Subcutaneous Mercury Injection by a Child: A Histopathology Case Report
A 15-year-old male child presented to our tertiary care trauma center with multiple non-healing ulcers on the left forearm since 2 months following trauma by a sharp object []. His general physical examination was unremarkable with stable vital signs. On local examination, there were multiple ulcers, the largest of size 2 × 2 cm over the distal forearm and nodular lesions over the volar aspect of the forearm and lower arm. The nodules were firm and fixed. There was no local lymphadenopathy. His systemic examination was normal. He was under treatment by a surgeon for non-healing ulcer in a peripheral hospital for the last 1.5 months. Discrepancy between history and physical examination prompted surgeons to suspect substance abuse; therefore, a psychiatric referral was performed. This revealed intentional subcutaneous injection of mercury at least thrice, obtained after breaking a thermometer and a sphygmomanometer. The patient was inspired by the movie X-Man Wolverine and wanted to simulate a character called “Mercury.” Interestingly, he had a past history of multiple bites by spiders to simulate Spiderman. Surprisingly, he had no other psychiatric problems and had a normal IQ. Complete biochemical and toxicology evaluations, including elemental mercury level in blood, urine and nails, were performed. X-ray and non-contrast computed tomography scan of the left upper limb was performed, which showed a diffuse area of multiple, subcutaneous radioopaque deposits up to the lower arm []. A Doppler study was performed to rule out any intravascular deposit, but all major vessels were patent, which led to the conclusion that the patient had injected mercury subcutaneously. Mercury was not detected in the serum and nails. However, the concentration of mercury in the urine was 0.139 mg/L (normal range = 0.020 mg/L). The chest X-ray was normal. Excision of the skin and subcutaneous tissue containing granuloma was carried out under X-ray guidance. The skin was left open and a split-thickness skin graft was applied later and the tissue was submitted for biopsy. The surgical wounds healed uneventfully.\nThe pathologic specimen consisted of three tissue pieces measuring 2 × 3 cm, 1 × 1 cm and 1 × 0.5 cm, comprising skin and subcutaneous tissue. The cut-section revealed hemorrhagic and necrotic areas with exuding shiny droplets of mercury. The tissues were processed and microscopic sections were stained with hematoxylin and eosin stain.\nThe microscopy showed epidermis along with dermis showing multiple cystic spaces containing concentric droplets of mercury, which appeared purplish-black in color. Surrounding these spaces were foreign body-type giant cells, histiocytes, lymphocytes and plasma cells [].\nSerum and urinary mercury levels were repeated 1 month after follow-up. The patient is on regular follow-up and there are no signs of systemic absorption until now.