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Potentially life-threatening emergency
Arsenic poisoning - Nail and Distal Digit
See also in: Overview
Other Resources UpToDate PubMed
Potentially life-threatening emergency

Arsenic poisoning - Nail and Distal Digit

See also in: Overview
Contributors: Shari Lipner MD, PhD, Susan Burgin MD, Bertrand Richert MD, Robert Baran MD
Other Resources UpToDate PubMed

Synopsis

Arsenic is a ubiquitous natural element and is the most common source of heavy metal poisoning in the world. It lacks odor, taste, and color and can result in both acute and chronic toxicity in humans accidentally, intentionally (suicide or crime), environmentally, or occupationally. Intoxication may result from ingestion or inhalation. The lethal dose in humans is 120-200 mg.

Environmental intoxication occurs mostly in rural settings. Pesticides, fungicides, and insecticides may contain arsenic (copper acetoarsenite, calcium, or lead arsenite). Surface soils and ground drinking water can contain high levels of arsenic. The use of plywood containing a chromium-copper-arsenate treatment could lead to intoxication. Occupational exposure is seen in workers in the mining, smelting, and glassmaking industries.

Arsenic in paste form was used to treat ulcers in the days of Aristotle and Hippocrates. It was used in the United States in 1850 to treat psoriasis, lichen planus, and syphilis.

The characteristic nail findings are transverse white bands called Aldrich-Mees' lines or Mees' lines. They are due to abnormal nail plate keratinization secondary to temporary injury to the nail matrix. They are apparent approximately 2 months after arsenic poisoning and are located 3-4 mm distal to the nail fold. Mees' lines may also be associated with systemic disease (eg, kidney disease, congestive heart failure), medications, including chemotherapeutic agents and sulfonamides, thallium, and severe stress. Mees' lines are most commonly due to arsenic toxicity.

Systemic signs and symptoms of acute poisoning (more likely accidental / intentional ingestion) include mucosal erosions, nausea, vomiting, abdominal pain, diarrhea, seizures, dermatitis (often exfoliative), edema of the face and eyelids associated with pruritus, hair loss, hyperpyrexia, jaundice, dark urine, acute renal failure, and coma. Death may occur.

Signs and symptoms of chronic poisoning (more likely environmental / occupational ingestion) include nausea, vomiting, anorexia, weight loss, "raindrop" hypomelanosis, hyperkeratosis punctata (arsenical keratoses of the palms and soles), cutaneous neoplasms (basal cell carcinomas, Bowen disease; often multiple, and commonly in areas of the skin without sun exposure), sensory motor distal neuropathy, liver failure, renal failure, and encephalopathy.

The use of "exotic medicines" (Chinese herbal medicine, aphrodisiacs) is a risk factor for arsenic poisoning. Acute arsenic poisoning may occur over a period of days to weeks. Chronic arsenic poisoning may occur over a period of months to years. Arsenic poisoning is most common in adults. Accidental and environmental exposure occurs equally in both sexes; however, occupational exposure is more common in men.

Codes

ICD10CM:
T57.0X1A – Toxic effect of arsenic and its compounds, accidental (unintentional), initial encounter

SNOMEDCT:
767146004 – Toxic effect of arsenic and its compounds

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed:10/10/2019
Last Updated:10/29/2019
Copyright © 2021 VisualDx®. All rights reserved.
Potentially life-threatening emergency
Arsenic poisoning - Nail and Distal Digit
See also in: Overview
Arsenic poisoning (Chronic) : Nausea/vomiting, Hyperpigmented patch, Mees lines, Peripheral neuropathy, Anorexia
Clinical image of Arsenic poisoning
Transverse white bands involving the fingernails. Arsenic exposure occurred 2 and 3 months before presentation (proximal and distal bands, respectively).
Copyright © 2021 VisualDx®. All rights reserved.