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Agency for Toxic Substances and Disease Registry
Case Studies in Environmental Medicine (CSEM)
Arsenic Toxicity
Case Study and Pretest
A 35-year-old carpenter has peripheral neuropathy and skin lesions
A fair-skinned, 35-year-old male is referred to your clinic for evaluation. His symptoms began approximately 3 months ago, with his chief complaint being insidious onset of numbness and tingling in his toes and fingertips, progressing slowly in the ensuing weeks to involve the feet and hands in a symmetric "stocking-glove" fashion. In the past 2 to 3 weeks, the tingling has taken on a progressively painful, burning quality, and he has noted weakness when gripping tools. A review of systems (ROS) reveals no ataxia, dysphagia, visual symptoms, or bowel or bladder incontinence, and the patient has not complained of headaches, back, neck pain, or confusion.
The patient's past medical history is remarkable for a flulike illness that occurred approximately 4 months ago and was characterized by 3 to 4 days of fever, cough, diarrhea, and myalgias, which resolved spontaneously.
Further questioning regarding the patient's social history reveals that he has been a carpenter since completing high school 17 years ago. For the last 10 years, he has lived in a rural, wooded area in a home he built. Approximately 10 months ago he married, and moved with his wife, an elementary school teacher, into a newly built home on an adjacent parcel of land. The patient consumes one to two alcoholic drinks a week, and quit smoking two years ago, but has a history of smoking approximately 15 packs a year. He takes one multivitamin a day, but no prescription medications. Family history is unremarkable; his wife, parents, and two younger brothers are in good health.
The physical exam demonstrates vital signs, as well as head, eyes, ears, nose, and throat (HEENT), to be within normal limits. Respiratory, cardiovascular, and abdominal signs are also normal to auscultation and palpation, and there is no hepatosplenomegaly. Joints show full range of motion (FROM), with no erythema or swelling. There is no lymphadenopathy.
Neurologic examination reveals diminished proprioception in the hands and feet, with a hyperesthetic response to pinprick sensation on the soles. Motor bulk and tone are normal, but there is slight bilateral muscular weakness in dorsiflexors of the toes and ankles, wrist extensors, and hand intrinsics. Reflexes are absent at the ankles and 1+ at the biceps and knees. Coordination and cranial nerve function are within normal limits. A dermatologic examination reveals brown patches of hyperpigmentation, with scattered overlying pale spots in and around the axillae, groin, nipples, and neck. The palms and soles show multiple hyperkeratotic cornlike elevations, 4 to 10 millimeters (mm) in diameter. Three irregularly shaped, sharply demarcated, erythematous, scaly plaques, measuring 2 to 3 centimeters (cm), are noted on the patient's torso. The remainder of the physical examination is normal.
On initial laboratory evaluation, the complete blood count (CBC) shows slight macrocytic anemia with hematocrit 35% (normal range 40% to 52%) and mean corpuscular value (MCV) 111 femtoliters (fL) (normal range 80 to 100 fL). White blood cell count (WBC) is 4.3 × 103/mm3 (normal range 3.9 to 11.7 × 103/mm3); the differential reveals moderate elevation of eosinophils at 9% (normal range 0% to 4%). Occasional basophilic stippling is noted on the peripheral smear. Liver transaminases are slightly elevated. Blood urea nitrogen (BUN), creatinine, and urinalysis are normal.
- What problem list is suggested for this patient?
- What further investigations would you undertake at this time?
- What treatment options would you consider?
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