Metal Poisoning (Lead, Arsenic, Iron)

Heavy metals poisoning is the toxic accumulation of metals in the body, which can occur due to ingestion or inhalation. These elements are normally found in nature and can have many applications (e.g., agriculture, medicine, industry); however, toxicity is rare. Common metals that the human body absorbs in toxic amounts are lead, arsenic, and iron. Presentation is variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables and management involves the use of chelating agents.

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Lead Poisoning

Etiology

Lead poisoning, also known as plumbism, may result from inhalation or ingestion of lead from:

  • Lead paint
  • Food and drinks in lead-soldered cans
  • Contaminated tap water
  • Lead bullets
  • Occupational exposure (e.g., batteries, ammunition, construction, renovation, alcohol distillation with lead soldering)

Pathophysiology

  • Hematologic effects:
    • Contributes to RBC membrane fragility → hemolysis
    • Inhibits ferrochelatase and aminolevulinic acid dehydratase ( enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes in the heme synthesis pathway) → ↓ hemoglobin synthesis
    • Inhibits ribosomal RNA RNA Ribonucleic acid (RNA), like deoxyribonucleic acid (DNA), is a polymer of nucleotides that is essential to cellular protein synthesis. Unlike DNA, RNA is a single-stranded structure containing the sugar moiety ribose (instead of deoxyribose) and the base uracil (instead of thymine). RNA generally carries out the instructions encoded in the DNA but also executes diverse non-coding functions. RNA Types and Structure degradation → RBCs retain aggregates of rRNA → basophilic stippling
  • Neurologic effects:
    • Lead displaces calcium ions → ↑ blood-brain barrier permeability → allows lead to cross and contributes to cerebral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Accumulation in astroglial cells and prevents myelin sheath formation → demyelination

Clinical presentation

Children:

  • Poor appetite
  • Nausea and vomiting
  • Lead lines on gingival border (Burton lines) 
  • Headaches
  • Encephalopathy
    • Somnolence
    • Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
    • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
  • Developmental delay
  • Behavioral changes

Adults:

  • Nonspecific symptoms:
    • Fatigue
    • Insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia
    • Arthralgia and myalgia
  • Gl symptoms: 
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
    • Anorexia
  • Neurological manifestations:
    • Headache
    • Short memory loss
    • Cognitive deficits
    • Peripheral neuropathy (e.g., wrist drop, foot drop, sensory neuropathies)
  • Chronic exposure leads to: 
    • Nephropathy
    • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension 
    • ↑ Risk of cardiovascular mortality
Lead line in gingiva - metal poisoning

Clinical findings associated with lead poisoning:
a. lead line along the gingival border (Burton lines)
b. wrist drop as a consequence of peripheral neuropathy

Image: “Radial neuropathy due to occupational lead exposure” by Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), India. License: CC BY 2.0

Diagnosis

  • In children, dense metaphyseal lines can be seen on X-ray (lead concentrates in metaphyses of growing bones):
    • Distal femur
    • Both ends of tibia
    • Distal radius 
  • Initial screening test: capillary (fingerstick) lead measurement
  • Confirmatory test: venous lead measurement
  • Other findings:
    • Normocytic or microcytic anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
    • Erythrocyte basophilic stippling on peripheral smear
    • ↑ Serum zinc protoporphyrin level
Giemsa stain of coarse basophilic stippling or erythrocytes due to lead poisoning

Wright-Giemsa–stained smear of peripheral blood: coarse basophilic stippling of the erythrocytes Erythrocytes Erythrocytes, or red blood cells (RBCs), are the most abundant cells in the blood. While erythrocytes in the fetus are initially produced in the yolk sac then the liver, the bone marrow eventually becomes the main site of production. Erythrocytes

Image: “Wright-Giemsa stained smear” by Yale Cancer Center, Section of Hematology, Yale University School of Medicine, New Haven, CT 06511, USA. License: CC BY 2.0

Management

  • Remove any source of lead exposure.
  • Nutritional interventions 
  • Provide lead education for the family.
  • In a child with acute lead ingestion, consider orogastric or nasogastric tube with whole-bowel irrigation (polyethylene glycol).
  • Chelation therapy:
    • Indicated for: 
      • Asymptomatic children with a blood lead level ≥ 45 μg/dL
      • Asymptomatic adults with a blood lead level ≥ 80 μg/dL
      • Symptomatic patients
    • Options:
      • 1st line: dimercaprol 
      • Calcium disodium edetate

Arsenic Poisoning

Etiology

  • Herbicides (vineyard workers)
  • Insecticides 
  • Metal smelting
  • Contaminated water (often from wells) 
  • Pressure-treated wood

