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Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023
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Image courtesy of Dr Abbas Koronfel.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
A 45-year-old man presented to the emergency department (ED) in February complaining of vomiting, watery diarrhea, lightheadedness, and headache. He had arrived in town the previous night to present at a conference and was staying at a local hotel. His roommate experienced similar, but less severe, symptoms. The patient received intravenous (IV) fluids, ondansetron, and ketorolac, and he was discharged a few hours later after feeling much better. The next morning, the patient failed to show up for his conference presentation. He was found in bed without a pulse and could not be resuscitated. His skin appeared pink and blotchy in places (shown).
Which of the following tests could have made the diagnosis on his initial presentation to the ED?
Carboxyhemoglobin (COHb)
Hemoglobin (Hb)
Serum bicarbonate
Methemoglobin (metHb)
White blood cell (WBC) count
Image courtesy of Dr Abbas Koronfel.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: A. Carboxyhemoglobin (COHb)
Two classic, but rare, dermatologic findings that are associated with CO poisoning are a cherry-red skin coloring (shown) and the development of cutaneous bullae; these occur only after excessive exposure.[1]
Carbon monoxide (CO), an odorless, colorless, poisonous gas, can cause sudden illness and is a leading cause of US poisoning deaths.[2,3] The patient in this case had a COHb level of 68% (normal range: 0-5%). The most common and earliest symptoms of CO poisoning are usually nonspecific (headache, confusion, dizziness, weakness, nausea/vomiting, chest pain),[2,3] and they are often diagnosed as a viral syndrome.
Initial therapy consists of administering 100% oxygen via mask or endotracheal tube until the patient is symptom-free, and performing serial neurologic exams.[2,4,5] Hyperbaric oxygen therapy may be necessary in severe cases (eg, COHb level >25-30%, cardiac involvement, neurologic impairment).
In the setting of any suspected poisoning, call Poison Control at 1-800-222-1222 or use the webPOISONCONTROL online tool for guidance. If someone is unconscious, not breathing, or having seizures, call 911 immediately.
Image from Mead MN. Environ Health Perspect. 2005;113(6):A378-86 PMID: 15929879; PMCID: PMC1257621. [Public domain.]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
This patient has patchy skin hyperpigmentation on her arms (shown), back, and chest. Her pertinent medical history includes water ingestion from a well over a prolonged time period.
Which of the following contaminants should be suspected in the water?
Strychnine
Foxglove
Arsenic
Cyanide
Belladonna
Image from Anita Ghosh/REACH via Flickr. [Creative Commons Attribution License 2.0 Generic (CC by 2.0).]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: C. Arsenic
The pigmented lesions in arsenic poisoning often present as bilateral, symmetrical, finely freckled or raindrop-like macules (shown).
Arsenic poisoning is often caused by industrial/workplace exposure[6,7]; ingestion of contaminated groundwater, food, or moonshine[6,7]; or malicious intent.[7] Arsenic affects nearly all organ systems,[7] but the skin is most sensitive to its effects.[6,7] Patchy hyperpigmentation,[6,7] a pathologic hallmark of chronic exposure, may be found anywhere on the body, but it occurs particularly on the eyelids, temples, neck, nipples, axillae, and groin. In severe cases, it extends broadly over the chest, back, and abdomen. Dark-brown patches with scattered pale spots are sometimes described as "raindrops on a dusty road."
Other signs/symptoms include vomiting, abdominal pain, diarrhea, paresthesia of the extremities, muscle cramping, and cardiac, neurologic, pulmonary, hepatorenal, and hematologic dysfunction.[6,7] A garlic odor may be present in the breath and body tissues.[7]
Image courtesy of Medscape.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
In addition to hyperpigmentation, the skin lesions that most often occur with chronic arsenic exposure are hyperkeratosis and several types of skin cancer[6,7] (eg, basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma).[8] Liver, bladder, and lung cancer can also arise.[6,7] Arsenical keratoses (shown) are usually multiple lesions and typically occur at sites of friction and trauma, especially on the palms and the soles,[6,7] as well as on the dorsum of the hands and the arms and legs. The keratoses usually appear as small, nontender, horny, hard, yellowish, 0.2- to 1-cm papules; the lesions may coalesce into larger verrucous papules or plaques. Benign arsenical keratoses may progress to malignancy.
