Medical Image of the Week: Elemental Mercury Poisoning

Figure 1. Panel A: Abdominal x-ray showing radiopaque matter. Panel B: Repeat x-ray after colonoscopy.

A 34-year-old woman presented to the Emergency department with abdominal pain after ingestion of an unknown liquid that family felt might be poisonous. The patient had a past history of prior suicide attempts, as well as a history of polysubstance and alcohol abuse. The patient was confused, tangential and a difficult historian. The patient had a heart rate of 72, was normotensive, and had an oxygen saturation of 100% on room air.  She was confused and answered questions intermittently. The remainder of her physical examination including her neurological exam was normal. The initial serum chemistry, anion gap, lactate, liver function tests were normal. Urine drug screen was positive for benzodiazepines, for which the patient was prescribed. An abdominal x-ray was performed showing a radiopaque substance in the abdomen (Figure 1A). It was eventually determined she ingested elemental mercury. Blood levels were elevated, and she did eventually have hematochezia. Colonoscopy was performed which removed some of the metallic liquid mercury (Figure 1B).

Mercury in any form is poisonous, with mercury toxicity most commonly affecting the neurologic, gastrointestinal (GI) and renal organ systems (1). Poisoning can result from mercury vapor inhalation, mercury ingestion, mercury injection, and absorption of mercury through the skin.

Elemental mercury is poorly absorbed after ingestion but easily vaporizes at room temperature and is well absorbed (80%) through inhalation. Once absorbed elemental mercury is mostly converted to an inorganic divalent or mercuric form by catalase in the erythrocytes. This inorganic form has similar properties to inorganic mercury (e.g., poor lipid solubility, limited permeability to the blood-brain barrier, and excretion in feces).

Treatment of mercury toxicity consists of removal of the patient from the source of exposure, supportive care, and chelation therapy. Our patient had limited symptoms, and for this reason, chelation therapy was not performed. She made an uneventful recovery after discharge to psychiatry. Her blood levels eventually returned to normal in a few months.

Michel A. Boivin, MD

Pulmonary/Critical Care/Sleep Medicine

Department of Internal Medicine

University of New Mexico

Albuquerque, NM USA

Reference

1. Olson DA. Mercury poisoning. Medscape. August 14, 2017. Available at: https://emedicine.medscape.com/article/1175560-overview (accessed 5/22/18).

Cite as: Boivin M. Medical image of the week: Elemental mercury poisoning. Southwest J Pulm Crit Care. 2018;16(5):287-8. doi: https://doi.org/10.13175/swjpcc067-18 PDF 

Medical Image of the Week: Diffuse Gastric Bleeding and ALL

Figure 1. Technetium 99m tagged RBC scan showing abnormal radio tracer accumulation throughout the stomach (Panel A), and subsequently passing into the small bowel (Panel B).

A 26-year-old man with a medical history significant for acute lymphoblastic leukemia (ALL) presented with hypovolemic shock secondary to large volume hematemesis. The patient was diagnosed with ALL and treated with high dose chemotherapy followed by peripheral blood stem cell transplant from a matched unrelated donor one year prior to presentation. His treatment course was complicated by grade 4 acute graft versus host disease (GVHD) and CMV colitis. Blood work on admission showed hemoglobin of 6.4 g/dL and a leukocytosis. Patient was intubated for airway protection, transferred to ICU, and EGD was performed, which revealed diffusely friable mucosa, inflammation, and ulcerations throughout the gastric mucosa with only a few areas of normal appearing mucosa. Additionally, areas of spontaneous bleeding were seen. Selective arteriography within the right gastric and gastroduodenal arteries showed no active extravasation from the stomach or duodenum. However the gastroepiploic and right gastric arteries were prophylactically embolized. Subsequently, a technetium 99m tagged RBC scan demonstrated abnormal radio-tracer accumulation throughout the stomach with subsequent passage into the small bowel (Figure 1). The patient continued to have refractory gastric bleeding even with an increased dose of cyclosporine. Surgical measures including gastrectomy were discussed with the family. However, the family decided on comfort care. The patient died the following day.

Although gastric bleeding is rare in ALL patients in general, it is more commonly associated with certain condition such as GVHD and colitis following allogeneic stem cell transplantation (SCT). One of the retrospective studies with 447 SCT patients showed that 21.1% of study population experienced major GI bleeding, requiring transfusions or surgical intervention. Also, their mortality was shown to be twice higher than patients without bleeding complication, although most cases of bleeding were mild and occurred in the peri-transplant period with concurrent severe thrombocytopenia (1).

Hemorrhagic complications occur predominantly during the first month of post transplant, and bleeding is more commonly associated with allogeneic SCT compared to autologous SCT (2). This is mainly secondary to GVHD with gastrointestinal involvement, which leads to destruction and fragility of the epithelium as well as hyper-perfusion and proliferation of the blood vessels. As such, the risk of hemorrhage in patients with acute and chronic GVHD greater than grade I was 2.9 and 4.2 fold higher, respectively, and these patients had 10.8 fold higher risk of severe bleeding. The risk of bleeding is further increased by CMV infection, which infects vascular endothelial cells, narrows capillary lumens, and leads to ischemia and ulceration of gastric mucosa (3). The combination of GVHD and CMV infection could have synergistically damaged the gastric mucosa leading to severe refractory bleeding in our case.

