Lessons learned from a fatal case of mercury intoxication.

CONTEXT: While many cases of metallic mercury poisoning have been reported, cases of metallic mercury poisoning from multiple exposure routes are rare. CASE
PRESENTATION: We report the case of a 36-year-old Latin American male who presented with rash, sore throat, fever, chills, cough, and diarrhea after chronic mercury vapor exposure and likely intravenous injection. Despite chelation treatment with meso-2,3-dimercaptosuccinic acid (DMSA) and 2,3-dimercaptopropanesulfonic acid (DMPS), the patient's clinical course was complicated by renal failure and he passed away after 18 days. DISCUSSION: The most striking aspect of this case is that despite use of chelators, a dramatic increase in blood mercury level occurred. We discuss the rationale for combined use of chelators with hemodialysis and other treatments such as plasma exchange in the setting of acute mercury poisoning. This case also illustrated the potentially serious side effects of the chelation drug DMSA, and we discuss the potential relevance of dosing frequency to the occurrence rates of such side effects. RELEVANCE TO CLINICAL PRACTICE: Despite the tragic outcome, on review of case literature, we believe this case provides valuable lessons concerning the use of DMSA and DMPS to treat mercury toxicity, particularly with regard to the combined use of chelation agents and hemodialysis.