Images in Clinical Medicine
Metallic Mercury Embolism to the Hand
N Engl J Med 2009; 360:507January 29, 2009
- Article
Severe pain developed in the left hand of a 46-year-old woman after open heart surgery was performed to repair an atrial septal defect. It was initially thought that this pain was due to a thrombosis associated with a pressure-monitoring device in her left radial artery. Physical examination showed erythematous lesions, cyanosis, and ischemia of her left hand (Panel A). Radiographic findings revealed radiopaque particles (Panel B, black and white arrows) that were consistent with the presence of mercury in the soft tissues of her hand. The particles most likely came from the manometer used with the arterial line (a common commercial arterial-line system used in Brazil). Particles of mercury could also be seen under the skin on her thumb and fingers (Panel A, single arrows). High levels of mercury were found in her blood (192.9 μg per liter; normal value, ≤9.9) and urine (2067 μg per gram of creatinine; normal value, ≤5), but there was no evidence of associated organ damage. The patient was treated with nitroglycerin patches (Panel A, double arrows), codeine, acetaminophen, and penicillamine. On follow-up at 3 months, the atrial septal defect had been successfully repaired and the painful symptoms in her left hand had resolved, but part of her fifth finger had been amputated because of ischemic necrosis (Panel C). The patient was lost to subsequent follow-up.
Antonio Carlos de Souza
M.D., M.Sc., Ph.D.
Adelino Moreira de Carvalho, M.D., M.Sc., Ph.D.
Alzira Velano Hospital — Unifenas, Alfenas, MG, CEP 37130-000 Brazil