Pathophysiology

  • Arsenic causes glycolysis Glycolysis Glycolysis is a central metabolic pathway responsible for the breakdown of glucose and plays a vital role in generating free energy for the cell and metabolites for further oxidative degradation. Glucose primarily becomes available in the blood as a result of glycogen breakdown or from its synthesis from noncarbohydrate precursors (gluconeogenesis) and is imported into cells by specific transport proteins. Glycolysis to produce zero net ATP.
  • Arsenic inhibits lipoic acid (part of pyruvate dehydrogenase complex).
  • Binds to sulfhydryl groups 
  • Disrupts cellular respiration and gluconeogenesis Gluconeogenesis Gluconeogenesis is the process of making glucose from noncarbohydrate precursors. This metabolic pathway is more than just a reversal of glycolysis. Gluconeogenesis provides the body with glucose not obtained from food, such as during a fasting period. The production of glucose is critical for organs and cells that cannot use fat for fuel. Gluconeogenesis

Clinical presentation

Acute:

  • General:
    • Garlic breath
    • Dehydration 
  • GI:
    • Vomiting
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Watery diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea 
  • Cardiopulmonary:
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
    • QT prolongation
    • Cardiac arrhythmias
    • Shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome
  • Acute encephalopathy:
    • Delirium Delirium Delirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium
    • Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
    • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
  • Renal:
    • Proteinuria
    • Acute renal failure

Chronic:

  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin manifestations: 
    • Mees lines on fingernails (transverse white bands)
    • Pigmentation (hypo or hyper) 
    • Hyperkeratosis
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin cancer ( squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma)
  • Stocking-glove neuropathy:
    • Burning
    • Painful hypersensitivity
    • Distal weakness
    • Hyporeflexia
  • Liver cancer (angiosarcoma) 
  • Lung cancer Lung cancer Lung cancer is the malignant transformation of lung tissue and the leading cause of cancer-related deaths. The majority of cases are associated with long-term smoking. The disease is generally classified histologically as either small cell lung cancer or non-small cell lung cancer. Symptoms include cough, dyspnea, weight loss, and chest discomfort. Lung Cancer
  • Pancytopenia

Diagnosis

  • Suspected through history and physical examination
  • Hemolytic anemia Hemolytic Anemia Hemolytic anemia (HA) is the term given to a large group of anemias that are caused by the premature destruction/hemolysis of circulating red blood cells (RBCs). Hemolysis can occur within (intravascular hemolysis) or outside the blood vessels (extravascular hemolysis). Hemolytic Anemia may be seen.
  • Urine arsenic level 
  • Plasma arsenic concentrations (helpful, but rarely available until after the decision to treat is made)

Management

  • Decontamination of the skin and GI tract
  • Supportive care
  • Chelation therapy in symptomatic patients only:
    • Dimercaprol (1st line)
    • Succimer (dimercaptosuccinic acid (DMSA))
    • Unithiol (2,3-Dimercapto-1-propanesulfonic acid (DMPS))
  • Hemodialysis in severe cases

Iron Poisoning

Etiology

  • Accidental ingestion by children (iron tablets may look like candy) 
  • Can be chronic in patients requiring multiple transfusions of RBCs

Epidemiology

Iron toxicity is one of the leading causes of deaths by poisoning in children < 6 years.

Pathophysiology

Absorption of excessive quantities of ingested iron can lead to:

  • Cellular toxicity:
    • Impaired oxidative phosphorylation and mitochondrial dysfunction → cellular death
    • The liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver is the most affected organ.
    • In chronic overload, iron deposits into myocardial cells → myocardial siderosis and death
  • Corrosive toxicity:
    • Iron is corrosive to GI mucosa.
    • Leads to GI symptoms and potential blood loss

Clinical presentation

  • Stage 1: GI
    • < 6 hours after ingestion
    • Nausea
    • Diarrhea
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Hemorrhagic gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis:
      • Hematemesis
      • Melena
    • Capillary leak/3rd spacing → hypovolemia or shock
  • Stage 2: latent
    • 6–24 hours after ingestion
    • GI symptoms resolve → patient seems to improve and recover
    • Some patients may demonstrate: 
      • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
      • Metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
      • Oliguria
  • Stage 3: metabolic/cardiovascular
    • 6–72 hours after ingestion
    • Metabolic acidosis Metabolic acidosis The renal system is responsible for eliminating the daily load of non-volatile acids, which is approximately 70 millimoles per day. Metabolic acidosis occurs when there is an increase in the levels of new non-volatile acids (e.g., lactic acid), renal loss of HCO3-, or ingestion of toxic alcohols. Metabolic Acidosis
    • Cardiovascular symptoms
      • Tachycardia
      • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
      • Pallor
      • Shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • Central nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. General Structure of the Nervous System symptoms:
      • Stupor
      • Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
    • GI hemorrhage
    • Acute lung injury or ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome
    • Coagulopathy
    • Renal dysfunction
    • Most deaths occur in this stage.
  • Stage 4: hepatic
    • 12–96  hours after ingestion
    • ↑ Liver enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes and bilirubin levels 
    • Coagulopathy
    • Hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia may accompany liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver dysfunction.
  • Stage 5: delayed
    • 2–8 weeks after ingestion
    • Scarring of the GI tract → gastric outlet or intestinal obstruction

