Preface

During the 1980s, when use of groundwater had assumed mammoth proportions in
Bangladesh and West Bengal, India, a new kind of disease was discovered in West Bengal.
The disease was incurable and people affected with the disease not only showed charac-
teristic skin lesions but also lost their physical well-being. In July 1983, the disease was
diagnosed as chronic arsenicosis and its origin was traced to the presence of arsenic in
tube well water. In the next few years, the problem acquired dimension of a widespread
epidemic affecting as many as 35 million people in Bangladesh alone. The natural
contamination of tube wells in Bangladesh with arsenic has led to widespread human
exposure to arsenic through drinking water. Arsenic, which is a metalloid element, is noto-
rious for its toxicity. It is found as a main component of arsenopyrite present in different
rocks and soil. Arsenic occurs in the environment in both organic and inorganic forms
with different degrees of toxicity. Inorganic arsenic is dissolved in groundwater and is
more harmful to human health than the organic arsenic present in food. Although the
largest number of people affected worldwide by the arsenic contamination of drinking
water are in Bangladesh, the problem is not unique to that area. As early as 1960, scientists
reported the link between various forms of cancer and arsenic in drinking water in Taiwan.
Communities in North and South America, Europe, Asia, and Australia also face the prob-
lem of arsenic-contaminated drinking water. The problem of arsenic-contaminated
groundwater is found in communities throughout Canada and the Western United States
that use groundwater as their source of drinking water. It is now almost certain that arsenic
contamination is a worldwide problem; however, some of the most affected regions lie in
the flood plains of the great rivers of Bangladesh, Nepal, and West Bengal, India. In Ban-
gladesh alone, 70 million people are impacted. Problems associated with drinking
groundwater were first noticed in Bangladesh by healthcare workers in the early 1990s.
Although the World Health Organization (WHO) and the Environmental Protection
Agency (EPA) regulate water sources of arsenic, lack of strict regulations on food, bever-
ages, and air quality can lead to increased arsenic exposure. Ingestion of arsenic activates
metabolic pathways for excretion, resulting in a number of metabolites, some of which are
more potent and toxic than the originally ingested inorganic form of arsenic.
The WHO’s upper limit, which is also a revised standard of the US EPA, is 10 ppb,
whereas in Bangladesh, the concentration of arsenic is reported to be as high as
600 ppb at certain places. And Bangladesh is not alone, the mineral is reported to occur
at high concentrations in the water supply of communities in diverse countries such as
India, Nepal, Vietnam, China, Argentina, Mexico, Chile, Taiwan, Mongolia, and the United
States of America. As many as 75 million people worldwide could be seriously affected

xxvii
xxviii Preface

eventually. Arsenic in drinking water thus constitutes the largest case of mass poisoning in
history.
The most deceptive and dangerous aspect of arsenic poisoning is its very slow and
insidious development. The overt clinical symptoms may not appear for as long as
10 years after someone starts drinking arsenic-laden water. The first sign of poisoning is
melanosis that appears in the form of black spots on the upper chest, back, and arms.
Palms of hands or soles of the feet become hard and lose sensation (keratosis). Melanosis
(i.e., dark pigmentation) and keratosis (i.e., dry, rough, and spotted nodules in palms
and/or soles) are the main symptoms of arsenical dermatosis (ASD). It is noteworthy that
there are various causes of melanosis and keratosis, but their combined presence in same
adult patients points to the diagnosis of ASD. Around 50% of the patients show spotted or
raindrop pigmentation on the chest, back, and sometimes limbs. The subject may also
suffer from conjunctivitis and bronchitis. When present in high concentrations, arsenic
can even cause diarrhea and abdominal pain. These are symptoms that indicate the first
stage of arsenicosis.
The second stage is marked by leucomelanosis, which appears in the form of white
spots mixed up with black spots on legs or trunk. Stimulation of melanocytes probably
produces the pigmentation and damage in the later stage is responsible for depigmenta-
tion spots. Leucomelanosis is common in persons with advanced arsenicosis. Further
thickening of keratosis lesions can give rise to crack or fissures, which may eventually form
sores called hyperkeratosis. These sores, which sometimes bleed, are highly characteristic
of arsenic poisoning. They can become infected and painful, and they make walking and
working difficult. In rare cases, edema develops in the feet. In addition to this, neural prob-
lems appear in the hands and legs, and kidneys and liver start malfunctioning. Asthmatics
bronchitis, liver enlargement (hepatomegaly), spleen enlargement (splenomegaly), and
fluid in abdomen ascites are common complications that are seen in several cases. Finally,
in the third stage, the sores may turn gangrenous, kidneys or liver may give way to malig-
nancies affecting skin, lungs, bladder, uterus, or other organs. Usually, cancer may show
up after 15–20 years from the onset of the first symptoms. Skin cancers are mostly mono-
centric, but occasionally occurrence of multicentric cancers has also been reported. They
usually have slow progress for years.
Although arsenic and its mode of action has been the subject of reviews and symposia,
little data exist regarding specific mechanism(s). The molecular mechanisms of arsenic
toxicity are still unknown mainly for the following reasons: (i) its predilection to undergo
a variety of complicated metabolic conversions in vivo, (ii) the complex interactions
between arsenic metabolites and intra- and extracellular macromolecules, (iii) the influ-
ence of concomitant exposure to other toxic agents, and (iv) the lack of appropriate animal
models for most of the pathologies associated with inorganic arsenic exposure.
Although high concentration of arsenic (V) has been shown to substitute for phosphate
in enzyme-catalyzed reactions, arsenic toxicity is postulated to be primarily due to the
binding of arsenic (III) to sulfhydryl group containing enzymes. Glutathione (GSH) plays
a critical role in both the enzymatic and nonenzymatic reduction of pentavalent arsenicals
 Preface xxix

