A 16-Month-Old Girl With Cough and Proteinuria

Melanie Malloy, MD, PhD; Sage W. Wiener, MD

Disclosures

December 10, 2015

Discussion

The patient exhibited signs of subacute mercury toxicity, most likely from exposure to inorganic mercury in the mother's skin-lightening cream. Her symptoms were likely related both to ingestion and dermal absorption of the mercury salt, resulting in the hypertension, characteristic pink discoloration of the hands and feet, and proteinuria, as well as inhalational exposure of mercury vapor from the cream resulting in the pulmonary findings.

Although federal law has banned mercury in concentrations >1 ppm from products made in the United States, mercury can be found as mercurous chloride (calomel) at high concentrations (≤210,000 ppm has been reported) in various cosmetic creams used to lighten the skin.[1] These products are readily available via the internet or internationally.

The principal route of toxicity is via ingestion; however, several cases of dermal and inhalational exposure have been documented.[2,3,4] The dermal absorption of mercury increases with prior hydration, making beauty creams an especially potent source of mercury toxicity. It is also excreted in breastmilk, which is another possible source of exposure in this patient.[5] Infants and toddlers are especially susceptible to toxicity from mercury-containing skin creams for numerous reasons. First, they are likely to be in close contact with family members using beauty products and are susceptible to inhaling mercury vapors, which have been found to be as high as 230 µg/m3 emanating from users' hands, far above the safe level of 1 µg/m3 set by the Environmental Protection Agency.[1] More importantly, because of the frequency of hand-to-mouth behaviors, they can ingest the material after coming into contact with users of the cream or with contaminated surfaces. Finally, their smaller size means that a smaller exposure, such as an indirect exposure via a family member, can result in toxicity because the dose per kilogram of body weight is higher. Specifically, inhaled doses are more toxic due to the larger lung surface area and minute ventilation per kilogram of body weight.[6]

Inorganic mercury is poorly lipid soluble and crosses the blood-brain barrier much less readily than organic mercury; however, chronic exposure can affect the brain. Large acute ingestions lead to corrosive gastroenteritis, with drooling, dysphagia, abdominal pain, and bloody diarrhea, followed by renal injury progressing to renal insufficiency, which results either in renal failure or eventual resolution, depending on the dose. This patient's exposure was likely more insidious, with dermal and inhalational exposure from close contact to her mother as well as possible ingestion of the cream.

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