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556 Arch Dis Child 1999;80:556–557

Mercury intoxication presenting with Arch Dis Child: first published as 10.1136/adc.80.6.556 on 1 June 1999. Downloaded from and

Willi Wöâmann, Martina Kohl, Gunnar Grüning, Peter Bucsky

Abstract excess but without cutaneous lesions or a An 11 year old girl presented with hyper- history of exposure to . tension and tachycardia. Excess urinary excretion suggested phaeo- Case report chromocytoma but imaging studies failed A Taiwanese girl was admitted to our institution to demonstrate a tumour. Other symp- because of hypertension (160/120 mm Hg) and toms included and weight loss, tachycardia (120 beats/min). She had suVered and she was found to have a raised from painful itching in her extremities but this concentration of mercury in blood and had resolved before admission. Oscillometric urine. Mercury intoxication should be 24 hour blood pressure monitoring revealed considered in the diVerential diagnosis of severe hypertension without nocturnal dipping hypertension with tachycardia even in (fig 1). Exposure to drugs and toxins was patients presenting without the skin le- denied, and there was no family history of sions typical of mercury intoxication and hypertension or malignant disease. Laboratory without a history of exposure. values showed normal thyroid and func- (Arch Dis Child 1999;80:556–557) tion. Urinary concentrations of vanillylman- delic acid (VMA) were slightly raised (5.6–5.8 Keywords: hypertension; tachycardia; mercury nmol/µmol creatinine; normal < 4.7); homova- poisoning; phaeochromocytoma nillic acid (HMA) was within the normal range. Investigations including abdominal and cervical ultrasound, computed tomography scans, and The diVerential diagnosis of hypertension, an M-iodobenzylguanidine scan did not reveal a tachycardia, weight loss, and psychiatric symp- tumour. She was treated with enalapril. After toms includes thyrotoxicosis, drugs—for exam- failing to attend for follow up, she presented two ple, cocaine, and catecholamine excess. The lat- months later with insomnia, depression, day- Department of ter can be caused by a catecholamine producing Paediatrics, Medical time fatigue, and loss of 12 kg body weight (ini- University of Luebeck, tumour—usually a phaeochromocytoma—or by tial body weight was 36 kg). On examination, 23538 Luebeck, mercury intoxication. A careful history and she could barely stand because of weakness and http://adc.bmj.com/ Germany clinical examination usually provides suYcient ataxia. She was irritable and remained hyper- WWöâmann evidence to distinguish between acrodynia and tensive despite medication. Nerve conduction M Kohl velocity of the peroneal and median nerves was G Grüning phaeochromocytoma. Acrodynia may be an P Bucsky appropriate diagnosis if a toddler shows charac- reduced and a cerebral magnetic resonance teristic skin manifestations and there is an obvi- imaging scan showed no abnormality. Again, Correspondence to: ous source of intoxication. This can be con- catecholamine concentrations (noradrenaline Dr Willi Wöâmann, (norepinephrine), dopamine, and VMA were Department of Paediatrics, firmed by the demonstration of increased on September 26, 2021 by guest. Protected copyright. Justus-Liebig-University, mercury concentrations in blood and urine.1–3 slightly raised. A screen for heavy metals was Feulgenstrasse 12, 35392 We report a case of an 11 year old girl with performed despite no history of exposure. The Giessen, Germany. mercury intoxication who presented with blood and urine of the patient (but not of her parents and younger sister) showed very high Accepted 19 January 1999 hypertension, tachycardia and catecholamine mercury concentrations (blood 20 µg/l, normal 160 160 for adults < 10; urine 217 µg/l, normal for Systolic adults < 20). Direct questioning did not reveal any obvious sources of mercury intoxication 140 140 such as recreational use, presence of a broken thermometer or use of old ointments or 120 Heart rate 120 Chinese cups during the last year. During treatment with D-penicillamine, mercury con- centrations returned to normal. At four 100 100 Diastolic month’s follow up her heart rate and blood pressure (without medication) were normal. 80 80 She gained weight, and ataxia resolved slowly over one year.

95th blood pressure centile Heart rate (beats/min) Blood pressure (mm Hg) 60 (120/76 mm Hg) 60 Discussion A catecholamine producing tumour is not the 40 40 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 6 7 8 9 10 11 12 13 only condition that causes hypertension and Time (hour) tachycardia as well as increased catecholamine Figure 1 Mean hourly systolic and diastolic blood pressure and heart rate of the patient at concentrations. In inorganic mercury poison- presentation by oscillometric 24 hour blood pressure monitoring. ing, the metal combines with the sulphydryl Mercury intoxication presenting with hypertension and tachycardia 557

group of S-adenosylmethionine, which acts further causes of intoxication.4 In this case, no as a cofactor for catecholamine-O- source could be found even after repeated Arch Dis Child: first published as 10.1136/adc.80.6.556 on 1 June 1999. Downloaded from methyltransferase (COMT). COMT inhibi- questioning of family members. We considered tion leads to accumulation of , exposure at home to be unlikely as the family of typically noradrenaline, (epine- our patient live together in a small apartment. phrine), and dopamine, and to a lesser degree Her parents and sister excreted only traces of VMA, but not usually HVA.24 The sympa- the heavy metal and we did not test the thetic overactivity explains the haemodynamic mercury levels in her home. A Chinese symptoms of acrodynia. Curiously, in our medicine containing a metal substance had patient, VMA was the catecholamine most been given to the girl, but was found to contain predominantly excreted. It is usual for mer- only traces of mercury. The child was, cury intoxication to show a much lesser degree therefore, placed under constant surveillance. of catecholamine excess than would normally Repeated psychological evaluation of both par- be expected in a phaeochromocytoma or neu- ents and children did not indicate child abuse, roblastoma. but this cannot be excluded. Clinical signs of the fully developed form of It is not known how many transient unex- acrodynia include pronounced mental changes plained hypertensive episodes in children such as insomnia and irritability, in the might be caused by mercury intoxication. Even extremities, typical skin lesions (hence the though acrodynia is rare, its diagnosis can be nickname “pink disease”), profuse sweating, made by a single urine analysis and, therefore, and anorexia as well as hypertension and acrodynia should be excluded before expensive tachycardia.5 Uncharacteristically, our patient and invasive procedures are performed to did not have even a transitory rash and was not discount phaeochromocytoma as the cause of sweating excessively. However, the symptoms. and pink palms and soles are unusual in children beyond toddler age because of in- 1 Velzeboer SCJM, Frenkel J, de WolV FA. A hypertensive creased skin thickness. toddler. Lancet 1997;349:1810. 2 Baudouin V, Bocquet N, Rybojad M, et al. Clinical quiz. Since mercury has been excluded from Pediatr Nephrol 1997;11:263–4. teething powders and ointments, inhalation of 3 Von Muehlendahl KE. Intoxication from mercury spilt on carpets. Lancet 1990;336:1578. mercury from broken thermometers has ac- 4 Henningsson C, HoVmann S, McGonigle L, Winter JSD. counted for most described poisonings in Acute (acrodynia) mimicking phaeo- toddlers,1–3 and recreational use and inorganic chromocytoma in an adolescent. J Pediatr 1993;122:252–3. 5 Warkany J. Acrodynia–postmortem of a disease. Am J Dis mercury warming have been suggested as Child 1966;112:147–56. http://adc.bmj.com/ on September 26, 2021 by guest. Protected copyright.