Cutaneous and Chest X‐Ray Manifestation in a Patient With Chronic Systemic Mercury Poisoning With Embolism

A 37-year-old woman received multiple intravenous injections over 15 days from a traditional medicine practitioner for an acute febrile illness 3 years earlier. About 1 month after the injections, she developed multiple subcutaneous nodules that began at the injection sites on the arms and then spread centrifugally to involve both upper limbs, the abdomen, and the dorsum of the tongue. The nodules progressively enlarged, later ruptured with purulent discharge containing silvery metallic globules, and healed with residual post-inflammatory hyperpigmentation (Figure 1). Chest radiography showed multiple punctate, high-density opacities that were initially dismissed as artifacts. Further evaluation with computed tomography (CT) and positron emission tomography–CT (PET–CT) revealed widespread, high-attenuation metallic emboli (2000–3000 Hounsfield units) in the lungs, liver, brain, and kidneys, findings consistent with systemic deposition of elemental mercury [1, 2]. Laboratory investigations demonstrated markedly increased 24-h urinary mercury excretion (> 100 μg/mL) with a normal serum mercury level (0.96 ng/mL). She was treated with D-penicillamine 1 g/day in divided doses for two weeks, then switched to dimercaptosuccinic acid (DMSA) 100 mg three times daily for 3 weeks, which resulted in significant clinical improvement (Figure S1). After 2 weeks of treatment, repeat testing showed urinary mercury levels decreased to 31 μg/mL while serum mercury levels paradoxically increased to 253 ng/mL, a pattern consistent with the “chelation challenge.” [3] Recurrent nodules, ulceration, discharging sinuses, or hyperpigmentation arising from injection sites should prompt consideration of mercury toxicity. Important clinical mimickers include cutaneous tuberculosis, atypical mycobacterial infection, foreign-body granuloma, sarcoidosis, deep fungal infections, subcutaneous vasculitis, and panniculitis [4]. Mucocutaneous involvement especially in the oral cavity favors a toxic etiology. Prompt recognition, supported by imaging and 24-h urinary mercury estimation, is essential because early chelation can reverse cutaneous lesions and prevent irreversible systemic injury. The authors thank the Department of Dermatology and Nephrology for their technical and clinical support in the diagnosis and management of this case. The authors have nothing to report. Institutional review board approval was not required for this single-patient case report, in accordance with institutional policy. Informed consent was obtained from the patient for publication of this case and associated images. The authors declare no conflicts of interest. All relevant data supporting the conclusions of this report are included within the article. Further details or anonymized raw data can be made available from the corresponding author on reasonable request. Figure S1: Posttreatment clinicoradiological images. (a) Chest radiograph showing reduction in diffuse pulmonary opacities. (b) Skin over forearm showing marked reduction in previously noted linear hyperpigmented lesions. (c) Oral cavity showing reduction in tongue discoloration and surface lesions with restoration of a healthier mucosal appearance. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.