Workup for arsenic poisoning includes urinary and serum arsenic levels, hematologic studies, arterial blood gases (ABGs), electrocardiography (ECG), and chest and abdominal radiographs.[7] In acute cases, aggressively monitor/support the patient's cardiopulmonary and hemodynamic functions, irrigate exposed areas, provide IV hydration, and, in symptomatic patients, administer chelation therapy.[9] For chronic cases, identify and, if possible, remove the toxic source.
Image courtesy of Medscape.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
A 25-year-old man who worked in a semiconductor manufacturing plant developed mild, persistent abdominal pain with intermittent severe pain and constipation. Three days after the initial painful episode, his hair started to fall out (shown); 2 days later, he was completely bald. One month later, he felt pain and tingling in his hands and feet and developed difficulty speaking, blurred vision, and trouble walking. He was hospitalized; 2 weeks later, he became comatose.
Which of the following was responsible for his signs/symptoms?
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: C. Thallium (Tl)
Mees lines, white lines that traverse the width of the nails (shown) (first described in arsenic poisoning), appear up to 4 weeks after Tl exposure.[10]
Tl can be absorbed into the body by inhalation, ingestion, and skin contact.[11] Alopecia is the most common and classic manifestation of Tl toxicity; it occurs 7-12 days after the initial onset of symptoms, and complete hair loss often occurs by 1 month.[10] (Se and arsenic toxicity can also cause rapid-onset alopecia.) A painful ascending neuropathy and gastrointestinal (GI) symptoms are also characteristic. In severe cases, death may occur 5-7 days after exposure.[11] Although many effects of Tl poisoning are nonspecific and occur over a variable time course, a clear toxic syndrome can be defined when the effects are combined.
Workup includes urinary, blood, and quantitative atomic absorption levels of Tl; liver function tests (LFTs); complete blood cell (CBC) count; ECG; plain abdominal radiography; and electromyography (EMG). Therapy includes cardiopulmonary support, activated charcoal, whole bowel irrigation with polyethylene glycol solution, Prussian blue (antidote), and hemodialysis/hemoperfusion.[10,11]
Image from Wikimedia Commons | James Heilman, MD. [CC by-SA 3.0.]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
A 74-year-old female with dermatitis herpetiformis presented to the ED with confusion, lightheadedness, weakness, and mild headache, as well as a grayish discoloration of the skin. She recently started dapsone, and her CBC was within normal limits. Despite treatment with 100% oxygen, the discoloration remained.
What is the most likely diagnosis?
Drug-induced dyspigmentation
Methemoglobinemia
Raynaud disease
Metabolic acidosis
Congestive heart failure
Image courtesy of Medscape.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: B. Methemoglobinemia
In the image above, the metHb fraction in tubes 1 and 2 is 70%, with the blood appearing brown. In tube 3, the metHb fraction is 20%, whereas in tube 4, it is normal.
Methemoglobinemia is a congenital or acquired condition in which red blood cells contain over 1% metHb[12] and hemoglobin (Hb) is unable to effectively release oxygen to body tissues.[13] Acquired causes include exposure to various chemicals (eg, organic and inorganic nitrites/nitrates, chlorates), foods, and drugs, including dapsone.[12,13] Symptoms are proportional to the metHb level; the most striking physical finding is discoloration of the skin (cyanosis or a grayish pigmentation) and blood (brown or chocolate).[12] At metHb levels of over 15%, neurologic and cardiac symptoms develop due to hypoxia; levels of over 70% are usually fatal. Suspect this condition when 100% oxygen fails to correct cyanosis.
Workup includes routine blood tests (eg, CBC with reticulocyte count, electrolyte levels), liver and renal function tests, Hb electrophoresis and/or DNA sequencing, ABGs and/or pulse oximetry, potassium cyanide test, and head, chest, and cardiac imaging studies.[12] Therapy includes administration of supplemental oxygen, IV hydration, and IV methylene blue; identification and, if possible, removal of the underlying cause; exchange transfusions; and hyperbaric oxygen therapy.[12,13]
Image from Wikimedia Commons | Grook Da Oger. [Creative Commons Attribution License Share Alike 4.0 International (CC by-SA 4.0).]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
While on vacation in the Caribbean, a couple had a local dinner of rice, cooked vegetables, mahi-mahi, and wine. An hour after eating, they both developed headaches and palpitations, and they started to feel a tingling sensation in their mouths. In addition, they noticed that their faces, necks, and chests had turned intensely red (the husband's eyes are shown). Because their skin also felt itchy, they took some diphenhydramine after returning to their hotel. A few hours later, their symptoms were almost gone.
