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Chronic mercury intoxication by subcutaneuous self-injection and oral

administration -case report

Article  in  Romanian Journal of Legal Medicine · December 2019

DOI: 10.4323/rjlm.2019.335

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Rom J Leg Med [27] 335-339 [2019]
DOI: 10.4323/rjlm.2019.335
FORENSIC PATHOLOGY
© 2019 Romanian Society of Legal Medicine 

Chronic mercury intoxication by subcutaneuous self-injection and oral

administration – case report

Marius Florentin Popa1, Lavinia Neculai-Cândea1,*, Doina Radu2, Sorin Deacu3, Ștefan Pricop4, Daniela Tăbârcă4

_________________________________________________________________________________________
Abstract: Both chronic and acute mercury exposure represents a threat to public health. Mercury is generally used
in several industrial areas to manufacture a variety of chemical products such as paint, explosives, batteries, thermometers,
electronics, etc. Although the medico-legal practice rarely deals with this specific pathology, it is not to be taken lightly, in most
cases being result of suicide attempts through self-injection and oral administration with systemic and local consequences –
mercurism. We present the case of a 56-year-old male admitted to the hospital with signs of acute renal failure of unknown origin
and severe metabolic acidosis. At the time of admission, there wasn’t sufficient data pointing to a chronic mercury intoxication.
This diagnosis was later suspected and ultimately confirmed by autopsy and laboratory results (toxicology and histopathology).
Key words: chronic mercury intoxication, self-injection, renal manifestation, cutaneous manifestation.

INTRODUCTION rising renal function tests, diarrhea (melena) and bilious

Mercury is the only high-toxicity metallic element
in liquid state at room temperature. It is encountered in
nature under 3 forms: elemental (or metallic) mercury,
inorganic mercury compounds, and organic mercury
compounds. Its metallic form is not very toxic, except in
the finely divided state. The degree of toxicity depends
on the type of product and is mainly associated with the
mercury ion. Basically, all mercury compounds are toxic
to a certain degree, depending on the type of chemical
compound, route of entry, absorption-accumulation
(chronic intoxication), and elimination. Each phase of the
intoxication has functional and clinical significance, with
multisystemic consequences (neurological, respiratory,
digestive and renal).
The purpose of this paper is to present the case of
a 56-year-old male admitted to the hospital for significant
weight loss (20 kg over the course a month), fatigue,
vomiting. He had no medical history of kidney disease,
nor did he hint in any way a possible intoxication. The
medical tests performed showed the following:
- Physical examination: several pseudo-tumorous
lesions on both forearms.
- Biopsy exams rise suspicion of sporotrichosis
and/or cutaneous mycobacteriosis; high-density spots in
organs suggestive of a lead/mercury intoxication.
- Imaging: radio-opaque areas and high-density
spots in viscera, pointing to a mercury/lead intoxication.
Pelvic and abdominal CT scan shows a heterogeneous
area in the stomach, multiple high-density spots in the
renal calyces, in the L5-S1 epidural space and at the site
of the S1-S3 sacral foramina (Figs. 1-3).
- Lower gastrointestinal endoscopy: shows
ischemic colitis.
- Toxicology tests: blood mercury level of 4231
micrograms/L (normal value under 1).

1) “Ovidius” University, Faculty of Medicine, Dept. of Forensic Pathology, Forensic County Service, Constanta, Romania
* Corresponding author: “Ovidius” University Constanta, Faculty of Medicine, Dept. of Forensic Phatology, Forensic
County Service, 2 Zmeurei Alley, Constanta, Romania, Tel. +40740359292, E-mail: lavinia_candea@ymail.com
2) National Institut of Forensic Pathology, Dept. of Toxicology, Bucharest, Romania
3) Forensic County Service, Dept. of Pathology, Constanta, Romania
4) Forensic County Service, Constanta, Romania

335
Popa M.F. et al. Chronic mercury intoxication by subcutaneuous self-injection and oral administration
Figure 1. Multiple millimetric spots of metallic density, located
in the right side of the heart.
Figure 3. Multiple millimetric spots of metallic density located
in both iliac vessels.
In the 13th day of admission, the patient’s status
started to deteriorate and he was in need of endotracheal
intubation with mechanical ventilation. Despite the
efforts, he died from a sudden cardiac arrest in the form
of asystole.
During the autopsy, the pseudo-tumorous lesions
appeared of high density and contained a white secretion
and a silver liquid (mercury) (Fig. 6). These aspects
uphold the diagnosis of subcutaneous self-injection of
mercury.
Moreover, during the internal examination of
the body, areas of intestinal ulceration and necrosis were
336
Figure 2. High-density areas located in both renal arteries and
their branches.
Figure 4. Multiple millimetric high-density spots spread randomly
throughout the pulmonary parenchyma and also pleurae.
observed. The colonic lumen contained dark-brown
blood (Fig. 7).
The macroscopic aspects observed stood by the
diagnosis of chronic mercury intoxication, which was
also supported by testing several tissue samples collected
during the autopsy exam.
The histopathological examination revealed
aspects as described in Figures 10-16.
The toxicology exam revealed: blood mercury
level of 183.5 micrograms/dL (normal value < 0.3), urine
mercury level: 1052.9 micrograms/L (normal value <10);
in the abscess itself: 66.2 milligrams/dL.
Romanian Journal of Legal Medicine Vol. XXVII, No 4(2019)

Figure 7. Large intestine fragment with thickened mucosa

with ulcerated areas and necrosis.

