Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2021
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2021
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Practice

Pink ladies: mercury poisoning in twin girls

Michael Weinstein and Stacey Bernstein
CMAJ January 21, 2003 168 (2) 201;
Michael Weinstein
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Stacey Bernstein
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Metrics
  • Responses
  • PDF
Loading

Previously well, developmentally normal 20-month-old twin girls presented with weakness, anorexia, a papular rash and increasingly swollen, red and painful hands and feet of 1 month's duration. They had no history of fever, conjunctivitis, lymphadenopathy or oral changes characteristic of Kawasaki disease. The children appeared irritable and unwell and were diaphoretic but afebrile. Both had tachycardia, and one had an elevated blood pressure of 130/90 mm Hg (95th percentile for age 108/62 mm Hg). Both children had reduced muscle power and diminished reflexes. Their palms and soles were erythematous and indurated with desquamation, judged to be acrodynia (Figs. 1 and 2).

Figure1
  • Download figure
  • Open in new tab
  • Download powerpoint

Figure 2. Photo: Images courtesy Dr. Michael Weinstein

Figure2
  • Download figure
  • Open in new tab
  • Download powerpoint

Figure 1. Photo: Images courtesy Dr. Michael Weinstein

Mercury toxicity was suspected, and further questionning revealed that the infants had been given a mercury-containing “teething powder” from India once or twice a week over the 4 preceding months. The girls' blood mercury levels were 176 and 209 (normally < 18) μmol/L. Chelation therapy with 2,3-dimercaptosuccinic acid was administered through nasogastric tubes. Before admission the twins had regressed developmentally and were unable to feed orally, sit or walk. Over the 8 weeks in hospital they showed some minor neurocognitive improvements, but their long-term prognosis is uncertain.

Mercury exists in inorganic and organic forms. Organic mercury has recently received attention because of the accumulation of methylmercury in some predatory fish1 and the use of thimerosal as a preservative in some vaccines.2 A type of inorganic mercury known as calomel (“sweet mercury”) was once commonly used to treat many ailments, including yellow fever, typhus and syphilis.3 Until the recognition of their toxicity in the 1940s, calomel-based teething powders caused a scourge of mercury poisoning called “pink disease” or acrodynia among infants and children.4

Acrodynia is characterized by a dusky pink discolouration, swelling, paresthesia and desquamation of the hands and feet. Symptoms of catecholamine excess such as sweating and hypertension occur because mercury blocks the degradation pathway of catecholamines. Other manifestations of mercury toxicity include renal dysfunction, peripheral neuropathy and neuropsychiatric symptoms (e.g., emotional lability, memory impairment and insomnia). Although calomel-containing compounds are banned in North America, they are still used in other parts of the world such as Southeast Asia, and calomel can also be found in various alternative medicine products.5

Clinical presentations suggestive of pheochromocytoma (e.g., excessive sweating, tachycardia and hypertension) or of Kawasaki disease but not meeting the full criteria6 should also prompt consideration of mercury toxicity. Although rash, oral mucosa and extremity changes are features of both Kawasaki disease and mercury toxicity, patients with the latter do not have a fever. Rash and extremity changes are not features of pheochromocytoma. The peeling of the skin on the extremities seen in cases of Kawasaki disease often occurs 1–3 weeks after presentation, as opposed to occurring concurrently with the rash and other findings in cases of mercury poisoning. Mercury poisoning is confirmed by measuring levels in blood, urine or hair samples.7,8

The most important step in the management of mercury poisoning is eliminating the source of exposure. The effectiveness of chelation therapy in reversing symptoms is not entirely clear.9

Our case stresses the potential harm of mercury. It reminds us to think of a toxic exposure when family members present with the same unusual constellation of symptoms. It also highlights the common misconception that all alternative medicines are safe and benign.10

Michael Weinstein Stacey Bernstein Department of Pediatrics Hospital for Sick Children Toronto, Ont.

References

  1. 1.↵
    Wooltorton E. Facts on mercury and fish consumption. CMAJ 2002;167(8):897.
    OpenUrlFREE Full Text
  2. 2.↵
    Exposure to thimersal in vaccines used in Canadian infant immunization programs, with respect to risk of neurodevelopmental disorders. Can Commun Dis Rep 2002;28(9):69-80.
    OpenUrlPubMed
  3. 3.↵
    Ozuah PO. Mercury poisoning. Curr Probl Pediatr 2000;30(3):91-9.
    OpenUrlCrossRefPubMed
  4. 4.↵
    Dally A. The rise and fall of pink disease. Soc Hist Med 1997;10(2):291-304.
    OpenUrlAbstract
  5. 5.↵
    Chopra A, Doiphode VV. Ayurvedic medicine: core concept, therapeutic principles, and current relevance. Med Clin North Am 2002;86(1):75-89.
    OpenUrlCrossRefPubMed
  6. 6.↵
    Han RK, Sinclair B, Newman A, Silverman ED, Taylor GW, Walsh P, et al. Recognition and management of Kawasaki disease. CMAJ 2000; 162 (6): 807-12.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    Weir E. Methylmercury poisoning [letter]. CMAJ 2001;165(9):1194.
    OpenUrlFREE Full Text
  8. 8.↵
    Ruedy J. Methylmercury poisoning [letter]. CMAJ 2001;165(9):1193-4.
    OpenUrlFREE Full Text
  9. 9.↵
    Baum C. Treatment of mercury intoxication. Curr Opin Pediatr 1999;11:265-8.
    OpenUrlCrossRefPubMed
  10. 10.↵
    American Academy of Pediatrics. Counseling families who choose complementary and alternative medicine for their child with chronic illness or disability. Pediatrics 2001;107(3):598-601.
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top

In this issue

CMAJ
Vol. 168, Issue 2
21 Jan 2003
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Pink ladies: mercury poisoning in twin girls
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Pink ladies: mercury poisoning in twin girls
Michael Weinstein, Stacey Bernstein
CMAJ Jan 2003, 168 (2) 201;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Pink ladies: mercury poisoning in twin girls
Michael Weinstein, Stacey Bernstein
CMAJ Jan 2003, 168 (2) 201;
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • References
  • Figures & Tables
  • Responses
  • Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Rash, Diaphoresis, Anorexia, and Loss of Motor Skills in a 10-month-old Boy
  • Interpreting Mercury in Blood and Urine of Individual Patients
  • Corrections
  • Google Scholar

More in this TOC Section

Practice

  • Asymptomatic hydrocephalus
  • How to use antihistamines
  • Pseudoaneurysm of the brachial artery in a patient who uses intravenous drugs
Show more Practice

Clinical Vistas

  • The mystery of the broken bones
  • Elderly woman with rapidly growing, ulcerated pigmented lesion
  • Cat naps: an elderly woman with recurrent syncope
Show more Clinical Vistas

Similar Articles

Collections

  • Topics
    • Pediatrics
    • Environmental issues

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of the resources on this site in an accessible format, please contact us at cmajgroup@cmaj.ca.

Powered by HighWire