Erythroid karyorrhexis in the peripheral blood smear in severe arsenic poisoning: a comparison with lead poisoning.

Three men with severe arsenic poisoning were hospitalized with working diagnoses, respectively, of peptic ulcer, pancreatitis, and viral gastroenteritis. In the first two patients, correct diagnosis was delayed until the return of heavy-metal screening tests ordered because of painful peripheral neuropathy in one and sudden flaccid paralysis, resembling Guillain-Barré syndrome, in the other. Both patients had coarsely stippled red blood cells with markedly abnormal nuclei in their peripheral blood smears. These distinctive hematologic features led to an early diagnosis in the third patient. The author's review of past cases of lead poisoning showed that red blood cell karyorrhexis also tends to occur in patients who consume illicit whiskey ("moonshine"). Karyorrhexis or marked dyserythropoiesis in the peripheral smear, not heretofore described in arsenic or lead poisoning, may indeed be a unique hematologic clue. Scrutiny of the peripheral blood and/or buffy coat smear in patients with perplexing gastrointestinal or neurologic symptoms may enable earlier diagnosis and better therapy of arsenic poisoning.