Arsenic Poisoning (cont.)
Charles Patrick Davis, MD, PhD
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
- Arsenic facts
- What is arsenic?
- What is inorganic arsenic?
- What is organic arsenic?
- What are the symptoms of arsenic poisoning?
- How is arsenic poisoning diagnosed?
- How is arsenic poisoning treated?
- What is the prognosis (outcome) of arsenic poisoning?
- In what foods (rice), products (apple juice) , or liquids (water) is arsenic found, where it is used, and what are safe limits?
- Find a local Doctor in your town
How is arsenic poisoning treated?
Acute toxic inorganic arsenic exposure and arsine gas exposure can rapidly result in death, and there are only a few ways to possibly save the patient's life. Hemodialysis can remove arsenic from the bloodstream, but only before it binds to the tissues so there is only a short time window for this treatment to work. Similarly, arsine binds to and causes rapid destruction of red blood cells, so blood transfusions and exchange transfusions may help the patient. In addition, if the arsenic was ingested, stomach or bowel irrigation may be attempted, but there is no good data to indicate these will be successful. Consultation with a nephrologists and a toxicologist as soon as possible is recommended; other consultants may need to be called (hematologist, psychiatrist, or others).
Chelation therapy (the use of drugs that selectively bind and effectively inactivate substances) is usually begun quickly through an intravenous line. The drug and the bound arsenic is then excreted through the urine. The chelation drug of choice is Dimercaprol (also termed BAL in oil); Succimer (DMSA) has also been used successfully, and Dimerval (DMPS) may also work as a chelator, but it is not readily available in the US.
What is the prognosis (outcome) of arsenic poisoning?
If the patient survives an acute toxic exposure, most will develop some degree of nerve damage to the peripheral nerves (sensory and motor disturbances); many survivors may have cardiac, liver, renal, and skin problems; the prognosis is fair to poor. Chronic poisoning and organic arsenic exposure have better outcomes with fewer and less severe problems.
In what foods (rice), products (apple juice) , or liquids (water) is arsenic found, where it is used, and what are safe limits?
People may be exposed through work in a metal foundry, mining, glass production, the semiconductor industry, in criminal attempts at murder by poisoning, suicide attempts, and as a biological warfare agent.
- Arsenic has been found to contaminate such common items as wine, glues, and pigments.
- Arsenic is commonly found in many foods both in its relatively nontoxic organic form, and also in the more toxic inorganic form. Consequently, such foods need to be tested for both inorganic and organic arsenic levels.
- Arsenic has been reported in milk and dairy products, beef, pork, poultry, and cereal.
- Arsenic is also often found in rice, representing a potentially serious source of exposure in certain at-risk populations (especially children).
- Many water sources in the world have high levels of arsenic in them, both due to normal arsenic leaching out of the ground and from mining and industrial waste.
Recent examples of concerns about arsenic have surfaced because of its presence in apple juice. In most studies, various sources of apple juice tested by government and consumer labs have found that most (over 95% tested) contain a very small amount of arsenic (less than 10 parts per billion) and are safe to drink (in contrast to a TV show that raised alarms about consuming apple juice). However, the FDA qualified their findings by indicating in July 2013, new standards would apply and any juice that contained 10 or more parts per billion (the same level set for safe groundwater) would not be permitted to be sold in the US. This is lower than the previous approved level of less than 23 parts per billion approved in 2008. Nonetheless, other groups suggest that only juice containing less than 3 parts per billion be FDA approved while others advise that only 6 ounces of apple juice per day (about one juice box) be consumed by children because of its high sugar content.
Two other sources of arsenic, especially of some concern for children, is arsenic in groundwater and subsequently, in rice that is grown in such groundwater. Rice is a common food for children but to date, there are no regulations about the levels of arsenic that are considered safe for consumption. The FDA and the EPA are currently collecting data to make a recommendation about safe levels but many groups are pushing the FDA to act soon. The groups claim some private laboratories have detected that a single adult serving of some commercially available rice can give about 1.5 times the amount of permissible arsenic in one liter of water (under 10 parts per billion), so action on permissible arsenic levels should be done quickly. In 2013, the CDC recommends only about 2 cups of cooked rice per individual (adult) per week.
Medically reviewed by a Board Certified Family Practice Physician
American Cancer Society. Arsenic.
CDC.gov. Arsenic (Inorganic).
ConsumerReports.org. Arsenic in your food.
FDA.gov. Questions & Answers: Arsenic in Rice and Rice Products.
npr.org. How Much Arsenic Is Safe In Apple Juice? FDA Proposes New Rule.
MedscapeReference.com. Arsenic Toxicity in Emergency Medicine.
MedscapeReference.com. Neurological Manifestations of Arsenic Intoxication Clinical Presentation.
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