Which of the following types of poisoning was the couple likely exposed to?
Paralytic shellfish
Tetrodotoxin
Ciguatera
Scombroid
Vibrio parahaemolyticus
Image courtesy of Amanda Oakley, MBChB, FRACP.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: D. Scombroid poisoning
Cutaneous symptoms of scombroid poisoning include an intense, diffuse, blanching erythema of the face, neck, and upper torso (shown).
Scombroid poisoning results from eating cooked, smoked, canned, or raw fish from temperate or tropical waters that have a high concentration of histidine in their dark meat (eg, tuna, mackerel, mahi-mahi, sardine, anchovy, herring, bluefish, amberjack, marlin, albacore).[14,15] Certain bacteria commonly found on the surface of the fish contain a heat-stable histidine decarboxylase enzyme that acts on warm (not refrigerated), freshly killed fish, converting histidine to histamine.
The onset of symptoms usually occurs 10-60 minutes after ingestion of the contaminated fish. Aside from cutaneous manifestations, symptoms include severe headache, palpitations, blurred vision, and GI features. Rarely, pruritus, urticaria, angioedema, and cardiopulmonary compromise may occur. Symptoms often resolve without treatment within 12 hours. Therapy includes supportive care (eg, IV fluids, antiemetics, cardiopulmonary support) and antihistamines.[14,15]
Image from Wikimedia Commons | Muumi. [CC by-SA 3.0.]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
A politician became seriously ill in the midst of a bitter campaign for presidency. After a dinner meeting, he complained of a headache, severe abdominal pain, and severe backache. He was initially diagnosed with acute pancreatitis. Then, a few weeks later, his face became jaundiced, bloated, and pockmarked (shown). He claimed to have been poisoned at the dinner meeting by government agents.
Which of the following chemical agents should be the suspected toxin?
Cyanide
Dioxin
Strychnine
Lead
Barbiturates
Adapted image from Furue M, Takahara M, Nakahara T, Uchi H. Arch Dermatol Res. 2014;306(9):769-79. PMID: 24966027; PMCID: PMC4220966. [CC Attribution License.]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: B. Dioxin
On the basis of the distinctive facial cysts (chloracne) (shown), toxicologists suspected dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin [TCDD]) poisoning. Testing confirmed blood dioxin levels that were 6000 times above the normal concentration.[16,17] Dioxins are a group of highly toxic, colorless organic compounds that are byproducts of some industrial processes and waste incineration; they are significant environmental pollutants.[18,19] Agent Orange is a dioxin that was used in the Vietnam War.[20] These agents can cause organ disease, increase the risk of cancer and heart attacks, suppress the immune system, interfere with hormones, and lead to diabetes, menstrual problems, increased hair growth, and weight loss.[18,19]
Workup includes LFTs, CBC, coagulation studies, and electrophysiologic studies, as well as the use of gas chromatography and high-resolution mass spectrometry to measure levels of TCDD and its metabolites in blood serum, adipose tissue, skin, and other biologic samples (urine, feces, sweat).[17] Treatment primarily consists of supportive care and symptomatic management. Unfortunately, chloracne is resistant to methods that are used to treat acne vulgaris.[21]
Image courtesy of American Academy of Dermatology | Universidad Peruana Cayetano Heredia.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
A patient presented with a lesion on his finger (shown). The lesion had a moist base.
Which causative agent should be suspected?
Typhus
Q fever
Brucellosis
Anthrax
Tularemia
Image courtesy of the American Academy of Dermatology.
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: D. Anthrax
Cutaneous anthrax is typically caused when individuals handle infected animals or contaminated animal products (eg, wool, hides, hair), and Bacillus anthracis spores enter through microscopic or gross breaks in the skin[22]; the head/neck and forearms/hands are most often affected.[23] A pruritic papule develops at the infection site and enlarges within 24-48 hours (range, 1-7 days) to form a 1-cm vesicle; subsequently (=7-10 days), a large, painless, necrotic ulcer with a black center (eschar) develops (shown).[23,24] Cutaneous anthrax often remains localized, but it can disseminate and result in bacteremia.
Workup for cutaneous disease includes detection/isolation of B anthracis, culture identification/genotyping, and serology.[23] Therapy for local disease includes a 7- to 10-day course of an oral antibiotic (fluoroquinolones, doxycycline, or, if the organism is susceptible, penicillin/amoxicillin/penicillin VK)[23,24] and/or an antitoxin (raxibacumab, anthrax immune globulin intravenous [AIGIV]).[24] Cutaneous anthrax is rarely fatal (<2% mortality) if treated.[23] Left untreated, however, about 5-20% of cutaneous cases progress to toxemia and death.[24]
Image from the CDC. [Public domain.]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
A patient presents several days after the onset of skin lesions on her face and extremities (left hand, right arm, and right thigh are shown). The facial lesions are more sparse and evolved more rapidly than the lesions on her extremities. What disease, considered to be a potential biologic weapon, is shown?
Yellow fever
Dengue
Venezuelan equine encephalitis
Ebola virus
Smallpox
Image from the CDC. [Public domain.]
Poisoning Clues on the Skin: 8 Cases
Jessica Harmon, MD; Raffi Kapitanyan, MD | November 10, 2023 | Contributor Information
Answer: E. Smallpox
Smallpox is a highly contagious, sometimes fatal disease that is spread through direct contact with infected bodily fluids or contaminated objects or via the air.[25,26] Owing to the efficacy of worldwide immunization, however, smallpox has been eradicated, with the last naturally acquired case reported in 1977 (although small quantities of the virus have been kept for research purposes).[25]
Variola major is the more severe (30% fatality) form of smallpox; variola minor is a milder disease (=1% fatality).[27] The characteristic and contagious smallpox rash first appears as small, red spots in the oropharynx that spread to the face and forearms and become small papules. The papules change into vesicles and pustules within 1-2 days and, in turn, form crusts and then scabs.[27] Patients are no longer contagious after all of the scabs fall off.[27]
Workup includes identification of variola DNA via polymerase chain reaction (PCR) assay or isolation of the variola virus, with PCR assay confirmation, in a CDC Laboratory Response Network facility.[28] No specific treatment exists; the only prevention is vaccination.[29] Because of the ease of production and aerosolization of the smallpox virus, there is concern about its potential use as a bioterrorism agent.
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Contributor Information
Authors
Jessica Harmon, MD
Special Operations Physician, Emergency Medicine
TeamHealth
Disclosure: Jessica Harmon, MD, has disclosed no relevant financial relationships.
Raffi Kapitanyan, MD
Partner, Brunswick Urgent Care
Emergency Medicine
Franklin Park/East Brunswick, NJ
Disclosure: Raffi Kapitanyan, MD, has disclosed no relevant financial relationships.
Reviewer
Brett Sloan, MD, FAAD
Professor of Dermatology
Residency Program Director
University of Connecticut School of Medicine;
Connecticut Veterans Affairs Healthcare System;
Editor-in-Chief
Journal of the American Academy of Dermatology Case Reports
Disclosure: Brett Sloan, MD, FAAD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for: Journal of the American Academy of Dermatology
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References
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MedlinePlus. Carbon monoxide poisoning. US National Library of Medicine. Reviewed: January 2, 2023. Available at: https://medlineplus.gov/ency/article/002804.htm. Accessed October 6, 2023.
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Sorg O, Zennegg M, Schmid P, et al. 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) poisoning in Victor Yushchenko: identification and measurement of TCDD metabolites. Lancet. 2009 Oct 3;374(9696):1179-85. PMID: 19660807
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Ju Q, Zouboulis CC, Xia L. Environmental pollution and acne: chloracne. Dermatoendocrinol. 2009 May;1(3):125-8. PMID: 20436879
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Hendricks K, Vieira AR, Traxler R, Marston CK. Travel-related infectious diseases. Anthrax. In: Nemhauser JB, Halsey E, LaRocque R, eds. CDC Yellow Book 2024: Health Information for International Travel. New York, NY: Oxford University Press; 2023: section 5. Available at: https://wwwnc.cdc.gov/travel/yellowbook/2024/infections-diseases/anthrax. Accessed October 13, 2023.
Savransky V, Ionin B, Reece J. Current status and trends in prophylaxis and management of anthrax disease. Pathogens. 2020 May 12;9(5):370. PMID: 32408493
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