A Mercury Toxicity Case Complicated byMatthew HyponatremiaCarter, DO, a Abdul Abdi, MD, a Fareeha Naz, MD, and a Farouq Thabet, Abnormal MD, a Arpita Vyas, MDa, b Endocrinological Test Resultsabstract Mercury (Hg) poisoning is considered a rare disease by the National Institutes of Health and the diagnosis can present great challenges to clinicians.‍ Children who are exposed to Hg can present with a wide variety of symptoms, including acrodynia, tremor, excessive salivation, aDepartment of Pediatrics and Human Development, and psychiatric symptoms, including insomnia.‍ However, endocrinologic College of Human Medicine, Michigan State University, East manifestations from Hg exposure are less well known.‍ This is a case report Lansing, Michigan bDepartment of Pediatrics, Texas Tech University, Odessa, Texas of a 12-year-old boy who presented with body rash, irritability, insomnia, and profuse sweating after returning from a summer camp.‍ The child was Dr Abdi was involved in the direct care of this patient and helped to draft the initial report, initially managed in the outpatient setting, and the investigation was mainly including literature reviews; Dr Carter was involved targeted toward infectious etiology, including Rocky Mountain spotted fever in the direct care of this patient, helped review and Lyme disease.‍ He was eventually admitted to the hospital with altered and edit the manuscript to its final copy, and was mental status and was noted to have hyponatremia with serum sodium of involved in literature reviews and submission of the report; Dr Naz was an attending physician involved 121 mEq/L.‍ Thyroid studies also revealed elevated free thyroxine levels in the patient’s care, and assisted with supervision in the presence of normal triiodothyronine and thyrotropin.‍ The patient of the project and in review of the manuscript; developed hypertension and tachycardia, and was found to have elevated Dr Thabet was involved in the direct care of this patient and helped to draft the initial report; Dr 24-hour vanillylmandelic acid and metanephrines.‍ Finally, heavy metal Vyas was the attending endocrinologist involved in measurements revealed a blood Hg level that was greater than the reference the patient’s care, coordinated and supervised the values of 0 to 9 ng/mL.‍ Chelation treatment with 2, 3-dimercaptopropane- project, and critically reviewed the report; and all authors approved the final manuscript as submitted 1-sulfonate was subsequently initiated and over a period of 8 months his and agree to be accountable for all aspects of the symptoms resolved and his thyroid function test returned to normal.‍ This work. case highlights some of the challenges commonly encountered in identifying DOI: https:// doi. org/ 10. 1542/ peds. 2016- 1402 Hg exposure.‍ More importantly, it illustrates that exposure to Hg should Accepted for publication Jan 10, 2017 be considered in children who present with the symptoms and abnormal Address correspondence to Arpita Vyas, MD, endocrinologic test results described in this report.‍ Department of Pediatrics, Texas Tech University, 701 W 5th St, Odessa, TX 79763. E-mail: arpita.vyas@ ttuhsc.edu Mercury (Hg) exposure can occur in occur in its vapor form, which, if PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). many ways, including contaminated inhaled, can result in toxic effects food, water, dental amalgams, disk on various tissues, as up to 80% Copyright © 2017 by the American Academy of Pediatrics batteries, inhalation of vapors from of metallic Hg vapor is absorbed 4 FINANCIAL DISCLOSURE: The authors have gold-mining activities, environmental from the lungs into the blood.‍ indicated they have no financial relationships accidents, and historically in laxatives1, 2 Clinical manifestations of metallic relevant to this article to disclose. and diaper and teething powders.‍ Hg vapor exposure can be diverse, FUNDING: No external funding. Thus, a thorough review of exposure including intention tremors, excessive pathways is necessary when Hg salivation, insomnia, body rash, To cite: Carter M, Abdi A, Naz F, et al. A Mercury exposure is suspected.‍ Metallic and mood and behavioral changes.‍ Toxicity Case Complicated by Hyponatremia Hg is a silver-white liquid at room Several body systems can be affected, and Abnormal Endocrinological Test Results. Pediatrics. 2017;140(2):e20161402 temperature and is present in various3 including the central nervous system, commercially available products.‍ cardiovascular system, kidneys,1, 5, 6lungs, Human exposure to metallic Hg can and the gastrointestinal tract.‍ The Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 2, August 2017:e20161402 CASE REPORT 120 – 125 156 100 toxicological effects of heavy metals, receiving 3% hypertonic saline.