Clinical and Forensic Signs Resulting from Exposure to Heavy Metals and Other Chemical Elements of the Periodic Table

Several heavy metals and other chemical elements are natural components of the Earth’s crust and their properties and toxicity have been recognized for thousands of years. Moreover, their use in industries presents a major source of environmental and occupational pollution. Therefore, this ubiquity in daily life may result in several potential exposures coming from natural sources (e.g., through food and water contamination), industrial processes, and commercial products, among others. The toxicity of most chemical elements of the periodic table accrues from their highly reactive nature, resulting in the formation of complexes with intracellular compounds that impair cellular pathways, leading to dysfunction, necrosis, and apoptosis. Nervous, gastrointestinal, hematopoietic, renal, and dermatological systems are the main targets. This manuscript aims to collect the clinical and forensic signs related to poisoning from heavy metals, such as thallium, lead, copper, mercury, iron, cadmium, and bismuth, as well as other chemical elements such as arsenic, selenium, and fluorine. Furthermore, their main sources of occupational and environmental exposure are highlighted in this review. The importance of rapid recognition is related to the fact that, through a high degree of suspicion, the clinician could rapidly initiate treatment even before the toxicological results are available, which can make a huge difference in these patients’ outcomes.

Acute human toxicity and mortality after selenium ingestion: A review

BACKGROUND

Although selenium is an essential element for humans, acute toxicity has been reported after high oral exposure.

METHODS

The published literature on the acute toxicity of oral selenium was gathered and reviewed.

RESULTS

Reported symptoms and signs include abdominal symptoms, such as vomiting, diarrhea, pain, and nausea, as well as garlic-like odor on the breath. In cases of severe toxicity, cardiac and pulmonary symptoms may develop and ultimately lead to mortality. Mortality has been described after the ingestion of gun bluing solutions, which often contain selenous acid among other potentially toxic substances. Mortality has also been reported after the ingestion of other forms of selenium. Ingested doses associated with mortality are in the range of 1-100 mg Se/kg body weight. Blood levels associated with mortality are above 300 μg Se/L (normal level: 100 μg/L), whereas urinary levels associated with the same endpoint are above170 μg Se/L (normal level: 20-90 μg/L).

CONCLUSION

The acute toxicity associated with oral selenium ingestion and the blood and urinary levels of selenium in different cases of poisonings were reviewed. Mortality is a risk of acute selenium poisoning. Concentrations of selenium in blood and urine samples in non-fatal cases are close to those observed in fatal cases.

Effects of 14-day oral low dose selenium nanoparticles and selenite in rat-as determined by metabolite pattern determination

Selenium (Se) is an essential element with a small difference between physiological and toxic doses. To provide more effective and safe Se dosing regimens, as compared to dosing with ionic selenium, nanoparticle formulations have been developed. However, due to the nano-formulation, unexpected toxic effects may occur. We used metabolite pattern determination in urine to investigate biological and/or toxic effects in rats administered nanoparticles and for comparison included ionic selenium at an equimolar dose in the form of sodium selenite. Low doses of 10 and 100 fold the recommended human high level were employed to study the effects at borderline toxicity. Evaluations of all significantly changed putative metabolites, showed that Se nanoparticles and sodium selenite induced similar dose dependent changes of the metabolite pattern. Putative identified metabolites included increased decenedioic acid and hydroxydecanedioic acid for both Se formulations whereas dipeptides were only increased for selenite. These effects could reflect altered fatty acid and protein metabolism, respectively.

Changes in Bronchoalveolar Lavage Cells after Intratracheal Instillation of Dimethyl Selenide in Mice

CD-1 mice were exposed to a single intratracheal instillation of either 0.025 or 0.075 mg Se/kg wt of dimethyl selenide (DMSe). They were studied over 4 weeks to define the cellular inflammatory response of the airways to DMSe. Bronchoalveolar (BAL) lavage was used to collect the DMSe-induced inflammatory exudates. The DMSe instillation resulted in phlogistic responses that had the neutrophil as the main leukocyte; they were present in BAL samples, mostly at days 1 and 7. Macrophages were also increased during DMSe-induced inflammation. The lower DMSe dose resulted in an inflammatory reaction lasting for 2 weeks. Mice treated with the higher DMSe dose still showed elevated numbers of neutrophils and macrophages 4 weeks after instillation. DMSe did not change the number of lymphocytes harvested from the airways. An early increase in total protein of BAL, and late enhancement in lactate dehydrogenase was observed in mice treated with the high DMSe dose. We conclude that inhalation of DMSe triggers a moderate and dose-dependent inflammatory reaction in the mouse airways, and that this phlogistic reaction is likely to participate in the damage of respiratory epithelia that occurs upon DMSe inhalation.

Toxic effects of selenium inhalation: acute damage of the respiratory system of mice

Accidental inhalation of selenium by humans has been associated with damage of respiratory tissues that is lacking a detailed histological definition. We have investigated the natural history of injury to the tracheal epithelium and lungs induced by a single intratracheal instillation of CD-1 mice with two different doses of dimethyl selenide (0.05 and 0.1 mg Se/kg of body weight). The animals were sacrificed 1, 7, 14, and 28 days after the single selenium treatment. Samples of the trachea and lungs were studied by light microscopy. The tracheal epithelium showed loss of cilia and acute necrosis that was followed by metaplastic transformation. Edema and diffuse alveolar damage was observed in the lungs. Our data suggest that: i) severity of respiratory lesions caused by selenium is dose dependent; ii) selenium causes transient metaplastic transformation of the tracheal epithelium; iii) chronic inflammation and increased thickness of alveolar septa occur in the lungs; iv) 4 weeks after selenium treatment, mice recover from the tracheal injury, whereas no amelioration of pulmonary lesions was observed.

