish, and algae are the richest organic solution as: leukaemia, skin conditions (psoriasis, dermatitis sources.31 These organic compounds cause raised arsenic levels herpetiformis, and eczema), stomatitis and gingivitis in infants, in blood but are rapidly excreted unchanged in urine.32 33 and Vincent’s angina. Fowler’s solution was also prescribed as a Arsenic intake is higher from solid foods than from liquids health tonic. Chronic arsenic intoxication from the long term including drinking water.34 35 Organic and inorganic arsenic 10 use of Fowler’s solution caused haemangiosarcoma, angiosar- compounds may enter the plant food chain from agricultural 11 12 13 coma of the liver, and nasopharyngeal carcinoma. Arsenic products or from soil irrigated with arsenic contaminated was the primary treatment for syphilis until World War II. water.36 Arsphenamine (neoarsphenamine), a light yellow compound containing 30% arsenic was used intravenously to treat syphilis, ABSORPTION yaws, and some protozoan infections. The major site of absorption is the small intestine by an elec- trogenic process involving a proton (H+) gradient.37 The CURRENT THERAPEUTIC USES OF ARSENIC optimal pH for arsenic absorption is 5.0,38 though in the milieu Arsenic trioxide (As2O3) is now widely used to induce remission of the small bowel the pH is approximately 7.0 due to pancre- in patients with acute promyelocytic leukaemia, based on its atic bicarbonate secretion.39 mechanism as an inducer of apoptosis (programmed cell death).14–18 Arsenic induces apoptosis by releasing an apoptosis- METABOLISM inducing factor (AIF) from the mitochondrial intermembrane The absorbed arsenic undergoes hepatic biomethylation to space from where it translocates to the cell nucleus.19 AIF then form monomethylarsonic acid and dimethylarsinic acid that effects apoptosis, resulting in altered nuclear biochemistry, are less toxic but not completely innocuous.40 41 About 50% of chromatin condensation, DNA fragmentation, and cell death. the ingested dose may be eliminated in the urine in three to AIF has been isolated and cloned and is a flavoprotein with a five days. Dimethylarsinic acid is the dominant urinary molecular weight of 57 000.20 metabolite
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