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Acute Arsenic Poisoning

Arsenic is highly toxic and can enter the body through the gastrointestinal tract, skin or lungs. Acute arsenic poisoning can occur through ingestion of contaminated water, occupational exposure and deliberate poisoning.


Presentation

Acute arsenic poisoning (AAP) can present with a number of features. Exposure to non-lethal amounts, less than 5 milligrams, leads to vomiting and diarrhea, which spontaneously resolve after a few hours [1]. The lethal dose is exposure to more than 100 milligrams.

Poisoning can occur through accidental ingestion of contaminated water, alcohol, produce that has been treated with certain pesticides, and herbal medicines. Occupational exposure in industries that handle metals, paint, glass, and ceramics can also result in arsenic poisoning [2] [3]. Arsenic can be ingested, inhaled or absorbed through the skin.

More severe gastrointestinal (GI) manifestations of AAP include abdominal pain, which is usually colicky, but may also appear as an acute abdomen, and passage of large volumes of watery diarrhea with blood. This may lead to severe dehydration, hypovolemia, and death. It is often described as bloody rice water as it is similar to cholera rice water stools. Hyper-salivation may be the only GI symptom in some cases [4]. Systematic examination may show inflammation of the esophagus and stomach [5].

Neurological symptoms include acute psychosis and seizures, encephalopathy, and peripheral neuropathy [4]. The latter has been reported to last up to 2 years after the poisoning episode.

The cardiovascular effects of AAP are cardiomyopathy, arrhythmias and ECG changes. Pulmonary system effects may manifest as adult respiratory distress syndrome, pulmonary edema, or respiratory failure.

AAP can lead to several hematological ailments that are exemplified by bone marrow suppression leading to normocytic anemia or pancytopenia, disseminated intravascular coagulation (DIC), and leukocyte abnormalities. Hemoglobinuria, hematuria as well as the excretion of arsenic in urine, are both features of AAP. Other systemic signs of AAP are the presence of a garlic odor, caustic burns, dysphagia, gangrene, rash, acute renal failure, liver failure, and metabolic acidosis [5] [6].

