Hyperintense lesions in brain MRI after exposure to a mercuric chloride-containing skin whitening cream

Abstract

Exposure to inorganic mercury (Hg) is a serious problem presenting with a combination of neurological and psychiatric symptoms along with weight loss, pruritus, erythema, arterial hypertension, tachycardia, and renal tubular dysfunction. We report a 4-year-old girl with chronic intoxication of inorganic mercury secondary to the accidental use of an Hg₂Cl₂- and HgCl₂-containing skin whitening cream (urine level of Hg, 41.1 μg/l; reference level, < 25 μg/l). Under treatment with dimercapto-1-propansulficacid, Hg level in the urine raised to 1,175.5 μg/l, neurological deterioration occurred, and brain magnetic resonance imaging (MRI) showed on fluid attenuated inversion recovery sequences new hyperintense lesions in the subcortical white matter. After 4 months, clinical signs and symptoms and brain MRI findings resolved. This is a first case of inorganic mercury poisoning showing hyperintense lesions in brain MRI and confirms earlier cases showing transient deterioration during chelation therapy. Although urinary excretion could be enhanced during chelation therapy, signs and symptoms of intoxication could be worsened.

Dementia, epilepsy and polyneuropathy in a mercury-exposed patient: investigation, identification of an obscure source and treatment

“…One corresponding MRI showed hyperintense lesions in the cerebral white matter, globus pallidus and putamen. NSE levels can be elevated 5 6. Our patient showed a set of symptoms not classically associated with mercury poisoning but similar MRI lesions and an elevated NSE.…”

“…Patients with inorganic mercury intoxications show neurological and psychiatric symptoms like fatigue, insomnia, weakness and acrodyna and general symptoms like pruritus, erythema, renal tubular dysfunction and nephrotic syndrome 5. One corresponding MRI showed hyperintense lesions in the cerebral white matter, globus pallidus and putamen.…”

Pediatric mercury poisoning, brain MRI, and white matter hyperintensities

“…In their valuable article of the first description in the literature of inorganic mercury salt poisoning associated with white matter lesions (WMLs) on T 2 -weighted MR images of the brain, Benz et al [1] describe a 4-year-old girl with a nonfatal percutaneous inorganic mercury intoxication due to topical application of mercurycontaining skin lightening cream. The authors are to be commended on their case report as they also provide an excellent discussion of the effects of chelation therapy with 2,3-dimercapto-1-propanesulfonic acid.…”

“…The authors are to be commended on their case report as they also provide an excellent discussion of the effects of chelation therapy with 2,3-dimercapto-1-propanesulfonic acid. In the "Introduction section" of their case report, Benz et al state that, "Data about magnetic resonance imaging (MRI) findings in intoxication from inorganic Hg did not exist up to now" [1].…”

“…We also wish to highlight the important finding in the case study of Benz et al [1] that overexposure to inorganic mercury salts was associated with elevated serum neuron-specific enolase (NSE) levels in response to mercury-induced neurotoxic injury, following damage to neuronal membranes. This observation is very interesting and concurs with our own anecdotal experiences.…”