Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
CROSSMARK LOGO Buy Reprints
PDF

Translate this page into:

Net Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_888_20

Cutaneous mercury granulomas, hyperpigmentation and systemic involvement: A case of mercury toxicity following herbal medication for psoriasis

Department of Dermatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
Corresponding author: Dr. Soumya Jagadeesan, Department of Dermatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India. soumyavivek@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Jagadeesan S, Duraisamy P, Panicker VV, Anjaneyan G, Sajini L, Velayudhan S, et al. Cutaneous mercury granulomas, hyperpigmentation and systemic involvement: A case of mercury toxicity following herbal medication for psoriasis. Indian J Dermatol Venereol Leprol, doi: 10.25259/IJDVL_888_20

Sir,

The use of alternative medicine is increasing across the globe due to the ease of access and favorable public perception about their safety and curative properties. However, there have been multiple reports of heavy metal toxicity following the usage of indigenous medicinal preparations. Although heavy metals used in traditional medicine are supposed to undergo extensive processing, rendering them safe, regulations regarding their manufacturing are found to be inadequate or ineffective. Analyses of preparations available in the market reveal presence of heavy metals in excess of the recommended daily exposure levels.1 Here, we present a case of mercury toxicity with generalized hyperpigmentation and cutaneous mercury granulomas following the use of herbal medicines.

A 65-year-old female, a known case of psoriasis (biopsy proven), under irregular follow-up for past three years - had been treated initially with oral methotrexate for six months, which she had then stopped and currently on topical medication, presented to the dermatology outpatient department with a non-healing ulcer on the lateral aspect of the right leg, just above the lateral malleolus for one month and generalized erythema and scaling for three days. She noticed a fluid-filled lesion on the right leg about one month back which ruptured forming an erosion that then progressed to form a painful ulcer. With a provisional diagnosis of exfoliative dermatitis secondary to psoriasis; she was treated with parenteral methotrexate and supportive treatment along with conservative management of the ulcer. However, she returned after a month with generalized scaling and morphologically different skin lesions – hyperpigmentation with charred appearance of skin [Figure 1] and the leg ulcer was persisting.

Figure 1a:: Charred pigmentation on the face
Figure 1b:: Charred pigmentation on the neck
Figure 1c:: Charred pigmentation on the abdomen

Repeat biopsy taken from the charred truncal lesions showed acanthosis, spongiosis and parakeratotic hyperkeratosis with lichenoid infiltrates and basal cell degeneration. Dermis showed edema with pigment incontinence and lymphocytic infiltrate mixed with eosinophils, plasma cells and histiocytes.

With these findings, the possibility of a superimposed drug reaction was considered. There was no history of any new drug intake; however, she gave a history of intake and application of herbal medications (powders to ingest and oily medications to apply) intermittently for several months. Debridement of the ulcer exuded a silvery fluid, condensing quickly to form spheres which tested to be mercury [Figure 2]. Biopsy from the ulcer showed extracellular round black deposits of mercury in the epidermis surrounded by necrosis [Figure 3]. X-ray of the right leg showed metallic densities in the anterior and lateral aspect of the right leg in the middle and lower 1/3rd of the soft-tissue plane [Figure 4]. Blood levels of mercury were found to be elevated – 101.99 mcg/L (inductively coupled plasma mass spectrometry; reference range: 0.46–7.5 mcg/L). Repeat estimation continued to show increased levels (118 mcg/L).

Figure 2:: Silvery sphere of mercury extruded from ulcer
Figure 3:: Mercury globules surrounded by necrosis (Hematoxylin and eosin, ×100)
Figure 4:: X-ray of the right leg showing metallic deposits

With these findings, the patient was suspected to have mercury toxicity with the ulcer being a cutaneous mercury granuloma. Neurological examination showed muscle weakness and tremors. Blood workup showed no significant abnormalities (Hemoglobin – 11.5 g/dl, random blood sugar – 180.5 mg/dl, sodium – 139 mmol/L and potassium – 4.8 mmol/L). Nerve conduction studies showed decreased amplitude in bilateral lower limbs. Chelation therapy with oral d-penicillamine (500 mg six hourly) was initiated for a period of seven days. Her symptoms including the charred appearance and pigmentation [Figure 5] improved. Her ulcer started to heal and she was discharged in a stable condition.

Figure 5:: Resolution of pigmentation post-chelation therapy

The presentation of mercury toxicity varies with form, route and duration of exposure. Systemic adverse events include gastroenteritis and nephrotoxicity (mercury salts); neurological and teratogenic effects (organic mercury) and interstitial pneumonitis and neuropsychiatric symptoms (elemental mercury vapors). In children, chronic exposure to any form of mercury can cause acrodynia.

Cutaneous hyperpigmentation can occur due to application of mercury containing topical agents or occupational exposure. We hypothesize that the charred hyperpigmentation seen in our patient was most likely due to mercury (perhaps, a lichenoid reaction, given the histopathological findings), considering the rapid improvement post-chelation therapy. Other dermatological adverse effects reported include acute contact dermatitis, lichenoid tattoo reaction, oral lichenoid reactions from mercury in dental amalgam and mercury exanthema.2

Introduction of elemental mercury into skin and soft tissue causes a localized granulomatous reaction called cutaneous mercury granuloma. Most reported cases are following traumatic inoculation with a few caused by self-injection.3 Repeated application of preparations containing mercury on wounds has been known to induce granulomas, as may have occurred in our case.2 Systemic toxicity associated with cutaneous mercury granuloma has been reported only in a few cases.4 Histopathological examination shows black spherical mercury globules surrounded by collagen necrosis in early cases, like ours; whereas, late lesions show mercury deposits surrounded by granulomatous foreign body reaction and mixed inflammatory infiltrate.5

The growing popularity of traditional Indian remedies necessitates a critical evaluation of associated risks. Clinicians should be aware of varied presentations of heavy metal toxicity when patients provide history of alternative medicine usage. Providing proper general awareness to consumers and producers, quality control and pharmacovigilance are needed to minimize these adverse events.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , , , , et al. Lead, mercury, and arsenic in US-and Indian-manufactured Ayurvedic medicines sold via the Internet. JAMA. 2008;300:915-23.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , . Mercury exposure and cutaneous disease. J Am Acad Dermatol. 2000;43:81-90.
    [CrossRef] [PubMed] [Google Scholar]
  3. . Soft-tissue injury by mercury from a broken thermometer: A case report and review of the literature. Am J Clin Pathol. 1974;61:296-300.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , . Cutaneous mercury granuloma: A case report. Cutis. 2011;88:189-93.
    [Google Scholar]
  5. , , , , . Cutaneous mercury granuloma. A clinicopathologic study and review of the literature. J Am Acad Dermatol. 1985;12:296-303.
    [CrossRef] [Google Scholar]

Fulltext Views
4,008

PDF downloads
40
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections