Agency for Toxic Substances and Disease Registry 
Case Studies in Environmental Medicine (CSEM) 
Chromium Toxicity
Clinical Assessment - History, Signs and Symptoms

Learning Objectives

Upon completion of this section, you will be able to

• describe characteristic clinical presentations of patients with acute and chronic chromium exposure.

Introduction

Characteristic clinical presentations of patients with Cr(VI) compound exposure include

• sinusitis, nasal septum perforation,
• allergic and irritant dermatitis, skin ulcers,
• respiratory irritation, bronchitis, asthma, and
• lung cancer [Lewis 2004].

Patient History and Physical Examination

Often, no clear diagnostic clues exist in chromium-exposed patients. A thorough history is therefore critical in evaluating a potentially exposed person.

The patient's recent activities are important. Occupation, location of residence and workplace in relation to industrial facilities or hazardous waste sites, and source of drinking water supply should be investigated.

In patients with known chronic chromium exposure, the physical examination should include evaluation of the respiratory system, kidneys, liver, and skin.

Signs and Symptoms

Acute Exposure

Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005].

Severe exposures to Cr(VI) compounds are usually accidental or intentional (suicide), and are rarely occupational or environmental.

Oral intake of Cr(VI) compound may cause

• intense gastrointestinal irritation or ulceration and corrosion,
• epigastric pain,
• nausea,
• vomiting,
• diarrhea,
• vertigo,
• fever,
• muscle cramps,
• hemorrhagic diathesis,
• toxic nephritis,
• renal failure,
• intravascular hemolysis,
• circulatory collapse,
• liver damage,
• acute multisystem organ failure, and
• coma, and even death, depending on the dose [Hay, Derazon et al. 2000; Lewis 2004; Meditext 2005].

Acute Cr(VI) poisonings are often fatal regardless of the therapy used. The average oral lethal dose of Cr(VI) in humans is 1-3 grams (Meditext 2005).

Systemic symptoms and death have occurred after external burns, with a delay of onset of gastrointestinal symptoms of hours and days. Burns initially resemble first and second degree burns, but extend to subcutaneous tissue within a couple of days [Schiffl, Weidmann et al. 1982; Meditext 2005].

Chronic Exposure

Repeated skin contact with chromium dusts can lead to incapacitating eczematous dermatitis with edema. Chromate dusts can also produce irritation of the conjunctiva and mucous membranes, nasal ulcers and perforations, keratitis, gingivitis, and periodontitis [Cohen and Costa 1998].

When a solution of chromate contacts the skin, it can produce penetrating lesions known as chrome holes or chrome ulcers, particularly in areas where a break in the epidermis is already present. These commonly occur on the fingers, knuckles, and forearms. The characteristic chrome sore begins as a papule, forming an ulcer with raised hard edges. Ulcers can penetrate deep into soft tissue or become the sites of secondary infection, but are not known to lead to malignancy. [Geller 2001; Lewis 2004; Meditext 2005].

Lung cancer is the most serious long-term effect [Cohen and Costa 1998; Lewis 2004; Meditext 2005]. Apart from the carcinogenic potential, prolonged exposure can result in bronchitis, rhinitis, or sinusitis or the formation of nasal mucosal polyps. Besides the lungs and intestinal tract, the liver and kidney are often target organs for chromate toxicity [Rom 2007].

Reports on adverse effects from low-level environmental exposures in human populations are limited. Hudson County, NJ, was a major center for the processing of chromium ore. A study using immune-function assay described reduced production of cytokines in individuals who were exposed to chromate [Snyder, Udasin et al. 1996]. Long-term studies in which animals have been exposed to low levels of chromium in food or water have produced no harmful effects [ATSDR 2000].

Key Points

• Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact.
• Severe exposures to Cr(VI) compounds are usually accidental or intentional (suicide), and are rarely occupational or environmental.
• In occupational settings, the most commonly reported effects of chronic chromium exposure are contact dermatitis and irritation and ulceration of the nasal mucosa.
• Lung cancer is a potential long-term effect of chronic Cr(VI) exposure.
• Besides the lungs and intestinal tract, the liver and kidney are often target organs for chromate toxicity from chronic exposure.

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