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Arsenic (Sankhyal, Somalkar) / hepatotoxic

heavy metallic inorganic irritant poison


metallic arsenic (black coloured) is not poisonous as it is insoluble in water &
is not absorbed from the alimentary canal
salts of arsenic (oxides of Arsenic, Na or K Arsenite, sulphides, scheele's
green (copper arsenite)) are poisonous eg: As when volatilized by heat:
arsenic unites with O2 & forms poisonous vapour of arsenic trioxide;
arsenious oxide or arsenic trioxide (sankhyal or somalkar) is poisonous: it
irritates tissue,depresses NS & prevents tissue respiration
2 organic arsenic non toxic variants mostly present in food regularly
consumed by humans are arsenobetaine & arsenocholine---they are found in
shell fish, cod, haddock
organic & inorganic arsenic compounds
physical properties:
colourless, odourless, tasteless
insoluble in water
small quantity can kill a person (a pinch of arsenic oxide can kill 6-7 persons)
used in printing & dye industries, insecticides to kill rats, in drugs, ointments,
fairness creams, as magic powder white variety is introduced to males to
attract them, little amount of arsenic act as aphrodisiac
Action:
interferes with cellular respiration by combining with SH groups of
mitochondrial enzymes, esp pyruvate oxidase, certain phosphatases,
particular target: vascular endothelium, leading to increased permeability,
tissue edema, hhg; esp in intestinal canal; locally it causes irritation of
mucous membrane, remotely depression of nervous system; arsenate causes
its toxicity by uncoupling mitochondrial oxidative phosphorylation; it
interferes with glycolysis
FD: 0.1-0.2 g ARSENIC TRIOXIDE; FP: 1-2 days
signs & symptoms
The fulminating
type (acute
fulminating type)

Massive dose (3-5


gm)- rapidly
absorbed; symp:
within an hr;

The gastroenteric
type (Subacute
type or common
form of acute
type): - 1hr after
ingestion; delayed
when taken with
food (2hr);
sweetish metallic
taste
Small doses of As
given at repeated
intervals;
resembles case of

Narcotic form

Chronic type

Very slight GI symptoms;


giddiness, formication,
tenderness of muscles;
delirium, coma & death;

Persons
engaged in
smeltering or
refining ore or

inhibition of SH
enzyme necessary
for cellular
metabolism

cholera or bacterial
food poisoning;
first dyspepsia,
cough & tingling in
throat (constriction
in throat, difficulty
swallowing,
burning colicky
pain, intense thirst,
severe projectile
vomiting)

rarely there is complete


paralysis of extremities

Death in 1-3 hrs


from shock &
peripheral
vascular failure

Followed by
vomiting, purging
(within 1-3 hrs)
with pain abdomen
& tenesmus,
irritation about
anus

Late sequelae of acute


exposure: haematuria,
acute tubular necrosis,
anaemia, leucopaenia,
thrombocytopaenia , (????
bone marrow suppression,
hypoplasia, leukaemia)

All capillaries are


markedly dilated,
esp in splanchnic
area (gi)with
marked fall in BP
(capillary
poisoning action)

Stool: expelled
frequently &
involuntarily, darkcoloured, stinking
& bloody first; then
later colorless,
odourless, watery
(rice-water stools
of cholera), garlicky
odour of breath &
faeces

long-term
exposure to As
compounds
(accidental
ingestion of
repeated small
doses by those
working with
metal, or by
food /drink with
traces of drug;
recovery from
large dose;
homicidal due
to repeated
small dose)
GIT: N/v, abd
cramps,
diarrhea,
salivation,
gradual wt
loss,
malnutrition,
fatigue, loss of
appetite, liver
cirrhosis
Skin:
pigmentation
consists of a
finely mottled
brown change
mostly on the
skin flexures,
temples,
eyelids & neck
which persists
for many
months
(raindrop type
of
pigmentation),
rash resemble
fading measles
rash ,

Direct action on
heart muscle
(myocardial
failure)

Hepatic: fatty
infiltration; renal:
oliguria, uraemia,
urine contains
albumin, red cells
& casts, pain
during micturition

GI symptoms are
absent

CVS: acute
circulatory collapse
with vasodilation,
increased vascular
permeability,
ventricular
tachycardia,
ventricular
fibrillation; skin:
delayed loss of
hair, skin
eruptions, death
due to circulatory
failure