Two fatal cases of selenium toxicity

Two patients, a 36-year-old female and a 36-year-old male, separately experienced new onset nausea, vomiting, diarrhea, abdominal pain, muscle weakness and pallor. Over a period of 14-16 h these symptoms continue and progress to include hypotension refractory to therapy, pulmonary edema and cardiovascular collapse. Autopsies show hemorrhagic pulmonary edema, splenomegaly and lack of anatomical cause for sudden death. Postmortem analysis, in one case post-embalming and exhumation, revealed elevated selenium concentrations and a determination of the cause of death. These two cases present several important features associated with selenium toxicity, two of which are previously unreported: (1) selenium as a potential homicidal agent, (2) the toxidrome and time frame of selenium toxicity, (3) selenium determination in exhumed, embalmed tissues, (4) postmortem urinary selenium concentration, and (5) decrease in tissue concentrations over time.

Fatal blood and tissue concentrations of more than 200 drugs

Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.

Suicide by sodium tetraoxoselenate(VI) poisoning

Selenium is one of the most toxic elements necessary for the life of mammals. Only a narrow range separates therapeutic (connected with a protective effect) and toxic doses. Selenium incorporated into animal or human tissues in larger amounts can exceed normal human levels and may be toxic (only elemental selenium and selenium sulphide are poorly absorbed). Acute poisonings with selenium or its compounds, especially fatal ones, occur extremely rarely in humans. Levels of selenium in four fatal cases are reviewed, and the levels in a fatal poisoning with sodium tetraoxoselenate(VI) are evaluated. Postmortem tissue selenium contents in the latter case were the following: brain, 1.45 and 1.60 microg/g; stomach, 6.12 and 6.37 microg/g; small intestine, 4.37 and 4.13 microg/g; large intestine, 4.53 and 4.43 microg/g; liver, 4.20 and 4.35 microg/g; kidney, 3.35 and 3.60 microg/g; lung, 1.80 and 1.60 microg/g; blood, 1.43 and 1.41 microg/ml measured by the use of ETA-AAS and fluorimetric methods, respectively.

Selenium

The 4 natural oxidation states of selenium are elemental selenium (0), selenide (-2), selenite (+4), and selenate (+6). Inorganic selenate and selenite predominate in water whereas organic selenium compounds (selenomethionine, selenocysteine) are the major selenium species in cereal and in vegetables. The principal applications of selenium include the manufacture of ceramics, glass, photoelectric cells, pigments, rectifiers, semiconductors, and steel as well as use in photography, pharmaceutical production, and rubber vulcanizing. High concentrations of selenium in surface and in ground water usually occur in farm areas where irrigation water drains from soils with high selenium content (Kesterson Reservoir, California) or in lakes receiving condenser cooling water from coal-fired electric power plants (Belews Lake, North Carolina). For the general population, the primary pathway of exposure to selenium is food, followed by water and air. Both selenite and selenate possess substantial bioavailability. However, plants preferentially absorb selenates and convert them to organic compounds. Aquatic organisms (e.g., bivalves) can accumulate and magnify selenium in the food chain. Selenium is an essential component of glutathione peroxidase, which is an important enzyme for processes that protect lipids in polyunsaturated membranes from oxidative degradation. Inadequate concentrations of selenium in the Chinese diet account, at least in part, for the illness called Keshan disease. Selenium deficiency occurs in the geographic areas where Balkan nephropathy appears, but there is no direct evidence that selenium deficiency contributes to the development of this chronic, progressive kidney disease. Several lines of scientific inquiry suggest that an increased risk of cancer occurs as a result of low concentrations of selenium in the diet; however, insufficient evidence exists at the present time to recommend the use of selenium supplements for the prevention of cancer. The toxicity of most forms of selenium is low and the toxicity depends on the chemical form of selenium. The acute ingestion of selenious acid is almost invariably fatal, preceded by stupor, hypotension, and respiratory depression. Chronic selenium poisoning has been reported in China where changes in the hair and nails resulted from excessive environmental exposures to selenium. Garlic odor on the breath is an indication of excessive selenium exposure as a result of the expiration of dimethyl selenide. The US National Toxicology Program lists selenium sulfide as an animal carcinogen, but there is no evidence that other selenium compounds are carcinogens.

The effects of treatment with selenite before and after the administration of [75Se]selenite on the exhalation of [75Se]dimethylselenide

The exhalation of dimethylselenium, as indicated by the respiratory loss of 75Se from injected Na75SeO3, depends not only on the dose, but also on previous exposure. Three days pretreatment with 1.2 mumol/100 g unlabelled selenite increased exhalation of 75Se from 0.1 or 1.2 mumol/100 g Na2 75SeO3 and decreased the retention of 75Se in blood and liver from the higher dose. Similarly the injection of 1.2 mumol/100 g unlabelled selenite 24 h after the last of 3 daily doses of 1.2 mumol/100 g labelled selenite increased the exhalation of 75Se in the following 24 h period. Thus, pre-exposure to selenium increased the exhalation of 75Se by making a higher proportion of the newly injected dose accessible for methylation. The exhaled dimethylselenide, however, is not derived solely from the injected dose, since in pretreated animals, it is possible to demonstrate exchange between injected and deposited selenium.