Anemia
  • Results may show microcytic or hemolytic anemia. Blood arsenic levels: This may show elevated levels of arsenic, however, patients are often already started on treatment by the time results are available.[symptoma.com]
  • ), frequent infections (leukopenia) and easy bruising / petechia (thrombocytopenia) Anemia and leukopenia are common in chronic arsenic toxicity, are often accompanied by thrombocytopenia and mild eosinophilia Chronic arsenic exposure may be associated[pathologyoutlines.com]
  • […] exposure, the more common effects include gradual loss of strength; diarrhea or constipation; pigmentation and scaling of the skin, which may undergo malignant changes; nervous manifestations marked by paralysis and confusion; degeneration of fatty tissue; anemia[britannica.com]
  • Non-specific features: Loss of appetite, nausea, vomiting, jaundice, weight loss and anemia Specific features: Hyperkeratosis of palms and soles Rain drop pigmentation of general skin surface with patches of leukoplakia Loss of hair Transverse white “[medchrome.com]
  • Other symptoms include breakdown of the hemoglobin of red blood cells (hemolysis), a low level of iron in the red blood cells (anemia), and low blood pressure (hypotension).[rarediseases.org]
Fever
  • Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever.[rarediseases.org]
  • You can find the following article here, referring to the new book ‘ Bitten by Witch Fever ‘ by Lucinda Hawksley. Slightly over a century ago, poison was a common part of everyday life.[mmoedlinger.eu]
  • Napoleon suffered stomach troubles, pain in the upper part of the stomach, anorexia, nausea, vomiting, hiccup (irritation of the diaphragm), dysuria, lethargy, spikes of fever, diarrhea, constipation, abdominal cramps, excessive weakness, heavy perspiration[napoleon.org]
Gastric Lavage
  • Treatment for acute arsenic poisoning 34 1 Remove ingested arsenic by gastric lavage or emesis and follow with a saline cathartic. 2 Antidote: give Dimercaprol for two days then Penicillamine.[ihcworld.com]
  • Gastric lavage: consider if a significant amount has been ingested Whole bowel irrigation with polyethylene glycol may be used to prevent arsenic absorption.[patient.info]
Vomiting
  • Exposure to non-lethal amounts, less than 5 milligrams, leads to vomiting and diarrhea, which spontaneously resolve after a few hours. The lethal dose is exposure to more than 100 milligrams.[symptoma.com]
  • Course of the disease Severe abdominal pain, cramps, blood circulation, severe diarrhea and vomiting begin after the adoption of a human poison. Water-salt balance is disrupted; the body loses a lot of protein.[medical-enc.com]
  • Exposure to arsine causes burning and stinging of the face and after 3-4 hours tightness of the chest, dysphagia, nausea, vomiting, diarrhoea and ventricular arrhythmia's.[ihcworld.com]
  • THALLIUM POISONING Symptoms associated with thallium poisoning include extreme drowsiness (somnolence), nausea, vomiting, abdominal pain, and bloody vomiting (hematemesis).[rarediseases.org]
  • Arsenic poisoning can be differentiated from cholera as follows: Trait Arsenic Poisoning Cholera Throat pain Before vomiting After vomiting Vomitus With mucus, blood and bile Watery and without mucus, blood or bile Purging After vomiting Before vomiting[medchrome.com]
Diarrhea
  • Exposure to non-lethal amounts, less than 5 milligrams, leads to vomiting and diarrhea, which spontaneously resolve after a few hours. The lethal dose is exposure to more than 100 milligrams.[symptoma.com]
  • Acute poisoning is manifested by abdominal pain, diarrhea and dehydration.[medical-dictionary.thefreedictionary.com]
  • Acute arsenic poisoning leads to nausea and vomiting, developing into massive intestinal tract inflammation with diarrhea two hours later.[dmsachelation.com]
  • Course of the disease Severe abdominal pain, cramps, blood circulation, severe diarrhea and vomiting begin after the adoption of a human poison. Water-salt balance is disrupted; the body loses a lot of protein.[medical-enc.com]
  • Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever.[rarediseases.org]
Nausea
  • Exposure to arsine causes burning and stinging of the face and after 3-4 hours tightness of the chest, dysphagia, nausea, vomiting, diarrhoea and ventricular arrhythmia's.[ihcworld.com]
  • Acute arsenic poisoning is associated initially with nausea, vomiting, abdominal pain, and severe diarrhoea. Encephalopathy and peripheral neuropathy are reported. Chronic arsenic toxicity results in multisystem disease.[ncbi.nlm.nih.gov]
  • Small amounts absorbed over a period of time may result in chronic poisoning, producing nausea, headache, coloration and scaling of the skin, hyperkeratoses, anorexia, and white lines across the fingernails.[medical-dictionary.thefreedictionary.com]
  • Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever.[rarediseases.org]
  • Symptoms of acute poisoning from swallowing arsenic include nausea, vomiting, burning of the mouth and throat, and severe abdominal pains. Circulatory collapse may occur and be followed by death within a few hours.[britannica.com]
Abdominal Pain
  • More severe gastrointestinal (GI) manifestations of AAP include abdominal pain, which is usually colicky, but may also appear as an acute abdomen, and passage of large volumes of watery diarrhea with blood.[symptoma.com]