Onyemaechi Okolo MD¹, Seongseok Yun MD PhD¹, Faiz Anwer MD, FACP²

¹Department of Medicine

²Department of Hematology & Oncology, Blood & Bone Marrow Transplantation Program

University of Arizona

Tucson, AZ, 85721

References

1. Pihusch R, Salat C, Schmidt E, Göhring P, Pihusch M, Hiller E, Holler E, Kolb HJ. Hemostatic complications in bone marrow transplantation: a retrospective analysis of 447 patients. Transplantation. 2002;74(9):1303-9. [CrossRef] [PubMed]
2. Törnebohm E, Lockner D, Paul C. A retrospective analysis of bleeding complications in 438 patients with acute leukaemia during the years 1972-1991. Eur J Haematol. 1993;50(3):160-7. [CrossRef] [PubMed]
3. Cheung AN, Ng IO. Cytomegalovirus infection of the gastrointestinal tract in non-AIDS patients. Am J Gastroenterol. 1993;88(11):1882-6. [PubMed]

Cite as: Okolo O, Yun S, Anwer F. Medical image of the week: diffuse gastric bleeding and ALL. Southwest J Pulm Crit Care. 2016;12(3):108-9. doi: http://dx.doi.org/10.13175/swjpcc010-16 PDF

Medical Image of the Week: Abdominal Compartment Syndrome Due to Massive Upper Gastrointestinal Hemorrhage

Figure 1. Coronal section demonstrating a section of the Minnesota Tube within the stomach (yellow arrow), severe dilatation of the stomach (green arrow) and small bowel (blue arrow) due to intraluminal filling from blood. There is markedly reduced lungs volumes due to superior displacement of the diaphragm.

Figure 2. Saggital section demonstration the Minnesota Tube in place within the esophagus and stomach (yellow arrow) surrounded with intraluminal blood. There is intraluminal filling of the small intestine as well (green arrow).

A 29 year old woman with history of a Whipple procedure for pancreatic cancer and nonalcoholic steatohepatitis cirrhosis presented with a massive upper gastrointestinal bleeding (UGIB) likely from esophageal varices and developed hemorrhagic shock.

Emergent upper endoscopy could not be performed due to hemodynamic instability. Therefore, a Minnesota Tube was placed emergently for balloon tamponade of the bleeding. A transjugular intrahepatic portosystemic shunt was also placed emergently to decrease bleeding by reducing portal pressure. By this time, the patient had received 4 liters of normal saline, 14 units of packed red blood cells, 6 units of platelets, and 4 units of fresh frozen plasma.

The Minnesota tube did control the bleeding somewhat, however, there was continued bloody drainage from the stomach port of the Minnesota tube. The patient’s abdomen became remarkably distended and was dull to percussion throughout. A CT scan of the abdomen and pelvis revealed severe dilatation of the stomach and multiple loops of small bowel filled with mixed density blood (Figures 1 and 2). Intraabdominal bladder pressure was elevated to 34 mmHg. Given the radiographic findings, elevated bladder pressures, worsening lactic acid level and renal function, the patient was diagnosed with abdominal compartment syndrome. She was not a surgical candidate due to her grim prognosis. A large bore tube was placed into the abdominal cavity to drain ascitic fluid in effort to relieve the abdominal pressure.

Aggressive resuscitation including fluids, blood products, and four vasopressors was continued for the next several hours. However, due to patient’s poor prognosis, a decision was made to proceed with comfort care and the patient shortly passed away.

Acute upper gastrointestinal bleeding is a frequently encountered condition in the intensive care unit . Initial management generally consists of airway protection, intravascular resuscitation, correction of any coagulopathies, and acid-suppressive therapy (1). For UGIB with hemodynamic compromise, immediate upper endoscopic evaluation is indicated. The upper endoscopy allows for determination of the specific etiology of UGIB and for interventional therapy. If endoscopy cannot be done, bleeding cannot be controlled with endoscopic interventions or the patient is hemodynamically unstable, balloon tamponade should be considered (2). It is important to note that balloon tamponade is considered a bridge to more definitive therapy. Lastly, a multidisciplinary approach for management of massive UGIB should always be utilized especially in difficult cases.

VuAnh N. Truong, MD

Department of Medicine

Loma Linda University Medical Center

Loma Linda, CA

References

1. Conrad SA. Acute upper gastrointestinal bleeding in critically ill patients: causes and treatment modalities. Crit Care Med. 2002;30(6 Suppl):S365-8. [CrossRef] [PubMed]
2. Chen YI, Dorreen AP, Warshawsky PJ, Wyse JM. Sengstaken-Blakemore tube for non-variceal distal esophageal bleeding refractory to endoscopic treatment: a case report & review of the literature. Gastroenterol Rep (Oxf). 2014; Gastroenterol Rep (Oxf). 2014;2(4):313-5. [CrossRef] [PubMed] 

Reference as: Truong VN. Medical image of the week: abdominal compartment syndrome due to massive upper gastrointestinal hemorrhage. Southwest J Pulm Crit Care. 2014;9(5):284-6. doi: http://dx.doi.org/10.13175/swjpcc133-14 PDF