A 54-year-old male with past medical history of degenerative joint disease, major depressive disorder, polysubstance dependence, and history of childhood burn presented to the Emergency Department (ED) complaining of imbalance, irritability, outburst of temper, fatigue, and weakness for the last five days after he ingested five ounces (oz) (148 cc) of mercury as a suicidal attempt. In the ED, the patient denied any changes in vision, hearing impairment, or tremors. He also denied shortness of breath, abdominal pain, nausea, vomiting, or diarrhea.
On physical examination, the patient appeared to be in no obvious distress. He seemed well developed, alert, and oriented to time, place, and person. Vital signs (BP 144/96, HR 74, RR 16, and temperature 96.3). A neurological examination yielded intact cranial nerves, with normal motor function and no sensory deficits. Abdominal examination showed a distended and nontender abdomen with normoactive bowel sounds. The rest of the physical examination showed no abnormalities.
On admission, laboratory workup was done and showed hemoglobin of 13.9 gm/dl (normal range 13.5-17.5), platelet of 309 k/ul (normal range is 40-440), WBC of 8 k/ul (normal range 4-12), a mildly elevated creatinine at 1.4 mg/dl (eGFR 56) (reference range 0.6-1.3 mg/dl), and a low potassium at 3.5 (reference range 3.7-5.1 mg/dl). A urine drug screen was done which was positive for amphetamine, benzodiazepine, and cannabinoid. A mercury toxicology workup was initiated and showed an elevation in serum mercury level at 110 microg/l (reference range < 10 microg/l), urine mercury level at 37 microg/l (reference range < 10 microg/l), and 24-hour urinary mercury level at 248 microg (no exposure < 20 microg/24, inconclusive 20-150 microg/24h, and potentially toxic > 150 microg/24h). Initial abdominal X-ray (Figure 1) showed diffuse radiopaque material visualized throughout the colon.
Due to the patient's toxic mercury levels and worrying neurological signs and symptoms, the patient was admitted to the intensive care unit with a one on one sitter available at his bedside. Vital signs, neurological checks, and electrolytes were measured on regular basis. The poison-control team was consulted upon admission and recommended starting the patient on succimer, as a chelating agent, to be given in a dose of 500 mg every eight hours for the first 5 days then every twelve hours for the 14 days. The patient was also started on polyethylene glycol 17 gm twice a day and magnesium citrate to enhance GI motility along with intravenous fluids and continuous replacement of electrolytes. The neurology team was consulted for further evaluation of the patient neurological complaints. They agreed with the current plan of care; head computed tomography (CT) was performed and showed no intracranial abnormalities.
The psychiatry team was asked to assess the patient for his suicidal attempt and was evaluated as nonsuicidal at that time and was started on escitalopram 10 mg. Bedside sitter was discontinued.
The patient was showing slow progress in term of feeling weak, fatigue, and imbalance during his stay but remained hemodynamically stable. The patient was transferred out of the ICU to the floor, and serial abdomen X-rays were done. The patient was having recurrent bowel movements on daily basis, and X-rays showed continued decrease in the amount of mercury in the descending colon with interval increase in the hyperdense materiel in the cecum and ascending colon. Mercury levels were trended during the patient's hospitalization, and results are shown in Table 1.
The gastroenterology team was consulted and recommended placing a nasogastric tube and to give 4 liters of polyethylene glycol through the tube and magnesium citrate every 8 hours in an attempt to enhance gastrointestinal motility and hasten mercury clearance. Repeated X-rays showed no advancement of the hyperdense material which remained in the cecum and ascending colon. The decision was made to do a colonoscopy for an attempt of colonoscopic decompression (Figure 2). The colon was evacuated with copious amount of washing, and a repeat abdominal X-ray showed decreased hyperdense material in the colon with a nonobstructive gas pattern (Figure 3). The patient was discharged in a good condition after a 10-day hospital stay and followed up after 3 months; at that time, he had a mercury level of 33, and an abdominal X-ray showed no hyperdense material in the colon (Figures 4 and 5). The patient followed up again 1 month later. His neurological symptoms resolved, and kidney function preserved. Also, his mercury level was trending down at 18.