Pink Ladies: Mercury Poisoning in Twin Girls

PRACTICE C LINICAL V ISTAS

Pink ladies: mercury poisoning in twin girls

reviously well, developmentally nor- Pmal 20-month-old twin girls pre- sented with weakness, anorexia, a papular rash and increasingly swollen, red and painful hands and feet of 1 month’s dura- tion. They had no history of fever, con- junctivitis, lymphadenopathy or oral changes characteristic of Kawasaki disease. The children appeared irritable and unwell and were diaphoretic but afebrile. Both had tachycardia, and one had an el- evated blood pressure of 130/90 mm Hg

(95th percentile for age 108/62 mm Hg). Images courtesy Dr. Michael Weinstein Both children had reduced muscle power and diminished reflexes. Their dusky pink discolouration, swelling, agement of mercury poisoning is eli- palms and soles were erythematous and paresthesia and desquamation of the minating the source of exposure. The indurated with desquamation, judged to hands and feet. Symptoms of cate- effectiveness of chelation therapy in re- be acrodynia (Figs.1 and 2). cholamine excess such as sweating and versing symptoms is not entirely clear.9 Mercury toxicity was suspected, and hypertension occur because mercury Our case stresses the potential harm further questionning revealed that the blocks the degradation pathway of cate- of mercury. It reminds us to think of a infants had been given a mercury- cholamines. Other manifestations of toxic exposure when family members containing “teething powder” from India mercury toxicity include renal dysfunc- present with the same unusual constella- once or twice a week over the 4 preced- tion, peripheral neuropathy and neuro- tion of symptoms. It also highlights the ing months. The girls’ blood mercury psychiatric symptoms (e.g., emotional common misconception that all alterna- levels were 176 and 209 (normally < 18) lability, memory impairment and in- tive medicines are safe and benign.10 µmol/L. Chelation therapy with 2,3- somnia). Although calomel-containing dimercaptosuccinic acid was adminis- compounds are banned in North Amer- Michael Weinstein tered through nasogastric tubes. Before ica, they are still used in other parts of Stacey Bernstein admission the twins had regressed devel- the world such as Southeast Asia, and Department of Pediatrics opmentally and were unable to feed calomel can also be found in various al- Hospital for Sick Children orally, sit or walk. Over the 8 weeks in ternative medicine products.5 Toronto, Ont. hospital they showed some minor neuro- Clinical presentations suggestive of cognitive improvements, but their long- pheochromocytoma (e.g., excessive References term prognosis is uncertain. sweating, tachycardia and hypertension) 1. Wooltorton E. Facts on mercury and fish con- or of Kawasaki disease but not meeting sumption. CMAJ 2002;167(8):897. 2. Exposure to thimersal in vaccines used in Can- 6 the full criteria should also prompt adian infant immunization programs, with re- Mercury exists in inorganic and organic consideration of mercury toxicity. Al- spect to risk of neurodevelopmental disorders. Can Commun Dis Rep 2002;28(9):69-80. forms. Organic mercury has recently re- though rash, oral mucosa and extremity 3. Ozuah PO. Mercury poisoning. Curr Probl Pedi- ceived attention because of the accumu- changes are features of both Kawasaki atr 2000;30(3):91-9. 4. Dally A. The rise and fall of pink disease. Soc lation of methylmercury in some preda- disease and mercury toxicity, patients Hist Med 1997;10(2):291-304. tory fish1 and the use of thimerosal as a with the latter do not have a fever. Rash 5. Chopra A, Doiphode VV. Ayurvedic medicine: 2 core concept, therapeutic principles, and current preservative in some vaccines. A type of and extremity changes are not features relevance. Med Clin North Am 2002;86(1):75-89. inorganic mercury known as calomel of pheochromocytoma. The peeling of 6. Han RK, Sinclair B, Newman A, Silverman ED, (“sweet mercury”) was once commonly the skin on the extremities seen in cases Taylor GW, Walsh P, et al. Recognition and management of Kawasaki disease. CMAJ 2000; used to treat many ailments, including of Kawasaki disease often occurs 1–3 162(6):807-12. yellow fever, typhus and syphilis.3 Until weeks after presentation, as opposed to 7. Weir E. Methylmercury poisoning [letter]. CMAJ 2001;165(9):1194. the recognition of their toxicity in the occurring concurrently with the rash 8. Ruedy J. Methylmercury poisoning [letter]. 1940s, calomel-based teething powders and other findings in cases of mercury CMAJ 2001;165(9):1193-4. 9. Baum C. Treatment of mercury intoxication. caused a scourge of mercury poisoning poisoning. Mercury poisoning is con- Curr Opin Pediatr 1999;11:265-8. called “pink disease” or acrodynia firmed by measuring levels in blood, 10. American Academy of Pediatrics. Counseling 4 7,8 families who choose complementary and alterna- among infants and children. urine or hair samples. tive medicine for their child with chronic illness Acrodynia is characterized by a The most important step in the man- or disability. Pediatrics 2001;107(3):598-601.

CMAJ • JAN. 21, 2003; 168 (2) 201