Aplastic anemia and membranous nephropathy induced by intravenous mercury
A 19-year-old female was referred to our hospital with a history of intravenous injection of 5 ml of elemental mercury with suicidal inten. She had been initially treated with local excision and broncho-alveolar lavage (BAL) and penicillamine are used to remove the extravasated mercury at the site of injection. Two weeks later, she developed recurrent bouts of fever and pancytopenia for which she had been given multiple blood transfusions. She was referred to us for further evaluation. Clinical examination was unremarkable except for pallor.\nInvestigations revealed pancytopenia with a hemoglobin of 5.7 g/dl, total WBC count of 3600 cells/cu.mm, and a platelet count of 15,000/cu.mm. She had normal liver and renal functions and urine analysis showed 3+ proteinuria with 8-10 RBCs/HPF. X-ray chest revealed multiple opaque deposits throughout the lung fields []; similar deposits were seen in the pelvis on X-ray abdomen. Qualitative mercury analysis of her blood and urine for mercury was positive; quantitative analysis by atomic absorption spectrometry revealed a blood level of 58 mcg/l, and a urine level of 138 mcg/l (reference values in non-exposed individuals are below 8 mcg/l in blood and 4 mcg/l in urine).[] Bone marrow biopsy revealed hypocellular bone marrow with organophilic heavy metal deposits [].\nShe was treated symptomatically with packed RBC transfusion and was kept under close follow-up. Her counts gradually improved and she was asymptomatic. She developed progressively increasing edema with hypoalbuminemia (serum albumin 2.9 g/dl) and nephrotic range proteinuria (24-h urine protein 3792 mg) with a serum cholesterol of 278 mg/dl, normal renal functions, and blood pressure. Ultrasonogram of abdomen showed normal kidneys. Kidney biopsy revealed nine non-obsolescent glomeruli with patent capillary loops and thick capillary walls on H and E stain []; focal lucent holes and fuschinophilic specs were seen on Jones Silver stain and Masson Trichrome, respectively. Tubules, interstitium, and vasculature were normal. IF revealed 3+ granular positivity for IgG and 2+ for C3. IgA, IgM, and C1q were negative. The biopsy was consistent with membranous nephropathy (MN). Her follow-up after 4 months showed complete resolution of pancytopenia (hemoglobin 13.5 g/dl, WBC count 9190 cells/cu.mm, platelet count 210,000) and after 2 years, the proteinuria had resolved completely (serum albumin was 4.62 g/dl and serum cholesterol was 170 mg/dl). The radiographic opacities in the lungs and pelvis have shown almost complete clearance over 4 years []. After 4 years of follow-up, she has normal hemogram and renal function and urine does not show any proteinuria. She is currently asymptomatic and is on follow-up.