Figure 5. Pseudo-tumorous lesion – cutaneous abscess.

Figure 8. Enlarged kidneys (approx. 500 gr) with generalized

paleness and cortical petechiae.

Figure 6. Incised pseudo-tumorous lesion – white exudate and

silvery liquid (mercury). Figure 9. Extensive fibrous adhesions - pericarditis.

10 11

Figure 10, 11. Acute inflammation - cubital fossa – post-injection of mercury, HE x4.

337
Popa M.F. et al. Chronic mercury intoxication by subcutaneuous self-injection and oral administration
Figure 12. Aspect of interstitial nephritis with areas of acute
tubular necrosis, HE x20.
Figure 14. Bowel necrosis accompanied by mucosal epithelium
hemorrhage and ulceration, HE x20.
Figure 16. Endocardium with eosinophilic mass surrounding
acute inflammatory cells and black amorphous droplets,
HE x20.
338
Figure 13. Renal vessel with intravascular black amorphous
droplet, HE x20.
Figure 15. Fragment of bowel with necrosis, hemorrhage and
extensive shedding of mucosal epithelium accompanied by
black amorphous droplets, Van Gieson x4.
DISCUSSION
It should be noted that mercury intoxication,
albeit rare, is a real concern of public health, proving
itself to be difficult to manage despite current treatment
options. In this particular case, the medical professionals
have tardily suspected a heavy metal intoxication, after
carefully evaluating the test results, in the meantime
disproving other diagnoses related to the signs and
symptoms presented. Moreover, the diagnosis was
also delayed by the patient’s lack of cooperation and a
continued reluctance to elaborate upon any circumstances
leading to his admission.
For this specific case, law enforcement
investigators were involved to clarify some of these aspects.
They found in the patient’s apartment several types of
medication and 5 mercury-in-glass thermometers.
In the case of acute mercury exposure, the
most violent symptoms include interstitial pneumonia
and necrotizing bronchiolitis, which this patient did
Romanian Journal of Legal Medicine Vol. XXVII, No 4(2019)

not present. In long-term exposure, this intoxication
poses a threat through neurodegeneration asserted by
progressive symptoms such as paresthesia, ataxia, cortical
visual impairment, dysarthria, hearing impairment
and ultimately death [1, 4]. In this instance, the patient
presented multiple internal mercury deposits, manifested
at the CT-scan as high-density spots and bilateral diffuse
pulmonary fibrosis. Despite all this, no signs of shortness
of breath or loss in pulmonary function were observed.
Also, no signs of neurological deterioration. The cutaneous
lesions represented by pseudo-tumorous lumps located
on the forearms were originally considered to be signs of
sporotrichosis or cutaneous mycobacteriosis.
Ultimately, by relying on several test results, the
medical team considered mercury injection as a possible
explanation for the cutaneous lesions. Isik et al. agreed
that early excision of the affected tissue could hinder
further local damage, as well as systemic absorption and
elimination of mercury [1, 5]. After removing said tissue,
mercury intoxication is best dealt with by improving the
patient’s vital signs and accelerating the rate at which this
toxic is eliminated. Mercury elimination is accomplished
through chelation therapy and urinary excretion. In
acute intoxication, chelation therapy must be promptly
administered to patients which exhibit symptoms [2].
In this particular instance, considering the
high mercury levels found in blood and urine samples
and also the multiple internal deposits (lungs, pleura,
pericardium, kidney, spine, etc.), it became clear it was a
chronic mercury intoxication. The high levels of mercury
did not cause death directly, but indirectly through
complications and accumulation in organs, ultimately to
the point of multiple system organ failure [2, 3].
In conclusion, chronic mercury intoxication,
albeit less apparent than the acute, no doubtfully
represents a life-threatening condition, taking into
account that symptoms occur after a certain period of
time following the intoxication, thus the presentation to
the hospital being somewhat tardy. This paper attempts
to issue a cautionary advice regarding the importance
of early recognition of mercury intoxication’s signs and
symptoms. We believe a collaboration between clinicians
and forensic pathologists to be of utmost importance if
we wish to reach a high degree of awareness regarding this
insidious intoxication. The treatment efficiency in such
cases is directly related to the delay between the moment
of intoxication and the diagnosis. Even so, a favorable
outcome is not guaranteed in spite of an immediate
diagnosis.
The case presented is one of the many exceptions
from the long-established rule of thumb: “When you hear
hoof beats, think of horses not zebras” [Professor Dr.
Theodore Woodward].
Conflict of interest. The authors declare that
there is no conflict of interest.

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