  • Acute arsenic poisoning is associated initially with nausea, vomiting, abdominal pain, and severe diarrhoea. Encephalopathy and peripheral neuropathy are reported. Chronic arsenic toxicity results in multisystem disease.[ncbi.nlm.nih.gov]
  • Acute poisoning is manifested by abdominal pain, diarrhea and dehydration.[medical-dictionary.thefreedictionary.com]
  • Gastrointestinal symptoms include a flu-like illness (gastroenteritis) that is characterized by vomiting; abdominal pain; fever; and diarrhea, which, in some cases, may be bloody.[rarediseases.org]
  • Symptoms of acute poisoning from swallowing arsenic include nausea, vomiting, burning of the mouth and throat, and severe abdominal pains. Circulatory collapse may occur and be followed by death within a few hours.[britannica.com]
Severe Abdominal Pain
  • Symptoms of acute poisoning from swallowing arsenic include nausea, vomiting, burning of the mouth and throat, and severe abdominal pains. Circulatory collapse may occur and be followed by death within a few hours.[britannica.com]
  • Course of the disease Severe abdominal pain, cramps, blood circulation, severe diarrhea and vomiting begin after the adoption of a human poison. Water-salt balance is disrupted; the body loses a lot of protein.[medical-enc.com]
  • Clinical findings Vague gastrointestinal (nausea, vomiting) and neurologic (apprehension and shortness of breath) symptoms, and a classic sign—“garlic” breath—followed by dysphagia, tachycardia, severe abdominal pain and bloody diarrhoea, then by renal[medical-dictionary.thefreedictionary.com]
Tachycardia
  • Clinical findings Vague gastrointestinal (nausea, vomiting) and neurologic (apprehension and shortness of breath) symptoms, and a classic sign—“garlic” breath—followed by dysphagia, tachycardia, severe abdominal pain and bloody diarrhoea, then by renal[medical-dictionary.thefreedictionary.com]
  • […] raise urinary arsenic): 50mg/day Arsenic in hair and nails Abnormal LFTs Hematology: Anemia, Leukocytosis Urine: Hematuria, Proteinuria ECG: QRS complex broadening, QT prolongation, ST-segment depression, T wave flattening and multifocal ventricular tachycardia[medchrome.com]
  • ECG changes including ST-segment changes, prolonged QT interval, ventricular tachycardia, torsades de pointes and ventricular fibrillation. Gangrene of extremities.[patient.info]
  • In some cases, affected individuals may exhibit increased salivation; yellowing of the teeth; an unusually rapid heart beat (tachycardia); low levels of iron within the red blood cells (anemia); bluish discoloration (cyanosis) of the skin and mucous membranes[rarediseases.org]
Hypotension
  • Other symptoms include breakdown of the hemoglobin of red blood cells (hemolysis), a low level of iron in the red blood cells (anemia), and low blood pressure (hypotension).[rarediseases.org]
Jaundice
  • Manifestations are suggestive of a general toxic state with alterations of consciousness, from confusion until delirium, crash, hematuria, jaundice and renal insufficiency.[pathopedia-india.com]
  • Jaundice, hepatomegaly; development of portal fibrosis and cirrhosis. Cardiac/respiratory: [ 12, 13 ] Coronary heart disease, increased further in those who also smoke. Myocarditis, pericarditis. Hypertension. Peripheral arterial disease.[patient.info]
  • Non-specific features: Loss of appetite, nausea, vomiting, jaundice, weight loss and anemia Specific features: Hyperkeratosis of palms and soles Rain drop pigmentation of general skin surface with patches of leukoplakia Loss of hair Transverse white “[medchrome.com]
  • […] breakdown of the hemoglobin of red blood cells (hemolysis); irregular heart rhythms (ventricular arrhythmias); coma; seizures; bleeding within the intestines (intestinal hemorrhage); and yellowing of the skin, mucous membranes, and whites of the eyes (jaundice[rarediseases.org]
Hyperpigmentation
  • Skin lesions : Hyperpigmentation, hyperkeratosis and cancer / Chien-Jen Chen -- ch. 4. Arsenics and urothelial carcinoma / Chung-Hsin Chen and Yeong-Shiau Pu -- ch. 5. Arsenic exposure and lung cancer / Chi-Ling Chen -- ch. 6.[books.google.com]
  • Hyperpigmentation on pressure points and acral surfaces can also be seen in Addison’s disease.[clinicaladvisor.com]
  • Mees' lines (transverse white lines on nails). [ 6 ] Hyperpigmentation (especially on the arms and upper chest) - diffuse dark areas or 'raindrop' pigmentation. Also, exfoliative dermatitis, alopecia, conjunctivitis, corneal ulceration.[patient.info]
  • Skin and nail symptoms include hardened patches of skin (hyperkeratosis) with unusually deep creases on the palms of the hands and the soles of the feet, unusual darkening of certain areas of the skin (hyperpigmentation), transverse white bands on the[rarediseases.org]
  • Hyperpigmentation and hyperkeratosis of the skin—particularly on the palms and soles of the feet—is common. 5,7 “Black foot disease” (gangrene of the feet), renal damage and cirrhosis of the liver have also been reported. 5,7 Long-term exposure can cause[reviewofoptometry.com]
Alopecia
  • Also, exfoliative dermatitis, alopecia, conjunctivitis, corneal ulceration. GI: Anorexia, weight loss, abdominal pain, diarrhoea. Jaundice, hepatomegaly; development of portal fibrosis and cirrhosis.[patient.info]
  • ARDS, renal and hepatic failure Bone marrow suppression develops over 24 – 72 hours reaching a nadir in 2 – 3 weeks and alopecia.[lifeinthefastlane.com]
