Nonfatal Arsenic Poisoning in Three Hmong Patients -- Minnesota

Between December 1983 and April 1984, physicians at the Saint Paul Ramsey Medical Center in Saint Paul, Minnesota, diagnosed arsenic poisoning in three Hmong patients. Hmong are recent immigrants to the United States from the highland area of Northern Laos. The source of arsenic poisoning is suspected to be Hmong folk remedies, although two of the three patients denied using them. None of the three patients had occupational exposures to arsenic-containing compounds or pesticides.

Patient 1: A 68-year-old woman was admitted in December 1983 with a 3-month history of abdominal pain, anorexia, sour taste and burning sensation in the mouth, generalized pain, and paresthesias. Six weeks earlier, she had been admitted with similar complaints. The diagnosis at that time was goiter and hyperthyroidism, and she was treated with radioiodine. During this second admission, leukopenia (3,200/mm((3))), anemia (hemoglobin 9.3 ug/dl, hematocrit 27.5%), and a prolonged QT-interval on electrocardiogram (EKG) were observed. She had elevated levels of arsenic in 24-hour collections of urine on both her first and sixth day of hospitalization (3,334 ug and 1,284 ug, respectively; the normal level for this laboratory is less than 25 ug per 24-hour urine collection). Her serum arsenic level on the sixth day of hospitalization was less than 0.01 ug/ml (normal for this laboratory is less than 0.07 ug/ml). She was treated with dimercaprol (BAL) intramuscularly and with oral penicillamine. Despite this therapy, moderately severe peripheral neuropathy developed, persisting for several months. All other manifestations of arsenic poisoning resolved. The patient denied using Hmong folk remedies.

Patient 2: A 47-year-old woman was admitted in March 1984 with a history of severe depression, anorexia, pain in the chest and arms, and malaise. She was found to have leukopenia (2,900/mm((3))), hypocalcemia (7.6 mg/dl), hypomagnesemia (1.3 mg/dl), and hypokalemia (2.7 meq/l). A prolonged QT-interval was noted on EKG. Her urine arsenic level 11 days after admission was 327 ug per 24-hour collection. Her serum arsenic was less than 0.01 ug/ml. She recovered, and all hematologic and biochemical abnormalities resolved without chelation therapy. The patient denied using folk remedies to overcome depression or any other illness.

Patient 3: A 39-year-old man suffered a "respiratory arrest" at home in April 1984. He had awakened in the middle of the night and had taken a root-type Hmong folk remedy. Ten minutes later, while awake, he became unconscious, and his wife called for help. Paramedics found his pulse to be 30 beats per minute, and his respirations were shallow and feeble. The man was resuscitated and hospitalized. His EKG showed sinus tachycardia with nonspecific ST changes. On monitoring, short runs of supraventricular tachycardia were noted. Pancytopenia and mild gastrointestinal bleeding developed during the patient's hospitalization. His 24-hour urine specimen contained high levels of several metals, including arsenic (1,815 ug), zinc (1,699 ug; normal is 300-600 ug), and iron (352 ug; normal is 100-300 ug). On dermatologic examination, he had hyperkeratosis of the palms and soles consistent with arsenic poisoning. He was treated with BAL and oral penicillamine and recovered. Reported by N Holtan, MD, S Hall, MD, F Knight, MD, B Campion, MD, C Drage, MD, Saint Paul Ramsey Medical Center; R Danila, MPH, Saint Paul Div of Public Health; JN Kuritsky, MD, Medical Epidemiologist, Minnesota Dept of Health; Special Studies Br, Chronic Diseases Div, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: These appear to be the first three reported cases of arsenic poisoning among the Hmong in the United States. Although the source of arsenic poisoning in these patients has not been identified, it is possible that their clinical conditions resulted from ingestion of arsenic-containing folk remedies. There has been concern about possible arsenic exposure in the Hmong, since arsenic (in addition to lead and mercury) was found in some samples of Hmong folk remedies (1). Arsenic poisoning also has been reportedly associated with herbal preparations used as medicine (2-4). Although only one of the three patients gave a history of using a folk remedy, that is still the likeliest source of arsenic poisoning. The use of folk remedies should be suspected in all Hmong patients--not only those with manifestations of acute or chronic illness, but also those who think they may be ill. Patients may go to great expense in seeking cures with herbal and other folk remedies. A reliable and accurate history of folk remedy usage from Hmong patients is very difficult to obtain. There have been incidents reported of Hmong admitting, and later denying, that they used folk remedies, as well as conflicting reports from within the same family about folk remedy use.

These patients had no other known exposures to arsenic, such as occupational exposures or use of arsenic-containing pesticides. Arsenic exposure from dietary sources (such as from seafood) usually does not result in acute toxicity as seen in these patients (5).

The near-fatal case of the 39-year-old man is suggestive of the sudden unexplained death syndrome (SUDS) among male Southeast Asian refugees reported recently (6). Although the epidemiologic investigations of those deaths suggested that poisoning was an unlikely cause of SUDS, toxicologic examinations did not include assays for arsenic or other heavy metals. While it is possible that preparations of folk remedies may have been taken at bedtime and could have resulted in effects shortly thereafter, family histories of such practice among the patients were negative. At present, there is insufficient evidence to link arsenic ingestion or folk remedy use with SUDS.

The root-type Hmong folk remedy taken by the 39-year-old man is being evaluated by health authorities and others to ascertain its potential toxic effects and chemical composition. Arsenic is toxic to multiple organs and has neurologic (central and peripheral), dermatologic, renal, hepatic, hematologic, and cardiac manifestations. The effects of arsenic on the heart include T-wave abnormalities and a prolonged QT-interval (5). Screening for arsenic, mercury, and lead is indicated in Southeast Asian refugees who present with symptoms consistent with heavy metal toxicity, especially those who report recent use of folk remedies. Testing for arsenic and mercury is best performed on 24-hour urine specimens collected in acid-rinsed containers; testing for lead poisoning should include blood lead and erythrocyte protoporphyrin in whole blood (7). Documented cases of heavy metal poisoning in the refugees should be reported to local and state health departments and to CDC.

References

1. CDC. Folk remedy-associated lead poisoning in Hmong children--Minnesota. MMWR 1983;32:555-6.

2. Tay C-H, Seah C-S. Arsenic poisoning from anti-asthmatic herbal preparations. Med J Aust 1975;2:424-8.

3. Tay C-H. Cutaneous manifestations of arsenic poisoning due to certain Chinese herbal medicine. Australas J Dermatol 1974;15:121-31.

4. Parsons JS. Contaminated herbal tea as a potential source of chronic arsenic poisoning. NC Med J 1981;42:38-9.

5. Perhsgen G. The epidemiology of human arsenic exposure. In: Fowler BA, ed. Biological and environmental effects of arsenic. New York: Elsevier Science Publishing Company, 1983.

6. Baron RC, Thacker SB, Gorelkin L, et al. Sudden death among Southeast Asian refugees. An unexplained nocturnal phenomenon. JAMA 1983; 250:2947-51.

7. CDC. Preventing lead poisoning in young children: a statement by the Center for Disease Control. Atlanta, Georgia: Center for Disease Control, April 1978.

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