This document provides information on mercury poisoning, including its physical appearance, types, uses, sources of contamination, toxic dose, clinical features of acute and chronic poisoning, diagnosis, and treatment. It describes two types of mercury - mercuric and mercurous. Clinical features of acute poisoning include tremors, gastrointestinal issues, and renal failure from inhalation, ingestion, or injection. Chronic poisoning can cause neurological and psychiatric symptoms as well as kidney damage. Diagnosis involves tests of urine, blood, hair and imaging. Treatment consists of chelation therapy, supportive measures, and removal of any injected mercury.

1. MERCURY
POISONING
HEAVY METAL TOXICOLOGY

2. Clinical Features
01
02
Treatment
Introduction
Diagnosis
03
04
Physical appearance,
Sources, Uses, Fatal Dose,
Toxicokinetics
Acute Poisoning, Chronic
Poisoning
Acute Poisoning, Chronic
Poisoning
Table of contents

3. SYNONYMS:
Quick Silver, Liquid Silver.
PHYSICAL APPEARANCE:
• Elemental Mercury exists as a heavy, silvery liquid which
is non-toxic but vaporizes at room temperature to give
toxic vapours of mercuric mercury.
• In solid state, mercury is a tin-white, ductile metal that is
malleable enough to be cut with a knife.
INTRODUCTION

4. 2 TYPES
1. MERCURIC (Hg++)
● Bivalent
● Examples: Mercuric
Chloride,
Mercuric Oxide, Mercuric
Sulfide
2. MERCUROUS (Hg+)
● Monovalent
● Examples: Mercurous
Chloride (Calomel)
● More toxic
● Examples: Phenyl mercury,
Methoxymethyl mercury,
Ethyl mercury, Methyl
mercury, Mercurochrome
● Methyl mercury is the most
toxic mercury compound.
Inorganic
Salts
Organic Salts
SALTS OF
MERCURY

5. ● Barometer, Thermometer
● Ceramics
● Dry cell batteries
● Electrical appliances
(mercury switches)
● Explosives and fire works
● Felt hats
● Fluorescent and mercury
vapour lamps
● Antiseptic and Disinfectant
● Dental amalgam
● Diuretic
● Purgative
Industry
Medicine and
Dentistry
USES OF
MERCURY
● Electroplating
● Embalming
● Fabric softener
● Finger print powder
● Fungicide
● Gold and Silver extraction
● Grain preservative
● Paints
● Pesticides
● Taxidermy
Miscellaneou
s

6. • Breaking of mercury fluorescent light bulbs, heating of mercury-
gold amalgams in order to extract gold, and the use of mercury-
containing latex paint or building materials.
• Ingestion or handling of liquid mercury following breakage of
thermometers or other mercury-containing devices.
• Insertion or removal of dental amalgam restorations can generate
mercury vapour or respirable particulates.
• Bruxism, chewing, and tooth brushing may increase amalgam
release of mercury vapour.
• Occupations which have the greatest exposure to mercury
vapours include mining and processing of cinnabar ore, the
chloralkali industry, and occupations in which mercury containing
instruments or materials are manufactured or handled.
• Dietary exposure to mercury (in the form of methyl mercury) from
consumption of fish, shellfish and marine mammals.
SOURCES / MODE OF CONTAMINATION OF
MERCURY:

7. • The amount of ingested mercury that would be fatal to a man is
estimated at 100 grams.
• Mercuric chloride: 0.5 to 1 gm/70 kg
• Mercurous chloride : 1.5 to 2 gm/70 kg
USUAL FATAL DOSE:
TOXICOKINETICS:
• After inhalation, elemental mercury is readily absorbed through
the alveolar membrane and enters the blood stream.
• Ingestion of mercury salts is asociated with slower rate of
absorption.
• Both organic and inorganic mercurials can be absorbed through
intact skin.
MODE OF ACTION:
• Mercury is rapidly converted to mercuric ions (Hg++) in the blood
which can lead to renal tubular damage during excretion.
• In the central nervous system, mercury acts mainly upon
cerebellum, temporal lobe, basal ganglia, and corpus callosum.

8. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
1. ACUTE POISONING:
a. Inhalation:
• Usually occurs while heating metal in a closed room, or on gold refining in
an enclosed area.
• Symptoms - dyspnoea, cough, fever, headache, chills, GI disturbances,
metallic taste, and blurring of vision.
• Stomatitis, swelling of the salivary glands and gingivitis. Teeth may
become loose due to gum inflammation.
• In severe cases there may be non-cardiogenic pulmonary oedema,
dyspnoea, convulsions, etc.
• Sometimes manifestations similar to Kawasaki disease (mucocutaneous
lymph node syndrome) are seen especially in children, which may be
mistaken for scarlet fever: conjunctival congestion, fever, reddened palms
and soles, deep red oral mucosa with strawberry tongue, skin rash, and
cervical lymphadenopathy.
CLINICAL FEATURES:

9. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
1. ACUTE POISONING:
b. Ingestion:
• Small quantities of elemental mercury usually cause no harm on ingestion.
• Sometimes even a relatively large amount may pass out of the body
uneventfully with the help of a mild laxative.
• Ingestion of mercuric salts produces corrosion leading to abdominal pain,
vomiting, diarrhoea, and shock. The mucosa of the GI tract usually
appears greyish. There may be haematemesis.
• In severe cases there is onset of renal failure, pulmonary oedema, and
coma.
• Urine may appear pinkish.
• Ingestion of button (or disc) batteries poses special problems since they
contain a variety of caustic substances apart from mercury. Each battery
contains a heavy metal (usually mercury) along with a variety of caustic
alkalis, like sodium or potassium hydroxide.
CLINICAL FEATURES:

10. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
1. ACUTE POISONING:
b. Ingestion:
• In the majority of cases of button battery ingestion there are no serious
consequences, and the object usually passes out in the stools quite
uneventfully over a period of 1 to 4 days.
• However if the contents of the battery leak out during transit, there can be
production of burns by the caustic alkalis.
MANAGEMENT
• Airway assessment and stabilization.
• Radiographs to visualize the neck, chest and abdomen.
• Emergency removal via Bronchoscopy, in patients with batteries in the
airway or lower respiratory tract.
• Immediate endoscopic removal by forceps or magnet, if the battery is
visualized in the oesophagus.
CLINICAL FEATURES:

11. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
1. ACUTE POISONING:
b. Ingestion:
MANAGEMENT
• If intact battery is located past the stomach in asymptomatic patients,
check for battery passage by serial stool examinations.
• If the battery fails to pass the pyloric region within 48 hours, endoscopic
removal of the battery may be necessary.
• Consider whole bowel irrigation with polyethylene glycol solution in
patients with poor mobility of batteries in the GI tract.
CLINICAL FEATURES:

12. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
1. ACUTE POISONING:
c. Injection:
• Subcutaneous or intramuscular injections of elemental mercury may result
in formation of abscess with ulcerations, extruding tiny droplets of
mercury.
• Intravenous injection can result in mercurialism characterised by repeated
haemoptysis, thrombophlebitis, granuloma formation, and pulmonary
embolism.
• Intra-arterial injection causes leakage of mecury into arterial blood
resulting in peripheral embolisation with ischaemia, and sometimes frank
gangrene.
• X-ray usually reveals multiple, tiny spheres in the veins draining the entry
site.
• Mercury globules may also be seen in various organs.
CLINICAL FEATURES:

13. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
2. CHRONIC POISONING:
a. Inhalation:
• Tremor: Referred to as the Danbury tremor. It begins in the hands and
later it progresses to the lips, tongue, arms, and legs. The advanced
condition is referred to as Hatter’s shakes. The most severe form of the
condition is referred to as concussio mercurialis when literally no activity is
possible. Even years after exposure to mercury has ceased, tremor may
persist.
• Metallic taste, nausea, anorexia and increased salivation.
• Gingivitis, halitosis, blue line on gums.
• Erythematous macular or papular rashes involving hands and feet is seen
with liquid mercury.
• Ataxia, gait, fasciculations of tongue and legs – seen in paediatric
patients.
• A parkinsonian syndrome with resting tremor, bradykinesia and cogwheel
CLINICAL FEATURES:

14. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
2. CHRONIC POISONING:
a. Inhalation:
• Erethism: refers to a cluster of psychiatric symptoms like abnormal
shyness, loss of self confidence, depression, irritability, amnesia,
excitability, delirium with hallucinations, or suicidal melancholia or manic
depressive psychosis (Mad Hatter).
• Mercuria lentis: characterized by the brown reflex of anterior lens capsule
of the eye. There may be fine punctate opacities, visual blurring and
concentric constriction of visual fields (Tunnel vision).
• Renal damage resulting in membranous glomerulonephritis with hyaline
casts and fatty casts in urine.
CLINICAL FEATURES:

15. POISONING WITH ELEMENTAL MERCURY AND INORGANIC
SALTS:
2. CHRONIC POISONING:
b. Ingestion:
• Colitis.
• Melanosis coli.
• Dementia.
• Tremor.
• Renal failure.
• Acrodynia (Pink disease): This is seen mainly in children. The onset is
usually insidious with anorexia, insomnia, profuse sweating, skin rash, and
photophobia. The hands and feet become puffy, pinkish, painful,
paraesthetic, perspiring and peeling. Teeth may be shed, with ulceration
of gums. In older children and adults the disease is milder, and is
characterised by antisocial behaviour, insomnia, aching extremities, and
alopecia.
CLINICAL FEATURES:

16. POISONING WITH ORGANIC SALTS:
• CNS features: dysarthria, ataxia, paraesthesias, neuropathiesm
diminished auditory and visual activity, mental deterioration and chorea.
• Organic mercurial poisoning through food:
o Minimata disease: cluster of neurological symptoms comprising
parasthesias, narrowing of vision, dysarthria, diminution of hearing,
amnesia, ataxia, staggering gait, weakness and emotional instability,
stupor and paralysis.
o Large amounts of industrial wastes, agricultural fungicides and volcanic
discharges containing mercury are released into the ocean and
methylation of mercury to methyl mercury occurs by a bacterium,
methanobacterium omelanskii.
o This bacterium is consumed by the plankons which are eaten by fishes.
o Ingestion of contaminated fish by human beings result in organic mercurial
poisoning.
CLINICAL FEATURES:

17. DIAGNOSIS
X-RAY
• Mercury is radio opaque and
can be visualized by
abdominal X-Ray after
ingestion.
URINE MERCURY LEVELS
• Best biological marker for chronic elemental
or inorganic mercury exposure.
• Also useful for assessing the response to
chelation therapy.
• Normal level is less than 10 to 15 mcg/100
ml.
• Symptoms of toxicity may begin to occur at
urinary mercury concentrations of 20 to 100
BLOOD MERCURY
LEVELS
• Flameless atomic absorption spectrometry.
• Normal level is less than 3 mcg/100 ml.
• Symptoms of toxicity may occur at blood
mercury concentrations of > 5 mcg/100 ml.
HAIR
ANALYSIS
• Done by cold vapour atomic
absorption spectrometry.

18. 1. Metallic mercury and inorganic
salts:
a. Inhalation:
- Supportive measures.
- Chelation
b. Ingestion:
- In elemental mercury ingestion,
take x-ray and repeat it to study
the progression. If mercury gets
lodged in the appendix, perform
appendectomy.
- Administer laxatives.
- Demulcents for corrosive
compounds such as mercuric
chloride.
- Stomach wash: It may be
advisable to add egg white or 5%
albumin or just plain milk to the
lavage fluid to bind the mercury.
- Chelation.
c. Injection:
- If there is abscess formation,
perform repeated incisions to
CHRONIC
POISONING
1. Chelation therapy:
– BAL (British Anti Lewisite)
- 100 mg by deep IM, every 4
hours for 48 hours, followed by
100 mg every 8 hours for 8 to 10
days.
OR
– DMPS ( 2,3 DiMercapto
Propane-1-Sulfonate)
- 5 mg/kg IV, or 6 infusions of
250 mg/day, followed by 100 mg
orally twice a day for 24 days.
OR
– DMSA (Meso 2,3 DiMercapto
Succinic Acid, or Succimer)
- 30 mg/kg/day orally for 5 days,
followed by 20 mg/day for 14
days.
OR
– D-Penicillamine
- 250 mg qid, for adults, (20
mg/kg/day) for 5 to 10 days.
- If the globules are very minute and
widely distributed in the intercellular
spaces, excise the affected tissue.
- Monitor the CNS and renal functions
for evidence of toxicity.
- Mercuric salts are relatively well
adsorbed by activated charcoal.
- Chelation.
TREATMENT
ACUTE
POISONING
2. Organic
Mercurials:
– Supportive measures.
– Chelation is not very effective.
– In severe manifestations with acute
renal failure resulting from any type of
exposure, the following may be tried:
haemodialysis, haemofiltration, or
plasma exchange.
- Haemoperfusion is said to be
ineffective.

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