  • Overexposure to selenium may cause irritation of the respiratory system, gastrointestinal tract, and eyes; inflammation of the liver; loss of hair (alopecia); loss of skin color (depigmentation); and peripheral nerve damage.[rarediseases.org]
Hematuria
  • Hemoglobinuria, hematuria as well as the excretion of arsenic in urine, are both features of AAP.[symptoma.com]
  • Manifestations are suggestive of a general toxic state with alterations of consciousness, from confusion until delirium, crash, hematuria, jaundice and renal insufficiency.[pathopedia-india.com]
  • Symptoms of acute arsenic poisoning include- Diarrhea Vomiting Cramping muscles Blood in the urine (hematuria) Stomach pain Hair loss Breath that smells like garlic Convulsions If arsenic poisoning is not treated properly, the patient could enter into[medindia.net]
  • […] arsenic (only detectable during 1st 2-4 hrs of exposure): may be 7mg/dl 24 hr urinary arsenic (after 48 hrs abstinence from sea food which can raise urinary arsenic): 50mg/day Arsenic in hair and nails Abnormal LFTs Hematology: Anemia, Leukocytosis Urine: Hematuria[medchrome.com]
Anuria
  • This can be discontinued when the urine arsenic falls below 50 mg in 24 hours. 3 In addition treatment for dehydration, shock, pulmonary oedema, anuria and liver damage may be required In very severe cases haemodialysis may be necessary after Dimercaprol[ihcworld.com]
  • Furthermore, prolonged administration of arsenic leads to renal failure and anuria (that is, failure to produce urine).[napoleon.org]
Oliguria
  • This leads to thirst, oliguria, collapse, cramps, convulsions, heart failure and death.[medchrome.com]
Peripheral Neuropathy
  • Features of Textbook of Peripheral Neuropathy Include : ̈ Practical yet comprehensiveóan accessible ìgo-toî reference for clinicians ̈ Covers all clinically relevant peripheral neuropathies ̈ Clinical Pearls and Key Points are set off from the text for[books.google.com]
  • Neurological symptoms include acute psychosis and seizures, encephalopathy, and peripheral neuropathy. The latter has been reported to last up to 2 years after the poisoning episode.[symptoma.com]
  • Peripheral neuropathy can develop later Chronic toxicity Insidious multi-system symptoms.[lifeinthefastlane.com]
  • Encephalopathy and peripheral neuropathy are reported. Chronic arsenic toxicity results in multisystem disease. Arsenic is a well documented human carcinogen affecting numerous organs.[ncbi.nlm.nih.gov]
  • Eventually gastrointestinal disturbances develop, along with changes in the skin and a peripheral neuropathy. The latter is characterized by paresthesias, motor palsies, and painful neuritis.[pathopedia-india.com]
Headache
  • Overexposure may cause headaches, drowsiness, confusion, seizures, and life-threatening complications.[rarediseases.org]
  • The symptoms of chronic arsenic poisoning includes headaches, confusion and drowsiness. As the poisoning develops, convulsions and changes in the fingernail pigmentation may occur and heart and breathing difficulties follow.[arsenictests.com]
  • Death is from circulatory failure with convulsions and coma being the terminal signs. 34 Large doses of arsenic insufficient to cause death will induce restlessness, nausea, vomiting, headaches, dizziness, chills, cramps, irritability and variable paralysis[ihcworld.com]
  • Headaches, confusion, drowsiness, convulsions, and changes in fingernail coloring may occur with chronic arsenic poisoning.[blog.imwithoutstress.com]
  • Increased Hair Loss Mucosa Skin Cancer Headaches Diarrhea Kidney Problems Rashes (eczematous, pustulating, ulcerous) Around The Nose Dark Gray Skin Pigmentation White Vertical Strips On Fingernails (called ‘Mees’ Bands’) Confusion Sleepiness Conjunctivitis[dmsachelation.com]
Seizure
  • Neurological symptoms include acute psychosis and seizures, encephalopathy, and peripheral neuropathy. The latter has been reported to last up to 2 years after the poisoning episode.[symptoma.com]
  • Overexposure may cause headaches, drowsiness, confusion, seizures, and life-threatening complications.[rarediseases.org]
  • GI haemorrhage may occur Encephalopathy and seizures Cardiovascular collapse within hours and acute myopathy as indicated by ECG changes and dysrhythmias.[lifeinthefastlane.com]
  • […] contaminated clothes and washing and rinsing skin thoroughly Bowel irrigation - Passing large quantities of polyethylene solution through the GI tract to flush out arsenic Blood transfusions Supportive treatment for complications like heart failure and seizures[medindia.net]
  • Seizures. Haematological: Acute haemolysis. Bone marrow suppression. Basophilic stippling and rouleaux formation may be seen on a blood film. Skin: rashes.[patient.info]
Paresthesia
  • The latter is characterized by paresthesias, motor palsies, and painful neuritis.[pathopedia-india.com]
  • […] loss and anemia Specific features: Hyperkeratosis of palms and soles Rain drop pigmentation of general skin surface with patches of leukoplakia Loss of hair Transverse white “Aldrich-Mees” line on nails Peripheral neuritis with itching, tingling and paresthesia[medchrome.com]
Dizziness
  • Death is from circulatory failure with convulsions and coma being the terminal signs. 34 Large doses of arsenic insufficient to cause death will induce restlessness, nausea, vomiting, headaches, dizziness, chills, cramps, irritability and variable paralysis[ihcworld.com]

