On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.1 Rio de Janeiro Jan./Feb. 2009
Eduardo Mello De CapitaniI; Elemir Macedo de SouzaII; Ronan José VieiraIII; Paulo Roberto MadureiraIV
Professor. PhD. Coordinator of the Center of Intoxication Control, Hospital
de Clinicas, State University of Campinas. (Unicamp) - Sao Paulo (SP), Brazil
IIAssistant Professor, PhD. Department of Dermatology, Hospital de Clinicas, State University of Campinas (Unicamp) - Sao Paulo (SP), Brazil.
IIIAssistant Professor. PhD. Center of Intoxication Control, Hospital de Clinicas, State University of Campinas (Unicamp) - Sao Paulo (SP), Brazil.
IVAssistant Professor. PhD. Center of Intoxication Control, Hospital de Clinicas, State University of Campinas (Unicamp) - Sao Paulo (SP), Brazil.
A clinical case of contact dermatitis following direct skin contact with elemental mercury is presented. Patient had metal mercury in contact with extensive part of his leg and foot skin resulting in erythematous, edematous, and vesicular dermatitis. Lesions evolved to erythematous plaques with small scattered areas of necrosis and drying vesicle lesions. Distant lesions appeared in the right forearm, chest and abdomen. Urinary mercury 36h after contact was 5.9 µg/L, and one week later 19.6 µg/L, indicating dermal absorption. Dermal
Keywords:Dermatitis; Mercury; Urine
Cutaneous granuloma caused by mercury is a characteristic dermatitis secondary to metal mercury implantation in the subcutaneous area, and it is related with granulomatous process to foreign body 1, 2 . In all cases described in the literature to present, metal mercury, when penetrating the skin, triggers a local dermal reaction. In some cases, in addition to granulomatous lesions, there may be depigmentation or hyperpigmentation. Distant dermal lesions have been reported in cases of accidental injections of mercury in the subcutaneous area 3. Elemental mercury and inorganic salts have been identified as sensitizing agents after inhalation, digestive, dermal (tattoos) or parenteral exposure 3-5. The involved immune mechanisms have not been clarified yet.
We report a case of extensive contact dermatitis associated with direct skin contact with elemental metal mercury, also causing distant skin lesions.
Male 18-year-old patient, he collected a 5ml glass bottle of metal mercury and maintained it in his pants' pocket for 36 hours; he did not realize it had leaked. Leakage led to infiltration of mercury through the fabric and contact with a great portion of his left lower limb (internal surface and foot dorsum). The duration of contact was enough to cause marked erythematous dermatitis with some vesicles and diffuse edema (Figure 1).
After one week, lesions progressed to erythematous plaques with some scattered areas of necrosis and dry vesicle lesions. Some distant papular-erythematous and vesicular lesions appeared in the right antecubital fold, on the abdomen and chest (Figure 2). The patient complained of mild local pruritus and burning sensation on the affected areas, especially the ones that had direct contact. He did not show lesions on the hands and no other symptoms were reported.
Urinary mercury was dosed in two samples of urine, using the technique Atomic Absorption Spectroscopy (AAS) with hydride generation. A sample was collected on the first day of the clinical assessment (the result was 5.9 µg/L, 26 hours after leakage and contact with the skin, and a second sample one week later revealed result of 19 µg/L). The values indicated that some mercury absorption had occurred in the period, because the inflammatory process could have impaired the natural defense barriers against a non-liposoluble substance such as elemental mercury. We prescribed systemic corticosteroids, but the patient was lost for clinical follow-up.
Many types of dermatological lesions may occur after exposure to mercury compounds, such as local inflammation and edema after a tattoo with mercury sulfate is made (cinabrium) 5, symmetrical macula-papula erythematous eruptions on the areas of limb flexion, which may occur some days after inhalation exposure to metallic mercury; liquenoid papulae on the oral mucosa (violet or brow) adjacent to the tooth amalgam containing metal Hg; hyperpigmented lesions after use of creams that contain mercury chloride and mercury oxide; granulomatous lesions after subcutaneous, intravascular (venous and arterial) or muscle injections of elemental mercury 3, 4.
However, acute contact dermatitis is probably the most common dermatological manifestation associated with mercury exposure, owing to the reaction by irritation. Many cases of contact dermatitis caused by topical use of thimerosal (merthiolate) and other anti-septic agents such as chromium mercury, phenylmercury salts, mercury chloride and oxide, have been published and are known by dermatologists. The present report may be taken as an example of contact dermatitis whose distant manifestation was systematically induced. Distant manifestations, without contact with the substance, are described as mercury exanthema, occurring symmetrically at flexures, which indicates that there has been systematization 6, 7, 8.
It is also known that patients allergic to chemical forms of mercury (organic compounds or mercury salts, for example) may react to another type of compound that contains mercury. Unfortunately, no epicutaneous tests had been performed in this patient, because he did not show up when we called him back for follow-up. Thus, it was not possible to determine whether the picture was due to a reaction of sensitivity or distant manifestations to mercury irritation action.
An interesting observation in this patient was the occurrence of mercury absorption in the elemental form through the skin, documented by the mercury analysis on the circulating blood performed in the first visit and on the 7th day. The inflammatory process on the affected areas by direct contact with mercury has probably favored the absorption of metal. Abundant skin washing with water and soup should be encouraged after accidents of this type to minimize the risk of occurrence of contact dermatitis and distant lesions, as well as mercury absorption.
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Eduardo Mello De Capitani
Caixa Postal 7042
13076 970 - Campinas - SP
Tel.: (19) 3788 7595, 3788 7907
Cel: (19) 9724 9916
Fax: (19) 3788 7907, 3788 7595
How to cite this article: De Capitani EM, Souza EM, Vieira RJ, Madureira PR. Dermatite de contato por mercúrio elementar com reação a distância. An Bras Dermatol. 84(1):75-7.