Skin Manifestations in Acute Arsenic Poisoning From the Wakayama Curry-Poisoning Incident

K. Uede, F. Furukawa

Disclosures

The British Journal of Dermatology. 2003;149(4) 

In This Article

Results

Within 2 weeks of the incident, skin lesions were seen in 28 patients (44%) or 35 patients (56%) if enanthemas were included. These comprised 17 male and 18 female subjects. Transient flushing erythema was seen in five patients (8%), mostly on day 1. Facial oedema was seen in 13 patients (21%) on days 2-5. A mildly pruritic maculopapular eruption was seen in eight patients (13%) on days 4-6. It appeared with the simultaneous development of hepatic dysfunction, and consisted of numerous discrete, brownish-red tiny erythematous papules suggestive of miliaria and symmetrically distributed in the intertriginous areas (Fig. 1). It also appeared on the lower abdomen, buttocks, lateral sides of the chest (Fig. 2), medial sides of the extremities, or lumbar regions in contact with patients' undergarments. Although no treatments were administered for this rash, it regressed spontaneously 2-3 weeks later, leaving some scaling and slight pigmentation. Acral hyperkeratosis and lamellar peeling (Fig. 3), similar to that observed in scarlet fever, were seen in 11 patients (17%) on days 6-17, and this type of rash tended to appear earlier and to persist in children. Conjunctival haemorrhage was seen in 15 patients (24%), mostly on day 1. Herpesvirus infection was confirmed in three patients: a 65-year-old woman had herpes zoster on day 18, a 29-year-old man had varicella on day 5, and a 16-year-old girl had a labial herpes simplex on day 4. In addition, one patient had stomatitis on day 4 of the illness, and two patients experienced alopecia ( Table 2 ).

Symmetrical discrete brownish-red papules in groups on intertriginous areas.

Confluent brownish-red papules on friction-prone areas.

Lamellar desquamation on the fingers.

Twenty-one patients underwent dermatological examinations by dermatologists at 3 months after the incident. There were 11 male and 10 female subjects. A total of 19 subjects (90%) exhibited dermatological changes after acute poisoning ( Table 3 ). Ungual changes were confirmed in 19 patients (90%): Mee's lines in 10 (48%) (Fig. 4), total leuconychia in seven (33%), Beau's lines in 11 (52%) (Fig. 5) and onychodystrophy in five patients (24%). Mee's lines tended to manifest as broader bands in children. Periungual pigmentation was observed in nine (43%) patients (Fig. 5), acral desquamation in four (19%), postinflammatory pigmentation in three (14%), acneiform eruption in two (10%), postinflammatory hypopigmentation in one (5%), and labial hyperpigmentation in one patient (5%). An examination 1 year after the poisoning, however, did not reveal any cutaneous or mucous lesions. We are conducting further annual health screenings for the victims; specific dermatological findings were not observed in 2000, 2001 or 2002.

Mee's lines on the fingernails.

Beau's lines on the fingernails and periungual pigmentation.

Seven days after the initiation of the rash, we obtained skin biopsy specimens from the brownish-red papules observed in three patients who showed a maculopapular eruption in the intertriginous areas. These revealed a moderate to marked perivascular lymphocytic and histiocytic infiltration around the dermal capillaries, with prominent endothelial swelling. Localized parakeratosis, mild epidermal spongiosis and slight oedematous changes beneath the basal layer were also detected. No abnormalities were seen in the hair follicles, sebaceous glands or eccrine sweat glands (Fig. 6).

Histopathological findings of the erythematous papules. Haematoxylin and eosin; original magnification: (A) x40; (B) x400.

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