Clinical Spectrum of Mercury Poisoning in India: Case-series from a Poison Control Center

Background: Mercury is a naturally occurring heavy metal that finds wide application in industrial and household settings. It exists in three chemical forms which include elemental (Hg0 ), inorganic mercurous (Hg+) or mercuric (Hg++) salts, and organic compounds. All forms are highly toxic, particularly to the nervous, gastrointestinal, and renal systems. Common circumstances of exposure include recreational substance use, suicide or homicide attempts, occupational hazards, traditional medicines, and endemic food ingestions as witnessed in the public health disasters in Minamata Bay, Japan and in Iraq. Poisoning can result in death or long-term disabilities. Clinical manifestations vary with chemical form, dose, rate, and route of exposure. Aims and objectives: To summarize the incidence of mercury poisoning encountered at an Indian Poison Center and use three cases to highlight the marked variations observed in clinical manifestations and long-term outcomes among poisoned patients based on differences in chemical forms and routes of exposure to mercury. Materials and methods: A structured retrospective review of the enquiry-database of the Poison Information Center and medical records of patients admitted between August 2019 and August 2021 in a tertiary care referral center was performed. All patients with reported exposure to mercury were identified. We analyzed clinical data and laboratory investigations which included heavy metal (arsenic, mercury, and lead) estimation in whole blood and urine samples. Additionally, selected patients were screened for serum voltage-gated potassium ion channels (VGKC)— contactin-associated protein-like 2 (CASPR2) antibodies. Three cases with a classical presentation were selected for detailed case description. Results: Twenty-two cases were identified between August 2019 and August 2021. Twenty (91%) were acute exposures while two (9%) were chronic. Of these, three representative cases have been discussed in detail. Case 1 is a 3.5-year-old girl who was brought to the emergency department with suspected elemental-mercury ingestion after biting a thermometer. Clinical examination was unremarkable. Chest and abdominal radiography revealed radiodense material in the stomach. Subsequent serial radiographs documented distal intestinal transit of the radiodense material. The child remained asymptomatic. This case exemplifies the largely nontoxic nature of elemental mercury ingestion as it is usually not absorbed from the gastrointestinal tract. Case 2 is a 27-year-old lady who presented with multiple linear nodules over both upper limbs after receiving a red intravenous injection for anemia. Imaging revealed metallic-density deposits in viscera and bones. Nodular biopsy was suggestive of mercury granulomas. A 24-hour urine mercury levels were elevated. She was advised chelation therapy with oral dimercaptosuccinic acid (DMSA). Case 3 is a 22-year-old lady who presented with acrodynia, neuromyotonia, tremulousness, postural giddiness, tachycardia, and hypertension for 2 months, associated with intractable, diffuse burning pain over the buttocks and both lower limbs, 1 month after completing a 3-week course of traditional medications for polycystic ovarian syndrome. A 24-hour urine normetanephrine levels and mercury levels were markedly elevated. Serum anti-VGKC antibodies were present. She was treated with glucocorticoids and oral DMSA with a favorable clinical response. Conclusions: The clinical manifestations of mercury toxicity are highly variable depending on the source, form, and route of mercury exposure and are related to its toxicokinetics.

The health situation in Jammu and Kashmir: What is the obligation of health professionals?

We are witness today to a democratic country violating multiple rights of an entire state of its own citizens. Starting from August 5, 2019, it is now over two months that the state of Jammu and Kashmir has been under a lockdown, and there was also a communication blockade. Initially all modes of communication – landline telephones, cellphones and the internet were blocked, and there were severe physical restrictions on the movement of civilians, with concertina wire barricades manned by soldiers every few metres. The Central Government put these measures in place along with thousands of additional troops brought into the state, in addition to the troops already deployed there, as it abrogated Article 370 and 35A of the Indian Constitution, and downgraded the state into two union territories.

Critical perspectives on the NIMH initiative “Grand Challenges to Global Mental Health”.

In July 2011 Nature carried a Comment titled “Grand Challenges to Global Mental Health”announcing research priorities to benefit people with mental illness around the world. The essay called for urgent action and investment. However, many professionals, academics, and service user advocate organisations were concerned about the assumptions embedded in the approaches advocated and the potential for the project to do more harm than good as a result. Nature refused to print a letter (sent on 20th August 2011) protesting against the issue, citing ‘lack of space’ as the reason. This letter is an effort to critique the initiative through wide participation and consensus

Aetiology of prolonged fever in antiretroviral-naïve human immunodeficiency virus-infected adults.

BACKGROUND: Prolonged fever is a common symptom among human immunodeficiency virus (HIV) infected individuals, and is usually due to a cause that is easily treatable. Limited data are available regarding the causes of fever in HIV-infected Indian patients. In this paper, we have profiled the causes of prolonged fever in a cohort of HIV-infected Indian patients and have developed suitable algorithms to assist in an early diagnosis. METHODS: From February 1997 to October 1998 (20 months), 100 HIV-infected patients (age > 12 years) were evaluated for 100 episodes of prolonged fever (fever > 100 degrees F for more than 2 weeks in outpatients and > 3 days in inpatients). Patients with terminal acquired immunodeficiency syndrome (AIDS) were excluded. Patients were evaluated on the basis of the symptoms associated with prolonged fever and investigated according to pre-existing algorithms. RESULTS: Among such episodes of fever, infection was the major cause and included tuberculosis, especially the extra-pulmonary and disseminated forms (69%), cryptococcosis (10%) and Pneumocystis carinii pneumonia (7%). Other causes included bacterial pneumonia, amoebic liver abscess, disseminated histoplasmosis and cerebral toxoplasmosis. Patients were naïve for antiretroviral therapy and did not receive prophylaxis for opportunistic infections. The diagnostic yield of ultrasound of the abdomen (85%), fine-needle aspiration cytology of enlarged lymph nodes (75.6%) and bone marrow trephine biopsy (41.6%) were found to be high in our study. CONCLUSIONS: Tuberculosis is the commonest cause of prolonged fever in HIV-infected adults in India. Non-infectious causes were not seen in this series. We have suggested an algorithmic approach for establishing the cause of fever in these patients. In situations where laboratory evaluation does not reveal a cause for prolonged fever, a therapeutic trial with antituberculous therapy in selected patients is justified.