Workup

Acute arsenic poisoning may be diagnosed if arsenic is detected in blood, hair or urine samples [7]. Care should be taken to differentiate between organic and inorganic forms of arsenic, as the former is abundant in seafood, and is harmless. Severely ill patients may need close monitoring of their vital signs, as well as urine output.

Laboratory tests that may be requested are:

  • Full blood count: This should be ordered with a reticulocyte count. Results may show microcytic or hemolytic anemia.
  • Blood arsenic levels: This may show elevated levels of arsenic, however, patients are often already started on treatment by the time results are available.
  • Urine arsenic levels: This includes both a spot test and 24 hour urine collection. The recent consumption of seafood may yield a false positive result.
  • Urinalysis.
  • Arterial blood gases.
  • Full metabolic panel: There may be electrolyte derangements due to vomiting and diarrhea.
  • Group and screen, and crossmatch: Blood transfusion may be needed in patients who have inhaled arsine, a gaseous form of arsenic.

Imaging techniques that may be carried out are abdominal and chest X-rays, electrocardiography, and nerve conduction studies [7].

Torsades De Pointes
  • ECG changes including ST-segment changes, prolonged QT interval, ventricular tachycardia, torsades de pointes and ventricular fibrillation. Gangrene of extremities.[patient.info]

Treatment

  • His primary research interests and publications have been involved with biological wastewater treatment, industrial water pollution control, industrial waste treatment, and municipal wastewater treatment.[books.google.com]
  • TDMPS is useful for the treatment of massive acute arsenic poisoning.[ncbi.nlm.nih.gov]
  • Blood arsenic levels: This may show elevated levels of arsenic, however, patients are often already started on treatment by the time results are available. Urine arsenic levels: This includes both a spot test and 24 hour urine collection.[symptoma.com]
  • The textbookprovides an evidence-based approach to testing, differential diagnosis, and treatment, and should serveas a trusted resource for healthcare professionals confronting the many manifestations of peripheralneuropathy in clinical practice.[books.google.com]
  • Side effects associated with these treatments are inflammation, oozing, ulceration, crusting, pain, hypo/hyperpigmentation, and treatment failure. Surgical excision can be performed for arsenical keratoses.[clinicaladvisor.com]

Prognosis

  • Prognosis In acute arsenic poisoning survival for more than one week is usually followed by complete recovery. With chronic arsenic poisoning recovery may require 6 months to 1 year.[ihcworld.com]
  • Tamra Carlson - 2019-01-07 15:18 Disease Topic Myeloproliferative Neoplasms- MPN implications for classification, diagnosis, and prognosis.[arupconsult.com]
  • Pregnancy and breast-feeding: arsenic is probably transferred to the baby via the placenta and breast milk. [ 2 ] Prognosis [ 2 ] The prognosis varies with the amount and rate of arsenic ingestion.[patient.info]
  • Early diagnosis is the key for this condition and offers the best prognosis visually, as well as systemically, for the affected patient. Dr. Pate is a Clinical Associate Professor at the University of Houston College of Optometry.[reviewofoptometry.com]

