The patient was brought to the emergency ward with a history of rashes, blebs on the skin mainly on the arms and feet, tingling and numbness in the hands and feet. He had consumed water from his workplace for the past 3 days and had been suffering from severe gastroenteritis. On examination, he had nail changes, sensory loss, dermatitis and went into shock, requiring admission to the ICU.

1. A patient was bought to the Emergency ward with history of rashes and blebs all over his skin mainly on his arms and feet. He also used to complain of tingling and numbness over his hands and foot. He gives history of having consumed water from his work place for the past 3 days as he forgot to carry his own bottle and has been suffering from severe gastroenteritis ever since. Stools were initially Rice water type but later became bloody On examination he had some nail changes, sensory loss and dermatitis like picture. His blood picture and abdomen radiography were as in the images. Patient went into shock and finally was admitted in the ICU 1 Telugu Doctors.co.in

2. Arsenic Poisoning A presentation by Telugu Doctor 2

4. the Italian family of Borgias used arsenic as their favorite poison for political assassinations.

5. It is believed that Napoleon was poisoned by arsenic-tainted wine served to him while in exile. 3 Telugu Doctors.co.in

7. It ranks 20th in abundance in the earth's crust, 14th in seawater, and 12th in the human body. 12th 20th 14th 4 Telugu Doctors.co.in

9. The possibility of heavy metal contamination of herbal preparations and so-called nutritional supplements must also be considered. 5 Telugu Doctors.co.in

12. An inverse correlation was found between consumption of vitamins A, C, and E, riboflavin and folic acid, and the existence of dermatological manifestations or chronic arsenic exposure. 7 Telugu Doctors.co.in

14. It is also known as White Arsenic.

15. No taste or smell and is sparingly soluble in water.

16. It is heavier than water by three and half times but freely floats on water.8 Telugu Doctors.co.in

17. Uses Of Arsenic Calico printing Fruit sprays Sheep-dips Rat poisons Preserving timber and skin against white ants Fly papers Taxidermy Weed-killers 9 Telugu Doctors.co.in

19. It particularly targets vascular endothelium leading to increased permeability, tissue edema and hemorrhage, especially in the intestinal canal.10 Telugu Doctors.co.in

20. Mode Of Action Locally it causes irritation of the mucous membranes and remotely depression of the nervous system. Arsenic also interferes with glycolysis. 11 Telugu Doctors.co.in

22. Easily obtained

23. Colourless

24. No smell

25. No taste

26. Small quantity is required to cause death.

27. Can be easily administered with food or drink.

28. Onset of symptoms is gradual

29. Symptoms simulate those of Cholera.12 Telugu Doctors.co.in

31. Can be detected in completely decomposed bodies.

32. Can be found in bones, hairs and nails for several years.

33. Can be detected in charred bones or ashes.13 Telugu Doctors.co.in

34. Signs And Symptoms The Fulminant type The Gastroenteric Type 14 Telugu Doctors.co.in

36. All the capillaries are markedly dilated, especially in the splanchnic area with a marked fall of blood pressure.15 Telugu Doctors.co.in

38. Symptoms usually appear half to one hour after ingestion, but may be delayed many hours especially when arsenic is taken with food.

39. Burning and colicky pain in the esophagus, stomach and bowel occur.

40. Intense thirst and severe vomiting which may be projectile are the common symptoms.16 Telugu Doctors.co.in

41. Signs And Symptoms Acute severe arsenic poisoning Vital signs - Tachycardia and hypotension, even shock CNS - Altered mental status, delirium, coma, and seizures (acute encephalopathy) Frequently, patients exposed to arsenic have a garlic smell to their breath and tissue fluids. 17 Telugu Doctors.co.in

43. Hemoglobinuria causes the urine to appear black, and the patient becomes rapidly obtunded and shocky.

44. Shaking chills are often described in these patients.Frequently, patients exposed to arsenic have a garlic smell to their breath and tissue fluids. 18 Telugu Doctors.co.in

46. vomiting (often times bloody) and

47. severe diarrhea (which may be rice-watery in character and often bloody);

48. these patients will experience acute distress, dehydration (often), and hypovolemic shock.19 Telugu Doctors.co.in

49. 20 Telugu Doctors.co.in

50. Chronic toxicity is more insidious and may manifest as a classical dermatitis (hyperkeratosis with a classical "dew drops on a dusty road" appearance) 21 Telugu Doctors.co.in

51. Contact dermatitis may also be induced in occupational arsenic poisoning. Arsenic dust coming into contact with the skin produces four main types of reactions: Toxic Eczematous Combined toxic and eczematous and Reactions characterized by follicular lesions. whitish lines (Mees lines) that look much like traumatic injuries are found on the fingernails. 22 Telugu Doctors.co.in

53. Acute hemolyticanemia is the rule with arsine exposure.

54. Type and screen or crossmatch blood for the transfusion in patients exposed to arsine gas.MicrocyticHypochromic Anemia 23 Telugu Doctors.co.in

55. Laboratory Studies Serum Magnesium Serum Potassium Serum Sodium Serum Calcium Serum Chloride Do Serum electrolytes in patients with Diarrhea and Vomiting 24 Telugu Doctors.co.in

57. The reported half-life of arsenic in blood immediately following ingestion is in hours, while whole-body clearance may be in days or months and is apparently dose-related.Plasma Arsenic Analyser Serum Arsenic Analysis 25 Telugu Doctors.co.in

59. 24-hour urine collection for total arsenic excretion

60. Methylarsonic acid (MMA) and dimethylarsenic acid (DMA) – metabolites of arsenic in the body26 Telugu Doctors.co.in

61. Laboratory Studies ECG Changes Reports of prolongation of the QT and ventricular fibrillation after acute arsenic intoxication make careful attention to cardiac status imperative. 27 Telugu Doctors.co.in

63. An abdominal radiograph may reveal the presence of radio-opaque densities 28 Telugu Doctors.co.in

65. Orogastriclavage – for acute arsenic poisoning

66. Whole bowel irrigation with polyethylene glycol may be effective to prevent GI tract absorption of arsenic.29 Telugu Doctors.co.in

68. Succimer (DSMA): used only in childhood lead poisoning.

69. Dimerval (DMPS): accepted DOC for treating most heavy metal poisonings.30 Telugu Doctors.co.in

79. Telugudoctors.co.in 40 Telugu Doctors.co.in