to trivalent arsenicals and in the complexation of arsenicals to form arsenicothiols during

the methylation process. Arsenic interacts with GSH and its related enzymes and changes
their redox status, which in turn may lead to alterations in their biological function.
Inactivation of GSH-related enzymes could have deleterious effects on the detoxification
processes and other critical cellular processes involving GSH-mediated redox regulation.
An important protective role of GSH against arsenic-induced oxidative damage has been
reported.
Recent studies have also indicated that arsenic exerts toxicity by generating reactive
oxygen species, but the mechanism is still unclear. These reports suggested that intracel-
lular peroxide level is correlated with arsenic-induced cellular apoptosis. Many workers
have also described lipid peroxidation as one of the mechanisms of arsenic toxicity in
experimental animals together with a concomitant decrease in cellular GSH concentra-
tion. GSH-related enzymes such as glutathione peroxidase and GSH-related reductase
function either directly or indirectly as antioxidant, and glutathione S-transferase (GST)
plays an important role in metabolic detoxification of arsenic. Depletion of intracellular
GSH therefore has adverse effect on these important antioxidant and detoxifying enzymes.
Arsenic is a Class A human carcinogen and reactive oxygen species (ROS) have also
been implicated in the pathogenesis of cancer. Oxidative stress can be involved in initia-
tion, promotion, or progression. Although the lung is one of the major organs that are
affected by arsenic, little information is currently available for the production of ROS in
arsenic-exposed lung cells. Kitchen provided an interesting explanation for arsenic’s
ability to cause human cancer at high rates in the lungs. High partial pressures of oxygen
are found in the lungs. Human lungs may be an organ responsive to arsenic carcinogen-
esis because of the high partial pressure of oxygen and the fact that dimethyl arsine, a gas,
is excreted via the lungs. Human bladder may be an organ responsive to arsenic carcino-
genesis because of the high concentration of dimethylarsinic acid and monomethylarso-
nic acid that is stored in the lumen of the bladder. Other than lung and bladder cancer, it
also increases the risk of cancer in various organs such as lung, liver, kidney, and skin.
The current management of acute and chronic arsenic poisoning relies on supportive
care and chelation therapy. The general management of arsenic poisoning begins with the
elimination of further exposure to the toxic agent and provision of a patent airway, ade-
quate ventilation, and cardiovascular support. Chelating agents are compounds that bind
to and enhance the urinary and fecal excretion of toxic metals by forming soluble
complexes with toxic metals in vivo. The water-soluble complexes, which are formed,
get readily excreted in the urine and feces leading to a depleted body metal burden. British
anti-Lewisite (BAL), i.e., 2,3-dimercaprol, was the first chelating agent to be used for coun-
tering toxic effects of arsenic, but its use has been discontinued because of some serious
drawbacks such as high toxicity and redistribution of metal to brain. Currently, water-
soluble, orally active analogs of BAL are being used for treating arsenic toxicity. These
are meso 2,3-dimercaptosuccinic acid (DMSA) and sodium 2,3-dimercaptopropane
1-sulfonate (DMPS). DMSA has been tried successfully in animal and in few case of
human arsenic poisoning. DMSA has been shown to protect mice from lethal effects of
xxx Preface

arsenic. However, in an interesting prospective, double-blind, randomized controlled trial

study conducted on few selected patients from arsenic-affected regions of West Bengal,
India, with oral administration of DMSA suggested that DMSA was not effective in produc-
ing any clinical or biochemical benefits or any histopathological improvements of skin
lesions. Like DMSA, DMPS is another analog of BAL and better known for its antidotal effi-
cacy against mercury. It has also been reported to be an effective drug for treating arsenic
poisoning. In experimental animals, intraperitoneal administration of DMPS increased
the lethal dose of sodium arsenite in mice by four-folds. Although these chelating agents
are effective in countering acute arsenic poisoning, when it comes to management of
chronic arsenicosis, they prove to be of only limited benefit. The principal reason being
their hydrophilic nature, which renders them incapable of crossing cell membranes. It
is well reported that in cases of chronic arsenicosis, metal gains access into the cell
and gets firmly bound to cellular biomolecules. To show significant clinical recovery in
such cases, a chelating agent must be able to cross a cell membrane so that it may chelate
intracellular arsenic. In an attempt to address this issue, a number of analogs of DMSA
were synthesized and tested. Monoesters of DMSA, especially the higher analogs, have
been reported to be more effective in reducing cadmium and mercury as well as brain
lead mobilization than the parent drug DMSA and maximum mobilization of metal
was observed with monoisoamyl meso 2,3-dimercaptosuccinic acid (MiADMSA), a
C5-branched chain alkyl monoester of DMSA. Presence of straight and branched chain
amyl groups in MiADMSA not only increases the lipophilicity but also increases the total
number of carbon atoms. Lipophilicity and molecular size of this new drug might be
important factors for the removal of arsenic from both intracellular sites possibly leading
to better therapeutic efficacy. In view of above, an attempt was made to evaluate thera-
peutic efficacy of MiADMSA and to determine optimum dose and route of administration.
Combination therapy is another new and novel option suggested by us. In the current
study, we have tested whether combined treatment with an antioxidant and a thiol che-
lator could be a better treatment protocol compared with monotherapy with a chelator.
The potential role for oxidative stress in the injury associated with arsenic poisoning sug-
gests that antioxidant may enhance the efficacy of treatment protocol designed to miti-
gate arsenic-induced toxicity. We recently reported that combined administration of
alpha-lipoic acid and DMSA provided a more pronounced recovery in lead-induced
altered biochemical variables indicative of oxidative stress. In an experimental study con-
ducted by us recently, we observed an in vivo evidence of arsenic-induced oxidative stress
in a number of major organs of arsenic-exposed rats and that these effects can be miti-
gated by pharmacological intervention that encompasses combined treatment with
N-acetylcysteine and DMSA. It is well known that chelation therapy with many synthetic
chelating agents is compromised with number of side effects such as essential metal
imbalance and specific organ toxicity. Combined administration of two differently acting
chelating agents can also be a useful strategy, for not only enhancing metal decorporation
from the body but also minimizing side effects of chelation therapy such as loss of
 Preface xxxi

essential trace elements. Although a number of such studies have been reported against
lead and cadmium intoxication, there is not much information available in case of arsenic
toxicity. It will therefore be interesting to see whether combination therapy could remove
arsenic to a greater extent from the target organ, and whether concomitant administration
of an antioxidant can ensure better recovery from arsenic-induced oxidative stress.
Handbook of Arsenic Toxicology, second edition, is a comprehensive resource on this
subject, comprising more than 33 chapters. The book is prepared in a user-friendly format
for academia, industry, and regulatory/governmental agencies. Stand-alone chapters are
provided on major topics, so the reader can easily find the required information. The vol-
ume covers an updated information on the effects of arsenic on different organs/system,
carcinogenesis, mechanism of toxicity, detection (including biosensor), diagnosis preven-
tion, and therapeutic measures.
Since the first edition of this book, a wealth of data has appeared. Several of the chap-
ters dealing with specific toxic effects on individual organs were completely rewritten and
others have undergone an extensive update. The number of chapters has expanded to
reflect new directions and importance of arsenic in human health. This second edition
is expanded by bringing in new chapters of current interest in arsenic toxicology.
Five new chapters have been added to this edition on timely topics, such as Chapter 29,
which describes the impacts of environmental arsenic contamination to wildlife, includ-
ing its source, chemical speciation, exposure, bioaccumulation, modes of toxic action, and
suborganismal and organismal toxic effects. Chapters 30 and 31 deal with testing and
assessment and development in arsenic toxicology. Chapter 32 provides a new and inter-
esting reading for researchers who should consider the use of adverse outcome pathways
(AOPs) in arsenic toxicology research. AOPs provide a framework for understanding how
chemicals such as arsenic impact mechanisms and pathways possibly related to the dis-
ease. Finally, a new chapter (Chapter 33) on the effect of arsenic on nonhuman species in
the environment too has been added, which provides some new information on the effects
of nonhuman species.
Finally, I am deeply indebted to all authors who agreed to revise and update their chap-
ters, and I thank them for their sincere and dedicated contributions to this second edition.
Sadly, few previous contributors have not been able to continue as authors in the
Handbook of Arsenic Toxicology; however, I acknowledge their previous contributions. I
am happy to welcome all the new authors who have contributed to this edition. I have
tried to get all new contributions written by specialists in the respective area, but again
missed a few well-known names who expressed their inability due to various professional
and personal commitments. The contributors of this book are highly qualified and con-
sidered authorities in metal toxicology in general and arsenic toxicology in particular.
Their hard work and dedication to this book is greatly appreciated. I consider these con-
tributions excellent summaries by some of the world’s outstanding young scientists/
researcher practitioners of arsenic toxicology and hope the readers will find them highly
enlightening and useful. A special word of thanks to Pat Gonzalez, Senior Editorial Project
xxxii Preface

Manager at Elsevier/Academic Press, who was a big support throughout the process and
provided vital input in the preparation of this book.
I immensely appreciate the tireless efforts of Ms. Kristi Anderson (Editorial Project
Manager), Ms. Kattie Washington (Acquisitions Editor), and other technical staff at
Academic Press/Elsevier for their various roles in the preparation of this book.

Swaran Jeet Singh Flora