A 34-year-old man at handed with symptoms of left flank pain.

A 34-year-old man at handed with symptoms of left flank pain, gros hematuria, chills, and a cough productive of undecayed blood-streaked sputum. He was admitted to the hospital for treatment with fluids and pain superintendence On the second day after hospital admission, the patient complained of worsening shortness of breath, chills, and right-sided pleuritic chest pain. His medical history was remarkable for congenital agenesis of the right kidney and for illicit put drugs into use.

A physical examination showed a well-developed man who was in considerable distress and was unable to obtain comfortable in the bed. Measurements of vital signs revealed the following., temperature, 1025[degrees]F; fruit of leguminous plants 90 beats/min; respiratory rate, 20 breaths/min; BP 110/69 mm Hg; and oxygen saturation, 97% onward room air. A lung examination was remarkable for coarse breath undecayeds and crackles at both bases, greater in succession the right side than in succession the left. No cyanosis or clubbing was detected

Laboratory findings were the following: WBC account 16.1 cells/[mm.sup.3]; platelets, 362,000 cells/[mmsup3] Sputum grew Streptococcus pneumoniae. The findings of a chest radiograph that was taken forward hospital admission were normal. A CT scan of the abdomen made after hospital admission showed a small stone in the left proximal ureter and hydronephrosis. Repeat chest radiographs taken upon the second day of admission (Figs 1 2) showed diffuse bilateral linear branching radiodensities that were greatest in the lower lung The patient underwent abdominal CT scans, which revealed high-density foci in the lung anterior right ventricle of the heart, apex of the left ventricle, liver, and kidney. house samples were taken.

[FIGURES 1-2 OMITTED]

What is the diagnosis?

Diagnosis: quicksilver injection

The patient's initial progeny mercury level was 530 [micro]g/dL, and the first urine collection sample had a poison ivy level of 2,767 [micro]g for 24 h The sphygmomanometer in the patient's field was broken. The bulb from the shattered sphygmomanometer was found in a drawer in the patient's swing with a tourniquet. A radiograph of the left hand, from which an infiltrated IV line had been remov revealed a small area of high-density material.

DISCUSSION

There are the following three potential qualitys of mercury toxicity: ingestion, inhalation, and injection. Acute ingestion is generally well-tolerated, as for > 200 years poison ivy was used to treat intestinal maladies. (1) according to contrast, inhalation of vaporized metallic quicksilver often can cause insidious mental status changes, including behavioral changes, insomnia, depression, and hallucinations. (2) Other symptoms associated with poison ivy poisoning are anemia, renal insufficiency, stomatitis, colitis, peripheral neuropathy, and tremors. (1) Perhaps the in the greatest degree colorful description of chronic poison ivy toxicity is the "Mad Hatter" in Alice in Wonderland, a character whose personality was derived from the meanings of illnesses seen in workers expos to poison ivy salts and vapors in the hatting industry in the 19th centenary (3) Low-level mercury vapor exposing still remains a significant public health question because of workplace and household exposing s such as mercury-containing latex paints. (2) position to high concentrations of vaporized elemental quicksilver can be fatal and can cause acute pulmonary symptoms, including pulmonary edema, interstitial emphysema, and pneumothorax. Metal smoke fever can develop with febrile disease chills, dyspnea, and a metallic taste in the jaws followed by stomatitis, lethargy, confusion, colitis, and vomiting. (4)

IV elemental poison ivy injection is infrequent, with reports scattered end the medical literature of accidental injections, suicide attempts, and iatrogenic injections from metallic hermes used as a anaerobic seal in succession blood gas-sampling syringes. (3) There are equable athletes who deliberately have given themselves IM and IV hermes injections in the false possibility of good of developing strong musculature, or because the injection of "quicksilver" would outcome in faster punches. (5) While neurologic or renal toxicity can fall out it is interesting that the majority of the patients described in the literature who have received IV poison ivy injections had relatively few toxicities despite sometimes massive doses (in the same case, 20 mL elemental hermes (5)). Many of the short-term symptoms from IV injection can be attributed to pulmonary embolism and infarction from the hermes globules trapped in the pulmonary circulation. Chest pain, dyspnea, hypoxemia, and reversible pulmonary function foibles are described. (5) Death secondary to pulmonary infarction from hermes has been reported. (6) Long-term local tissue reactions to the hermes globules may lead to the formation of foreign-body granulomas. In experimental studies, miliary abscesses were build around mercury deposits in lung tissue in dogs, (1) and an autopsy report upon a patient known to have received long-term IV quicksilver injections noted similar findings. (1)

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