Diagnosis

  • Suspected by history and physical examination 
  • Serum iron levels will confirm the diagnosis.
  • Supporting studies: 
    • ↑ Anion gap metabolic acidosis
    • Check liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver function, CBC, coagulation factors, glucose, and renal function tests.
  • Abdominal imaging may show radiopaque tablets in the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach.

Management

  • Stabilize the patient.
  • IV fluids
  • Orogastric lavage and/or whole-bowel irrigation is indicated in patients with a significant number of radiopaque pills in the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach on imaging.
  • Chelation therapy (IV deferoxamine, oral deferasirox) is indicated if any of the following is present: 
    • Severe symptoms (altered mental status, hemodynamic instability, persistent vomiting, and/or diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • ↑ Anion gap metabolic acidosis 
    • Serum iron concentration > 500 μ/dL  
    • Significant number of pills on abdominal X-ray
  • Dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis (exchange transfusion or continuous veno-venous hemofiltration) is indicated if chelation therapy fails to improve patient symptoms.

Differential Diagnosis

  • Sideroblastic anemia Sideroblastic anemia Sideroblastic anemias are a heterogeneous group of bone marrow disorders characterized by abnormal iron accumulation in the mitochondria of erythroid precursors. The accumulated iron appears as granules in a ringlike distribution around the nucleus, giving rise to the characteristic morphological feature of a ring sideroblast. Sideroblastic Anemia: microcytic anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview in which the bone marrow Bone marrow Bone marrow, the primary site of hematopoiesis, is found in the cavities of cancellous bones and the medullary canals of long bones. There are 2 types: red marrow (hematopoietic with abundant blood cells) and yellow marrow (predominantly filled with adipocytes). Composition of Bone Marrow produces sideroblasts (ring-shaped RBCs) instead of normal, round-shaped RBCs due to the inability of the body to place iron properly into hemoglobin. Lead poisoning inhibits the conversion of protoporphyrins necessary for heme synthesis, resulting in sideroblastic anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview.
  • Esophagitis Esophagitis Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Esophagitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation or irritation of the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus. The major types of esophagitis are medication induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia, and retrosternal chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain. Diagnosis is by endoscopy and biopsy. Management depends on the etiology but includes medications and possible surgery.
  • Herbicides: substances used to control the growth of unwanted plants and in the construction industry. Different types of herbicides result in different clinical manifestations. Early management and treatment are important to prevent further intoxication.
    Pesticides: chemical substances used to control pests, including weeds. Important types include organochlorines (dichlorodiphenyltrichloroethane (DDT)) and organophosphates (malathion and parathion). Different types of pesticides result in different clinical manifestations. Early management and treatment are important to prevent further intoxication.

References

  1. Blumenberg, A. (2019). Arsenic Toxicity Clinical Presentation. Emedicine. Retrieved March 14, 2021, from https://emedicine.medscape.com/article/812953-clinical
  2. Buggs, A. (2021). Emergent Management of Lead Toxicity. Emedicine. Retrieved March 15, 2021, from https://emedicine.medscape.com/article/815399-overview#a4
  3. Spanierman, C. (2020). Iron Toxicity. Emedicine. Retrieved March 14, 2021, from https://emedicine.medscape.com/article/815213-overview
  4. Sample, J. (2020). Childhood lead poisoning: Clinical manifestations and diagnosis. UpToDate. Retrieved March 14, 2021, from https://www.uptodate.com/contents/childhood-lead-poisoning-clinical-manifestations-and-diagnosis
  5. Goldman, R. and Hu, H. (2020). Lead exposure and poisoning in adults. UpToDate. Retrieved March 14, 2021, from https://www.uptodate.com/contents/adult-occupational-lead-poisoning
  6. Golfman, R. (2020). Arsenic exposure and poisoning. UpToDate. Retrieved March 13, 2021, from https://www.uptodate.com/contents/arsenic-exposure-and-poisoning
  7. Liebelt, E. (2020). Acute iron poisoning. UpToDate. Retrieved March 13, 2021, from https://www.uptodate.com/contents/acute-iron-poisoning

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