PATHCHAT Edition No. 27
Please contact your local Ampath pathologist for more information.
Author: Dr. Nereshni Lutchman, Chemical Pathologist
Introduction
🔹 Occupational exposure to metals poses serious health risks.
- Toxicity depends on:
- The type of metal.
- Duration and dose of exposure.
- Route of exposure (inhalation, ingestion, skin contact).
- Individual health factors.
- Preventive strategies include:
- Occupational screening and surveillance programs.
- Environmental exposure controls.
- Workplace safety measures.
- Access to occupational health services.
✅ Diagnosing metal-related occupational diseases requires:
- A thorough occupational history.
- Clinical examination for systemic effects.
- Laboratory tests for biological monitoring.
A. Occupational History Taking
🔹 A detailed work and environmental history is essential.
✅ Key Questions to Ask the Patient:
1️⃣ Current job details:
- Job title, industry, and workplace conditions.
- Use of personal protective equipment (PPE).
2️⃣ Symptoms related to workplace exposure:
- Does the patient suspect work-related illness?
- Are co-workers experiencing similar symptoms?
3️⃣ Employment history:
- Chronology of previous jobs.
- Any trends between workplace exposure and health problems.
4️⃣ Environmental exposures (outside work):
- Hobbies (e.g., welding, painting, shooting).
- Household exposure (e.g., lead in plumbing, pesticide use).
- Smoking, herbal medication, and community exposures.
5️⃣ Specific workplace exposures:
- Exposure to fumes, dust, metals, chemicals.
6️⃣ Pre-existing medical conditions:
- Chronic illnesses that could worsen metal toxicity.
B. Clinical Examination & Laboratory Investigations
🔹 Most metals affect multiple organ systems.
✅ Systemic Examination Focus Areas:
- Neurological system: Peripheral neuropathy, cognitive impairment.
- Respiratory system: Chronic cough, fibrosis.
- Cardiovascular system: Arrhythmias, hypertension.
- Gastrointestinal system: Abdominal pain, liver damage.
- Renal function: Proteinuria, nephropathy.
- Skin & mucous membranes: Rashes, ulcers, discoloration.
✅ Recommended Laboratory Tests:
- Full Blood Count (FBC) – Detects anaemia or changes in blood cells.
- Urinalysis – Screens for kidney damage.
- Kidney Function Tests (Creatinine, Urea, eGFR).
- Liver Function Tests (ALT, AST, ALP, Bilirubin).
- Electrocardiogram (ECG) – If cardiac toxicity is suspected.
- Pulmonary Function Tests & Chest X-ray – If respiratory exposure is suspected.
- Allergy Testing – In cases of metal hypersensitivity reactions.
✅ Metal-Specific Biological Monitoring:
- Blood, urine, and tissue metal testing confirm exposure.
C. Common Metals, Health Effects & Testing
🔹 Each metal has a unique clinical picture and diagnostic test.
1. Arsenic
✅ Health Effects:
- Garlic-like odour on breath and sweat.
- Hyperpigmentation ("raindrop" spots), hyperkeratosis.
- Peripheral neuropathy ("glove-and-stocking" pattern).
- White streaks on fingernails (Mees lines).
- Cardiac arrhythmias, liver and kidney damage.
- Haemolytic anaemia (with arsine gas exposure).
- Carcinogen (skin, lung cancer).
✅ Testing:
- Urinary arsenic levels (best for recent exposure).
- Hair and fingernail arsenic levels (detect past exposure, 6–12 months).
2. Aluminium
✅ Health Effects:
- Chronic obstructive airway disease (Shaver’s disease).
- Asthma, fractures, osteomalacia, dementia.
- Proximal muscle weakness, microcytic anaemia.
✅ Testing:
- Aluminium levels in urine and blood.
3. Antimony
✅ Health Effects:
- Skin pustules (antimony spots).
- ECG changes (altered T waves), high blood pressure.
- Pneumoconiosis, bronchitis, emphysema.
✅ Testing:
- Urinary antimony levels.
4. Cadmium
✅ Health Effects:
- Proteinuria, nose ulcers, loss of smell.
- Severe bone pain, joint pain ("waddling gait").
- Fanconi’s syndrome, kidney stones, osteomalacia.
- Emphysema, prostate cancer.
✅ Testing:
- Blood and urine cadmium levels.
5. Chromium (Hexavalent Chromium)
✅ Health Effects:
- Bronchitis, asthma, lung cancer.
- Ulceration of nasal septum, "chrome ulcers" on skin.
✅ Testing:
- Total chromium in urine.
- Chromium in blood, plasma, or red cells.
6. Lead
✅ Health Effects:
- Lead encephalopathy, anaemia, abdominal pain ("lead colic").
- Kidney damage, foot-drop, wrist-drop.
✅ Testing:
- Blood lead levels.
7. Manganese
✅ Health Effects:
- Severe pneumonia from inhalation.
- Parkinson-like syndrome, multiple sclerosis.
✅ Testing:
- Blood and urine manganese levels.
8. Mercury
✅ Health Effects:
- Tremors, personality changes, hallucinations.
- Gingivitis, metallic taste, nephrotic syndrome.
- Bronchitis, gastrointestinal necrosis.
✅ Testing:
- Total mercury in blood and urine.
9. Nickel
✅ Health Effects:
- Nasal irritation, sinusitis, asthma.
- Contact dermatitis ("nickel itch").
- Pulmonary fibrosis, reduced sperm count.
- Lung and gastrointestinal cancer.
✅ Testing:
- Urinary nickel levels.
10. Thallium
✅ Health Effects:
- Gastroenteritis, hair loss (alopecia).
- Burning tongue, neurological disorders.
- Constipation followed by diarrhoea.
✅ Testing:
- Urine thallium levels.
- Thallium in hair and nails.
11. Vanadium
✅ Health Effects:
- Pneumonitis, chronic bronchitis.
- Nervous system and cardiovascular effects.
✅ Testing:
- Urine vanadium levels.
D. Occupational Exposure & Reproductive Risks
✅ Metal exposure can impact fertility and fetal development.
🔹 Lead:
- Males: Reduced sperm quality and fertility.
- Females: Miscarriages, premature birth, low birth weight, cognitive impairments.
🔹 Mercury:
- Males: Linked to fetal loss.
- Females: Menstrual disorders, reduced fertility, fetal loss.
Key Takeaways for Clinicians
✅ Occupational metal exposure can affect multiple organ systems.
✅ A thorough occupational history is critical for diagnosis.
✅ Biological monitoring via blood and urine testing confirms exposure.
✅ Certain metals pose reproductive and carcinogenic risks.
✅ Early detection and preventive strategies are essential to protect workers.