Mercury (Quick silver, Liquid metal, Para, Padarasa): nephrotoxic

liquid metal volatile at room temperature

metallic mercury: heavy, bright liquid, non-poisonous when swallowed as it is
not absorbed
inhalation of dusts & vapours (volatilizes at room temperature): toxic or
poisonous (applied to skin or mucosa in finely divided state or inhaled-----absorption---toxic)
most poisonous is HgCl2 (mercuric chloride)
2 series of compounds are:
i)
mercuric: soluble & intensely poisonous
ii)
mercurous: much less soluble, less active
uses: mercury switches, mercury containing devices (thermometers,
thermostats, barometers), laboratories, dental offices, industrial sources,
mirrors, drugs, explosives, paints

FD: 1-4gm
FP: 3-5 days
Action:
pure metallic form: non-toxic
mercurial compound (mercuric ion): bind with the SH (sulphhydryl ) group of
enzymes, cellular proteins, mitotic apparatus, nucleic acid, etc and
inactivates the SH enzymes; interfere with enzyme & cellular transport
function; interfere with cellular metabolism
mercuric ions in blood can lead to renal tubular damage
CNS: mainly upon cerebellum, temporal lobe, basal ganglia, corpus callosum
acute exposure to elemental mercury vapour: corrosive bronchitis with fever,
chills & dyspnoea; may progress to pulmonary oedema & fibrosis; sometimes
esp. in children: manifestations similar to Kawasaki disease (mucocutaneous
lymph node syndrome)
Hg Poisoning
rapid onset
constriction of throat more marked
kidney involvement is more common
(nephrotoxic)
urinary excretion: >500 microgram of

As poisoning
less comparatively
constriction of throat less marked
kidney involvement is less common
(hepatotoxic)

Hg/24 hrs: Hg poisoning

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Toxic or poisonous compounds:

mercuric chloride (HgCl2: corrosive sublimate): colourless masses of
prismatic crystals or as white crystalline powder; has no smell; but a styptic,
nauseous, metallic taste
mercuric oxide: brick-red crystalline powder
mercuric iodide: scarlet-red powder
mercuric cyanide: white prismatic crystals
mercuric sulphide: cinnabar, sindoor; artificial preparation occur as red
crystalline powder known as vermilion
mercurous chloride (calomel)
mercuric nitrite
mercuric sulphate (white crystalline powder)
sulphate of mercury (lemon-yellow powder)
ammoniomercuric chloride
organic compounds of mercury

Hg: Inorganic (mercuric chloride, mercuric oxide, mercuric sulphide, mercurous

chloride, diethyl mercury & dimethyl mercury, mercury fulminate) & Organic
(Neptal, Thiomerin sodium / mercaptomerin sodium, mercurophyllin used as
diuretics & has low toxicity when used in therapeutic doses; metaphen,
merthiolate / thiomersalate used as antiseptic for sterilizing skin & instruments;
Minimata disease)

Signs & Symptoms

ACUTE POISONING
GI, cns, renal, CVS, RESP

Acute poisoning

Chronic poisoning

First phase
Acid metallic taste
Feeling of
constriction in
throat; hoarse
voice
Difficulty in
breathing

Corroded mouth,
tongue, face with
swollen, greywhite coating

Hot burning
radiating pain; n/v
(grayish slimy
mucoid with blood
& shreds of
mucous
membrane),
diarrhea,
tenesmus,
circulatory
collapse
Fume inhalation:
nervous systems
(ataxia, paresis,
delirium,
restriction of
visual field)

Second phase
If survives: begin in
1-3 days
24-36 hrs:
glossitis(ulcerative),
severe infection,
loosening of teeth,
jaw necrosis
2-3 days: renal
tubular necrosis,
transient polyuria,
albuminuria,
cylindruria,
uraemia, acidosis
10-14 days:
recovery; many
days: ulceration of
colonic mucosa,
haemorrhage,
dysentery,
membranous colitis
Im injection
produces abscess
with ulceration, iv
injection:
mercurialism,
thrombophlebitis,
granuloma
formation,
pulmonary
embolism, repeated
haemoptysis

(Hydragyrism/Mercurialism): classical
triad
Gingivitis & salivation
Tremors
Neuropsychiatric changes

Mercuria lentis

Kidney damage

(GI, CNS, RENAL, OPTHALMO)

Acrodynia or pink disease

t/t of acute poisoning:

Milk, egg-white, 5% salt-poor albumin, 5% sodium formaldehyde sulphoxylate, or 25% sodium bicarbonate may be used for gastric lavage to bind mercury; uncertain
benefit: activated charcoal
Whole bowel irrigation but not cathartics
Penicillamine for less severe mercury vapour & inorganic mercury poisoning:250
mgX4 a day orally)
Do not use Ca-EDTA as it is nephrotoxic with mercury
Chelating agent of choice: BAL (never use BAL & penicillamine together as they
cause formation of toxic compound); dose same as for arsenic
Keep urine alkaline
Significant kidney damage: haemodialysis
High colonic lavage: 1: 1000 soln of sulphoxylate twice daily

Chronic poisoning: results from i) continuous accidental absorption by

workers (victim exposed to mercury fumes in factories) ii) excessive
therapeutic dose or excessive use of mercurial compounds for a prolonged
period iii) recovery from a large dose iv) if ointment is used as external
application for a long timeHydragyrus/mercury; symptoms appear at blood
levels of 100 nanogram per cent of mercury; repeated contact with poison in
small doses; more common than acute poisoning; occurs in persons working
in factories for mercury salts (barometer, thermometer, mirror)
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Neuropsychiatric (psychological effect of Hg toxicity)changes (eg:people

working in mercury in hat industry, mirror manufacturing firms) : Mercurial
erethism (=personality change)is a peculiar change in the personality of the
affected person & is characterized by:
a) abnormally high degree of irritability or sensitivity or excitability
b) nervousness or anxiety or loss of confidence
c) shyness or timidity; emotional instability
d) amnesia (loss of memory)
e) insomnia
f) delusions
g) hallucination; mental depression or suicidal melancholia
h) leading to insanity = manic depressive psychosis (also known as MAD
HATTER)
-Tremors
a) Danbury tremor: tremor in hand in early stage (change in handwriting
of person as it affects muscles of fingers); first tremor occurring in
hand; is moderately coarse & is interspersed by jerky movements; then
progress to lips, tongue (stammering & slurring speech), finally involve
muscles of face, arms & legs
b) Hatter's shake or glass-blower's shake or mercurial tremors: advanced
condition; common in persons working in glass-bowling & hat
industries (mercury was used extensively in giving peculiar kinking
shape to the felt hats; the pt is unable to dress himself, write legibly or
walk properly
c) Concussio mercuralis : most severe form; in which no activity is
possible
Mercuria lentis: develops to brownish deposit of mercury through the cornea
on the anterior lens capsule; observed as a malt-brown reflex fromanterior
lens capsule on slit-lamp examination; peculiar eye changes due to exposure
to vapour of mercury; it is bilateral & hasa no effect on visual acuity
GI:
excessive salivation (ptyalism/sialorrhoea) with painful swollen salivary gland,
metallic taste in mouth, glossitis, ulcerative gingivitis (inflammation of the
gums, swollen painful spongy gums), necrosis of the jaw, Burtonian line (a
blue line on the gums or junction of gums & carried teeth, common clinical
finding of chronic poisoning), GI disturbances (nausea, vomiting, colicky pain,

diarrhea), anorexia, loss of wt, anaemia, sore mouth & throat, loosening of
teeth
Chronic inflammation of the kidneys with progressive uraemia: renal damage
results in membranous glomerulonephritis with hyaline casts & fatty casts in
the urine, kidney is the primary target (nephritis & uraemia)
Acrodynia or pink disease: onset: insidious; an idiosyncratic hypersensitivity
reaction particularly seen in children, can be caused by chronic mercury
exposure in any form (who use tooth powder containg mercury salts);
characterized by a generalized body rash (hands & feet become puffy,
pinkish, painful, paraesthetic with peeling of skin ) with anorexia, insomnia,
sweating/perspiration, skin rash, photophobia, teeth may be shed, skin
eruption, gum ulceration
Minimata disease: type of organic mercurial poisoning due to eating of fish
poisoned by mercury, occurred as a disaster in Japan in 1956 by eating
contaminated fish from Minimata Bay; organic mercury poisoning by methyl
mercury through poisonous fish ; note: organic mercurials (phenyl &
methoxymethyl mercury, ethyl & methyl mercury, CNS symptoms: ataxia,
dysarthria, paraesthesias, neuropathies, mental deterioration, chorea, etc;
are more toxic)

T/t of chronic poisoning:

Removal of pt from further exposure
Demulcents like egg albumin
Saline purgatives; oral hygiene
Chelation therapy (not effective for organic mercurials): specific chemical antidote:
BAL(dimercaprol: 3-4mg/kg 4hrly; 100 mg im 4hrly for 2 days; 100 mg 8 hrly for
10days) or D-penicillamine (250mg-2gm orally; 250 mg X 4 times a day for adults
until urine <5 ug/L; max 1gm in children in 2 divided doses; 25-40 mg/kg/day in 2
divided doses) or DMPS or DMSA or sodium formaldehyde sulphoxylate (5%
SFSgastric lavage & leave 100 ml of SFS in stomach after lavage) (edta?)
Medicinal charcoal : MgSO4
Sodium thiosulphate i.v 450/600 mg in 5 cc of NaCl on alternate days
Oral antiseptics at regular intervals
Symptomatic therapy

levels in blood should not exceed 3.6u/L & urine 15u/L; symptoms when blood level
> 20u/L & urine > 60u/L
TEST: a copper wire in a soln of Hg with few drops of HCl then the wire is silver
coated with Hg
ML aspect:
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metallic Hg is not poisonous

Poisoning by Hg vapours/ointment is accidental (accidental poisoning by
mercuric chloride due to use of strong soln in washing abscess cavities or
irrigating vagina, uterus or rectum (vaginal douching), mercury as diuretic, as
a dental restorative material in dental clinics lead to accidental poisoning by
overdose; esp in children like Pharaoh's serpent (Diwali poison) is a black
colored tablet shaped fire cracker, which contains mercuric thiocyanate, on
ignition yields a long black coloured tubular ash;
rarely suicidal or homicidal
introduced into vagina as contraceptive or producing abortion
Hg is an industrial poison used in industries, connected with manufacture of
thermometers, barometers, mercury vapour lamps, firecrackers, explosives,
paints, etc Hatter's shake or glass blower's shake are moderately course
tremors interspersed by jerky movements found in workers of glass blowing &
hat industry are examples of chronic poisoning of industrial origin, chronic
mercury poisoning manifestations are prevalent among the gold miners &
gold refining industry workers who are exposed to Hg used in the process

PM appeareance:

GIT mucosa (lips, mouth, pharynx): inflammation,congestion, coagulation

(diffuse greyish white eschar) & corrosion
stomach & intestine: severe irritation & corrosion with ulceration & softening
if survives for few days: LI shows necrosis due to re-excretion of Hg into large
bowel (caecum, colon, rectum inflamed, ulcerated, even gangrenous)
acute tubular & glomerular degeneration or haemorrhagic glomerular
nephritis (kidney : toxic nephritis)
liver: congested, cloudy swelling or fatty change, fatty degeneration
heart: subendocardial haemorrhages, fatty degeneration