Replaces P4 in

CNS: headache,

prolonged
contact:
hyperkeratosis
of palm, sole,
with irregular
thickening of
nails (BCC)&
dev of
transverse
white lines in
fingernails
(Aldrich-Mees
lines); alopecia
Arsenical
neuritis (CNS):
polyneuritis,
optic neuritis,
anesthesia,
paresthesia,
encephalopath
y, atrophy of
extensors
leading to wrist
& foot drop
Catarrhal
changes:
running nose,
headache,
conjunctivitis,
bronchial
catarrhal, eyes:
congestion,
watery,
photophobia;
hepatomegaly,
cirrhosis,
jaundice;
anaemia, wt
loss, hair loss,
brittle nails;
cough,
hemoptysis,
dyspnea
Chronic

bone ; gets
deposited in bone,
hair

vertigo,
hyperthermia,
tremors,
convulsions, coma,
general paralysis, a
peripheral
neuropathy
(sensory > motor)
asymmetric, distal
stocking-glove
distribution after 12 weeks of acute or
chronic exposure

nephritis,
cardiac failure,
dependent
oedema

Mees's lines: the victim's nails manifest whitish lines 1-2 mm breadth across
the nails of the fingers & toes, representing deposition of poison (As) as a
result of high sulphhydryl content of keratin (also seen in Thallium); linear

transverse pigmentation seen in thallium or arsenic poisoning

Trait

Pain in throat
Purging
Stools

Tenesmus & anal irritation


Vomited matter
Voice
Conjunctivae
Analysis of excreta

Arsenic poisoning
(subacute/acute
gastroenteric type)
Before vomiting
After vomiting
Dark-colred & bloddy,
later rice-watery
Present
Contains mucus, bile &
blood
Not affected
Inflamed
Arsenic present

Cholera

After vomiting
Before vomiting
Rice-watery, not bloody &
passed in continuous
involuntary jet
Absent
Watery without mucus,
bile, blood
Rough & whistling
Not inflamed (normal)
Cholera vibrio present

Circumstantial evidence
Pain in throat

Of As poisoning may be
present
Present before vomiting

Other cases of cholera in


locality
No pain or after vomiting

PM appearanceof acute poisoning


-

External: body is dehydrated (eyes sunken, body shrunken), skin is


pigmented or rarely jaundiced, hands & feet cyanosed (skin cyanosed), with
Mee's lines on the nails, RM unusually longer
Internal:
mouth, pharynx, oesophagus: usually not affected; in some cases inflamed or
ulcerated
mouth-mucosa inflamed or ulcerated
lesions are mainly found in stomach; mucosa: swollen, oedematous, & red
either generally or in patches, esp in pyloric region; there may be lines of
redness running along the walls or curved lines of submucous hhgs; usually
groups of petechiae are seen scattered over the mucosa & sometimes large
submucosal & subperitoneal hemorrhages; stomach mucosa resembles red
velvet; small acute ulcerations or large erosions may be found, esp at the
pyloric end; a mass of sticky mucus covers the mucosa in which particles of
arsenic may be seen; congestion is most marked along the crest of
rugae;inflammation is more marked at the greater curvature & posterior part
& cardiac end of stomach
SI: appears flaccid, contains large flakes of mucus with very little faecal
matter, mucosa is pale-violet & shows signs of inflammation with submucous
haemorrhages along its whole length
LI: caecum & rectum show slight inflammation, sometimes arsenic penetrates
through the walls of stomach, appears in liver, omentum & endocardium
if putrefaction has taken place: yellow streaks will be found in subperitoneal
layer of stomach & to less extent of the intestines due to absorbed arsenic
been converted into sulphide
in fulminating type: stomach & intestines may not show signs of inflammation
liver, spleen, kidneys: congested, enlarged, cloudy swelling, occasionally fatty
change
lungs: congested; subpleural ecchymoses
nephritis: glomerular type
haemorrhages in the abdominal organs, mesentries, occasionally in larynx,
trachea & lungs
brain: oedema, patchy necrosis or haemorrhagic encephalitis; congested
meninges
GIT: mucosa red & inflamed with submucous hhg, velvet or crimson plus
stomach

stomach contents dark


stomach: velvety red or brownish, patchy areas with small ulceration seen on
the stomach mucosa, gastric contents emit garlicky odour
heart: subendocardial petechial hhg of the ventricles (seen inarsenic
poisoning or even when stomach shows little signs of irritation; typical of As
poisoning but also found in poisoning by P4, Ba, Hg, & cases like heat stroke,
acute infectious disease like influenza or in traumatic asphyxia)
few days: fatty deposits occur in heart, liver, kidneys
kidneys: acute tubular necrosis
other viscera(liver, kidney, heart): fatty degeneration
brain: acute encephalitis with haemorrhagic spots
death by As: X-ray may show presence of arsenic in GIT; arsenic values in
liver & blood in excess of 1 mg % are usually present
T/T: i) emetics are not recommended
ii) empty & wash stomach repeatedly with large amounts of luke warm
water & milk; washed at intervals to remove iron compounds & adherent
arsenic
iii) butter & greasy substances prevent absorption
iv) alkalis should not be given as they increase solubility of arsenic
v) freshly precipitated hydrated ferric oxide orally in small doses converts
toxic arsenic to non-toxic ferric arsenite
vi) BAL or penicillamine
vii) DMSA (succimer) or DMPS instead of BAL
viii) demulcents lessen irritation
ix) castor oil or MgSO4 to prevent intestinal absorption of arsenic
x) glucose-saline with NaHCO3 : to combat shock & improve alkali reserve
xi) haemodialysis or exchange transfusion: renal failure
xii) chelation therapy: ineffective in arsenic poisoning

