THE DARK SIDE OF SUPERSTITION : CASE OF ELEMENTAL MERCURY INDUCED NELL-1 ASSOCIATED MEMBRANOUS NEPHROPATHY WITH ACUTE TUBULAR INJURY , CHALLENGES IN CHELATION AND MANAGEMENT

7 Feb 2025 12 a.m. 12 a.m.
WCN25-AB-3669, Poster Board= FRI-485

Introduction:

Mercury despite being  poisonous is frequently used in alternative medicine and various religious practices. Although self injection of elemental mercury is very rare , its effects are well described in literature. Early detection and termination of exposure by removal of stores along with chelation therapy is mainstay to avoid long term toxicity. There is paucity of literature on how to proceed with chelation therapy among patients who are anuric and are exposed to elemental mercury toxicity.

Methods:

A 35 year old male came with history of progressive edema since 20 days , reduced urine output since 4  days, nausea and poor appetite since 3 days  with a background  history of thorn prick and cellulitis of right upper limb according to the patient which was managed at a peripheral center  with debridement , antibiotics and analgesics. The patient initially had nephrotic range protienuria and subsequently developed AKI requiring initiation of renal replacement therapy. The patient underwent renal biopsy and was suggestive of membranous nephropathy , NELL-1 positive with acute tubular injury moderate degree , acute interstitial nephritis mild degree .Upon retrospective enquiry  the patient's family members revealed that he had injected liquid form  elemental mercury  into his  forearm by self as he believed this will grant him supernatural abilities  to influence and control others behaviour . X ray / CT  forearm was suggestive of metallic deposits( Fig 1,Fig 2)and punch biopsy from skin demonstrated elemental mercuric globules ( Fig 3) , very high blood and urinary mercury levels further  confirmed mercury poisoning.

Fig 1 - Pre operative X- ray forearm lateral view showing extensive subcutaneous metallic deposits

Fig 2 - 3D reconstruction image of CT forearm showing extensive subcutaneous mercuric deposits

Results:

Surgical debridement of mercuric deposits were done under fluoroscopic guidance( Fig 4 ) and chelation therapy with BAL (British Anti Lewisite) was done . Post operative X-ray ( Fig 5  )  shows  significant clearance of mercuric deposits and  was taken for skin grafting at  a later date following which patients urine output improved but despite this the patient continued to have persistent protienuria / deranged renal function and eventually progressed to CKD . This case highlights the sequelae of chronic subcutaneous exposure to elemental mercury , challenges faced with surgical clearance in patients with extensive subcutaneous  fibrosis and practical  difficulties faced in  chelation and extracorporeal removal of mercury in a anuric patient 

Fig 4 - fluroscopy guided debridement of mercuric deposits

Fig 5 - Post operative Xray forearm lateral view showing extensive subcutaneous deposits

Conclusions:

 Rapid diagnosis , early decontamination and chelation therapy are the mainstay of treatment in patients with  mercury poisoning but more large scale studies and recommendations are needed on how to proceed with chelation therapy for heavy metal toxicity in patients who are dialysis dependent . Even in mentally sound individuals , concealing of relevant history due to strong personal beliefs can result in atypical clinical course of the disease and long term toxicity despite adequate therapy .This case  highlights how  deeply rooted superstitious belief can have a dark side .

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.