Multi-organ toxicity due to chronic occupational heavy metal exposure
Twist, D.J.L. van, Hoge, C.V., Koek, G.H., Cate, H. Ten
Voorzitter(s): prof.dr. J.L.C.M. van Saase, Rotterdam & dr. J.W.J. van Esser, Breda
Locatie(s): Zaal 0.4
Categorie(ën):
Case: A 59-year-old man without relevant medical history was referred to our hospital because of recently diagnosed type 2 diabetes mellitus and thrombocytopenia. The patient complained of recurrent episodes of general weakness, myalgia, feverishness, and dry cough. Physical examination revealed purpura of the lower legs and decreased sensibility of both feet. Routine blood count showed thrombocytopenia (100*109/L), elevated erythrocyte sedimentation rate (100 mm/hour), and normochromic anemia.
As we suspected a systemic vasculitis, a biopsy from the purpura was taken. This demonstrated leukocytoclastic vasculitis with perivascular C3 depositions. Chest CT-scan showed mediastinal lymphadenopathy and abdominal ultrasound revealed livercirrhosis and splenomegaly with extensive collaterals, suggesting portal hypertension. Auto-immune serology and viral hepatitis tests were negative. Levels of ceruloplasmin, serum copper and iron were normal, and no nodular abnormalities or iron depositions were found on MRI of the liver. As the patient used no medication, drugs, or alcohol and liver biopsy was not possible due to the thrombocytopenia and presence of extensive collaterals, the etiology of the Child-Pugh-A liver cirrhosis remained unclear. Propranolol was initiated because of esophageal varices, but this resulted in substantial edema and weight gain. Echocardiography indeed revealed decreased left ventricular ejection fraction (30%).
When asked, he mentioned running a galvanizing and enameling company for art production for over thirty years. Under suspicion of a heavy metal intoxication we performed blood tests. Indeed, high levels of metals were found: aluminium 0.58 (normal <0.3) µmol/L, lead 2.02 (<0.14) µmol/L, cadmium 8.0 (<6.5) nmol/L, manganese 111.5 (<11.3) nmol/L, nickel 86.5 (<13) nmol/L, and cobalt 33.7 (<7) nmol/L.
The patient interrupted the galvanizing and enameling activities, resulting in a significant decrease in metal levels within a few months, but also in a spectacular improvement of his general performance: skin abnormalities, mediastinal lymphadenopathy, and anemia disappeared and ESR normalized. Interestingly, behavioral and cognitive changes were noted: Whereas we formerly saw an apathetic and lethargic patient with memory difficulties, he now made jokes, had good memory, and took initiative to undertake activities.
Discussion: We describe a unique case of multi-organ involvement of chronic intoxication with several heavy metals due to chronic occupational exposure. This induced an inflammatory reaction (leukocytoclastic vasculitis, mediastinal lympheadenopathy and so-called ‘metal fume fever’) and chronic damage to liver, nervous system (behavioral and cognitive changes and polyneuropathy), and (probably) heart. This case illustrates the risks of chronic heavy metal exposure and the importance of obtaining a thorough occupational history in each patient.