‍ Pulse, 60 Beats per Min including Hg, are more devastating in Initial blood work was suggestive the pediatric population, with respect of hyponatremia, secondary to to the developing central7 nervous the syndrome of inappropriate system in particular.‍ Furthermore, antidiuretic hormone.‍ Brain imaging Height 144/93 113/73 102/58 the endocrinologic manifestations studies, including MRI, were normal <123/<78 mm Hg for Sex/Age/ Blood Pressure, from Hg exposure are less known, with the exception of pars intermedia and abnormal laboratory test results cyst in the pituitary area.‍ During may further distract the clinician his 2.‍5-week hospitalization, his e from making a prompt diagnosis.‍ symptoms progressed to include 9.9 11 10.3 mg/g Cr VMA, <7.0 This case report highlights the effects episodes of syncope, tachycardia, of Hg exposure on systemic hormonal hypertension, disinhibited behavior, milieu, including perturbation of and muscle fasciculation.‍ Thyroid g/24 h e thyroid hormone and catecholamine blood test results showed elevated μ 212 244 177 levels, together with sodium free thyroxine (T4) and intermittently 221 – imbalance.‍ high total T4, with normal free 69 Metanephrines, triiodothyronine (T3) and thyrotropin PATIENT PRESENTATION levels.‍ Thyroid-binding globulin, thyroid-stimulating immunoglobulin, 6 — 112 Range thyroid anti-microsomal antibody, and Reference Established Urine Hg, No anti-thyroglobulin antibody studies A 12-year-old boy with no significant – 9 past medical history presented were normal.‍ Elevated nore pinephrine – in the late summer to an urgent 991 pg/mL8 (reference range 70 750 <1 care clinic after developing an pg/mL) and dopamine 39 pg/mL8 ng/mL erythematous macular rash involving (reference range <30 pg/mL) Serum Hg, 0 ’ the palms and scalp hairline, muscle were noted.‍ These laboratories twitching, irritability, insomnia, and and the patient s tachycardia, 178 – — profuse sweating.‍ He had recently hypertension, profuse sweating, and ng/dL 87 Total T3, returned from a summer camp in anxiety prompted investigation for the midwestern United States where possible pheochromocytoma and d 1.37 – his symptoms had begun.‍ Over the paraneoplastic syndrome.‍ Full-body ng/dL Free T4, 0.61 course of a month, he clinically imaging was essentially normal, with decompensated with increasing the exception of a fine nodular pattern 4.01 – fatigue, headaches, poor sleep, in the left middle lung.‍ These findings 1.29 0.90 IU/mL μ 0.35 muscle twitching, and more frequent resolved on follow-up computed Thyrotropin, syncopal episodes, in addition to other tomography.‍ A fungal serology panel symptoms.‍ There were no known was normal.‍ The patient also had 1200 – — 161774 1.03 1.16 2.24 1.68 140 102 13 17 elevated 24-hour vanillylmandelic Urine sick contacts or fever, and history 9.5 months after symptom onset. 1 month after symptom onset. ∼ ∼ 250 mOsm/kg Osmolality, reated for Suspected Hg Poisoning did not reveal any known exposures, acid and metanephrines; serum ingestions, or intoxications.‍ The norepinephrine and dopamine levels patient was initially managed as an remained elevated.‍ His hyponatremia 295 – outpatient, with the investigation resolved with daily fluid restriction — Serum 280 mOsm/kg focused on ruling out infectious of 1500 mL/d.‍ Inductively coupled Osmolality, etiologies, including Rocky Mountain plasma-optical emission spectroscopy spotted fever and Lyme disease.‍ He revealed an elevated blood Hg level of 4.5 – K, was treated with a 10-day course of 13 ng/mL, greater than the reference mEq/L 8 3.5 , no value. 2.5 months after symptom onset. DMPS used for chelation therapy,5 mg/kg 3 times a day for 2 weeks. — ∼ doxycycline, but continued to worsen values of 0 to 9 ng/mL.‍ This level was clinically.‍ Without improvement, inaccurately deemed insignificant by 145 – Na, 121140141 3.4 3.5 3.7 250 286 the patient presented to a local toxicology during his admission due to mEq/L 135 emergency department and was found minimal elevation.‍ Laboratory and Vital Sign Values of a Child T to have serum sodium level of 121 c a b 3 1 2 mEq/L, potassium of 3.‍4 mEq/L, serum After discharge of the patient, Before chelation therapy, Free T4 level was obtained 3 months after the treatment started. Initial laboratory samples were collected over a 2-week course, Checked 10 days after starting DMPS. Laboratory samples collected 7 months after chelation therapy, osmolality of 250 mOsm/kg, and urine further toxicological consultation TABLE 1 Laboratory, Reference Range VMA, vanillylmandelic acid. a b c d e osmolality of 161 mOsm/kg (Table 1).‍ resulted in a full investigation.‍ As He was transferred to our PICU after the local health department