CHRONIC POISONING PM CHANGES


-

stomach: normal or chronic gastritis, some rugae may show patchy


inflammatory redness, some cases: patchy hhg gastritis with acute & chronic
erosions
SI: dilated, reddened, with thickened mucosa
kidney : tubular necrosis
liver: fatty or severe necrosis
there may be jaundice
T/t: remove pt from source of exposure; administration of BAL
PM imbibition of arsenic:
in exhumation (lawful digging): possibility of imbibitions of arsenic from
stomach into neigbouring viscera, also contamination from surrounding earth
(arsenic found in soil is usually an insoluble salt, keratin tissues absorb
arsenic by contamination from outside ----so concentration in hair & nails thus
contaminated is much likely to be greater than concentration of arsenic in
contaminating fluid; if arsenic is introduced in stomach after death, the

transudation occurs into the organs of the left side before those of right & the
signs of inflammation & ulceration are absent
Tolerance: some people take arsenic daily as a tonic or as an aphrodisiac; &
they acquire tolerance upto 0.3 g or more in one dose; such people are
known as arsenophagists
CHEMICAL TEST/diagnosis (reinsch's & marsh's test are absolete)
1) Reinsch's test: 1-2 strips of bright copper foil + suspected acidified soln /
previously acidulated (HCl)---boil for 5-10 mins-------cooling of copper foil
with steel gray or black deposit arsenic-------wash it with DW, alcohol,
ether-----put in test tube & heat---white deposit on cooler portion of test
tube ------------take deposit on a slide------------under microscope-----------octahedral crystal of arsenic (white deposits of arsenious oxide:
octahedral crystal on microscopy) (RCC-REINSCH'S: HCl +Cu)
2) Marsh's test: sensitive test ; can detect small quantity arsenic 1/1000 mg;
based on the principle that arseniuretted hydrogen is liberated when
nascent hydrogen reacts with arsenic; thus a suspected material is
exposed to nascent hydrogen formation of hydrogen arsenide is
detected by chemical means (HIS MAJESTY: H=HYDROGEN; M=MARSH):
Arseniuretted hydrogen: when inhaled acts as a direct poison to the
haemoglobin, producing haemolysis, haemoglobinuria, renal failure &
death is almost instantaneous
3) Urinary excretion > 100ug in 24hrs (Diagnosis; blood & hair levels
are not reliable)
4) Detection by atomic absorption spectroscopy
5) by neutron activation analysis quantities in nanograms can be detected
6) Gutzeit's test
-

ML Importance
Arsenic is an ideal or popular homicidal poison (Napoleon Bonaparte)
because: it is cheap, easy to obtain, easily mixed with food/drink, no smell,
no taste, colourless, potent-small quantity required, symptoms resemble
cholera or gastroenteritis, gradual onset of symptoms (lag period=15-30
mins), disadv: legal restriction on sale; easily detected in dead bodies in
1/1000 mg dilution : Marsh's test----as it doesnt deteriorate by itself so
revealed on chemical analysis; retard putrefaction so body preserved for
longer duration; can be found in bone, hair, nails for several years, even in
charred bones or ashes, even in burnt bodies as heat doesnt destroy it;
duration can be said if chemical analysis done from root to tip hair grows 1
cm/month, nail grows 0.3 cm/month, etc ------orally mixed with food like
sweets, bread, milk, tea, cold drinks, etc; mass homicidal poisoning occurs
when mixed with food or in a well; sometimes mixed with tobacco or cigars
(Passing Show cigarettes) for homicide or to rob (railway passengers)
Accidental: when used for aphrodisiac (quick remedy for impotence), eating
arsenic arsenophagy, for better respiratory stamina among mountaineers,

improper medicinal use, admixture with food ,etc---who consume arsenic in


overdose or irrationally----chronic poisoning from drinking well water
containing arsenic-------white arsenic mistaken for sugar, chunam (lime) with
betel leaves, etc-------common bvyy consumtion of weel water esp tube well
water (exposed to arsenic tainted water)
Suicide-rare as it causes much pain; taking orpiment
frequently used as cattle poison : fed to the animal mixed with cattle fodder
sometimes ingested or applied locally in the form of a paste or ointment to
abortion sticks to produce abortion
arsenious acid, copper arsenite (Scheel's green), copper acetoarsenite (Paris
green), liquor arsenicals (Fowler's solution which is 1% arsenious oxide) were
used in the past as medicine for treating fever, potassium arsenite & sodium
arsenite is used to make flypapers, rodenticides, fungicides, sheep dips;
arsenic sulphides used for making yellow pigment for art