A 16-Month-Old Girl With Cough and Proteinuria

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

Disclosures

December 10, 2015

Treatment of mercury toxicity is with chelation therapy and differs by the form of mercury. First-line treatment for inorganic mercury toxicity in the United States is British anti-Lewisite (BAL, dimercaptopropanol). The standard dose of BAL is 3-5 mg/kg intramuscularly every 4 hours for 2 days, followed by 2.5-3 mg/kg every 12 hours for 7 days, or until 24-hour urine levels of mercury are below 50 µg/L. Alkalinization of the urine helps to stabilize the BAL-mercury complex and can be considered. Side effects include nausea, headache, and abdominal pain. Because of this, oral treatment with succimer (2,3-dimercaptosuccinic acid) can also be considered for treatment of inorganic mercury poisoning, especially for subacute or chronic exposures. D-penicillamine is an alternative chelator; however, serious side effects such as thrombocytopenia, rash, leukopenia, and gastrointestinal distress limit its use when compared with succimer or BAL.

BAL must be used with caution in cases of organic mercury toxicity because it may further mobilize mercury into the brain. Limited data have shown succimer to be a better choice for acute methylmercury toxicity; however, due to the insidious nature of most organic mercury toxicity, as well as the generally irreversible effects thereof, chelation therapy has a limited role in these cases.

In this case, the patient was successfully treated with a course of succimer, with complete resolution of symptoms within 2 months. The home was decontaminated with garden sulfur, with a decrease in mercury vapor levels to acceptable levels.

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