Etiology

  • Besides skin and lung cancer, industrial and agricultural exposure to arsenic has been implicated in the etiology of cancers of the urinary bladder, kidney, and liver in exposed populations.[pathopedia-india.com]
  • […] c-Jun / AP1 transcription complex High doses of inorganic arsenicals induce release of TNF alpha Arsenic can induce cross tolerance to cytotoxicity, genotoxicity and apoptosis induced by nickel and other metals ( Toxicol Appl Pharmacol 2001;176:127 ) Etiology[pathologyoutlines.com]
  • Tentative Diagnosis and Follow-Up The tentative assessment at this visit was optic atrophy of an unknown etiology.[reviewofoptometry.com]
  • (This article gives a thorough review of the literature regarding the etiology, epidemiology, and most common clinical presentations of chronic arsenic exposure.[clinicaladvisor.com]

Epidemiology

  • […] table Free element of arsenic appears in two allotropic forms: grey and yellow (crystalline) Can also exist in various oxidation states, inorganic and organic forms, exposure to inorganic arsenic is associated with most cases of arsenic induced toxicity Epidemiology[pathologyoutlines.com]
  • Epidemiology In Victorian times arsenic was famous as a homicidal or suicidal poison; it is now thankfully much harder to obtain. Health and safety at work have also improved so that, in the UK, both acute and chronic arsenic poisoning are rare.[patient.info]
  • (This article gives a thorough review of the literature regarding the etiology, epidemiology, and most common clinical presentations of chronic arsenic exposure.[clinicaladvisor.com]
Sex distribution
Age distribution

Pathophysiology

  • […] is present in air, usually due to volcanic eruption and purposeful human activities Arsenic also found as sulphuric compound in lead, copper, nickel and ferrous ores; also in soil in small quantities Also a medicinal used by physicians for 2000 years Pathophysiology[pathologyoutlines.com]
  • Pathophysiology The exact mechanism for chromosomal damage has yet to be fully elucidated.[clinicaladvisor.com]

Prevention

  • Treatment and Prevention of Arsenic Poisoning Arsenic poisoning is capable of causing life- threatening health issues and can even prove fatal if not treated on time.[medindia.net]
  • Systemic Implications and Complications It’s important to treat squamous cell carcinomas early on to prevent the risk of metastasis.[clinicaladvisor.com]
  • One of the most effective preventive measures against arsenic poisoning is to make sure you drink clean, filtered water. You can also make sure that all foods are prepared in clean water.[healthline.com]
  • Tamra Carlson - 2019-05-01 11:34 Disease Topic Emergency Toxicology ARUP Consult’s Trace Elements topic with Lead Poisoning and Arsenic Poisoning sections) Urine ... management, and prevention of poisonings due to drugs, occupational and environmental[arupconsult.com]
  • Sulfer containing amino acids such as cystine B6 help eliminate arsenic and can prevent arsenic poisoning.[dmsachelation.com]

References

Article

  1. Kingston RL, Hall S, Sioris L. Clinical observations and medical outcomes in 149 cases of arsenate ant killer ingestion. J Toxicol Clin Toxicol. 1993;31(4):581-591.
  2. Lai MW, Boyer EW, Kleinman ME, Rodig NM, Ewald MB. Acute arsenic poisoning in two siblings. Pediatrics. 2005;116(1):249-257.
  3. Correia N, Carvalho C, Friões F, Araújo JP, Almeida J, Azevedo A. Haemolytic anaemia secondary to arsenic poisoning: a case report. Cases J. 2009;2:7768.
  4. Campbell JP, Alvarez JA. Acute arsenic intoxication. Am Fam Physician. 1989;40(6):93–97.
  5. Ghariani M, Adrien ML, Raucoules M, Bayle J, Jacomet Y, Grimaud D. Subacute arsenic poisoning. Ann Fr Anesth Reanim. 1991;10(3):304-307.
  6. Lerman BB, Ali N, Green D. Megaloblastic, dyserythropoietic anaemia following arsenic ingestion. Ann Clin Lab Sci. 1980;10(6):515-517.
  7. Ratnaike RN. Acute and chronic arsenic toxicity. Postgrad Med J. 2003;79(933):391-396.

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Last updated: 2018-06-21 23:07