CHAPTER 111 ENVIRONMENTAL TOXINS AND DISORDERS OF THE NERVOUS SYSTEM
Individual cases of lead poisoning were reported as early as 200 B.C. Nevertheless, the need for the evaluation and treatment of the medical effects caused by exposure to chemicals was not recognized until the 20th century. Many of the offending chemicals affect both the central nervous system (CNS) and peripheral nervous system (PNS), and high-level exposure often results in delirium, seizures, or coma.1–4 Although residual effects can include mood and cognitive disorders, they are often not attributed to exposure to these chemicals.
Because the diagnosis of toxin-mediated neurological deficits is one of exclusion, it is important to substantiate a history of significant exposure. Neurological examination and neuroimaging techniques are not very helpful in making a specific diagnosis of toxic encephalopathy but might rule out other causes for the patient’s clinical presentation.5,6 Neuropsychological assessment is essential in the evaluation of these patients. However, decrements in performance on these tests may be erroneously interpreted by clinicians who are not versed in neurobehavioral toxicology. In addition, evaluation of toxic effects on the brain must be considered in the context of each patient’s personality because psychiatric changes can be primary or secondary to chemical exposure.
METAL INTOXICATION
Arsenic
Clinical Features and Diagnosis
Acute toxicity is characterized by fever, headaches, anxiety, and vertigo. Seizures are common. Neurological examination reveals nystagmus, increased tendon reflexes, neck stiffness, and sometimes paralysis.7 Mees’ lines (white lines in the nails) usually appear 2 to 3 weeks after acute exposure to arsenic. Encephalopathy with marked excitement followed by lethargy and signs of acute peripheral neuropathy can develop within a few hours. In patients with fatal acute poisoning, coma and death ensue within a few days. Patients with subacute or chronic arsenic encephalitis can suffer from relentless headaches, physical and mental fatigue, vertigo, restlessness, and focal pareses. Spinal cord involvement is associated with weakness, sphincter disturbances, and motor and sensory impairments. Optic neuritis, manifested by cloudy vision and visual field defects, can also occur subacutely or be delayed for years. In general, a mixed sensory and motor neuropathy develops within 7 to 10 days after ingestion of toxic amounts of arsenic, and patients often complain of severe burning sensation in the soles of the feet. Long-standing cognitive changes have been reported.
Arsenic intoxication should be considered in a patient with severe abdominal pain, dermatitis, painful peripheral neuropathy, and seizures. A history of arsenic exposure and toxic arsenic levels in hair, urine, or nails confirm the diagnosis. Arsenic is poorly tolerated in the presence of alcohol. Therefore, patients with alcohol-related disease have a greater risk of developing arsenic neuropathy. Although hair and nail samples may be useful, measurement of urinary arsenic levels is the test of choice. A level of arsenic in urine (24-hour measurement) greater than 50 μg/g creatinine is considered elevated. Because urinary level may be high after ingestion of seafood, a dietary history should be obtained. More reliable values can be obtained by measuring urinary inorganic arsenic metabolites: monomethylarsonic acid and dimethylarsinic acid.
Management
In patients with acute oral ingestion of arsenic, gastric lavage with electrolyte replacement is recommended. Excretion of absorbed arsenic can be enhanced by chelation with dimercaprol (British antilewisite), D-penicillamine, or dimercaptosuccinic acid. Chelating agents can reverse or prevent the attachment of heavy metals to various essential body chemicals (Table 111-1). Although chelating agents may alleviate the acute symptoms, they might not improve chronic symptoms such as peripheral neuropathy or encephalopathy. Dimercaprol treatment is not considered effective after the appearance of neuropathy. Intravenous fluids for dehydration and morphine for abdominal pain are also recommended. Prognosis with severe arsenic poisoning is poor, with a mortality rate of 50% to 75%, usually within the first 48 hours.
Lead
Inorganic Lead
Cause and Pathogenesis
Lead poisoning has a very long history. Although it was identified as early as 200 B.C., it remains a common occurrence even today. More than 1 million workers in more than 100 occupations are exposed to lead. In lead-related industries, workers not only inhale lead dust and lead fumes but may eat, drink, and smoke in or near contaminated areas, increasing the probability of lead ingestion. Family members can also be exposed to lead dust by workers who do not wash thoroughly before returning to their homes. Other sources of lead exposure include surface dust and oils. The de-leading of gasoline has significantly decreased that source of lead exposure. The current major sources of lead in the environment are lead paint in homes built before 1950 and lead used in plumbing, which was restricted in 1986. In 1991, median blood levels of lead in adults in the United States were estimated at 6 μg/dL.8
Children 5 years old or younger are especially vulnerable to the toxic effects of lead. Elevated lead levels in children are caused by pica (compulsive eating of nonfood items) or by the mouthing of items contaminated with lead from paint dust. Children also absorb and retain more lead than do adults. For example, approximately 10% of ingested lead is absorbed by adults whereas 40% to 50% of ingested lead is absorbed by children. Young children with iron deficiency have increased lead absorption. The risk of in utero exposure is high because lead readily crosses the placenta.9
Lead encephalopathy has been associated with softening and flattening of convolutions in the brain. On occasion, there are punctate hemorrhages, dilation of the vessels, and dilation of the ventricular system, especially in the frontal lobes. Histologically, extensive involvement of the ganglion cells is evident. The developing brain appears to be vulnerable to levels of lead that were once thought to cause no harmful effects.
Clinical Features and Diagnosis
In children, exposure to toxic doses of lead can cause listlessness, drowsiness with clumsiness, and ataxia. Very high levels can cause convulsions, respiratory arrest, and coma. A diagnosis of lead toxicity should be considered in a child who shows changes in mental status, gait disorder, or seizures. Chronic low-level exposure in children can result in attention and learning disabilities or in cognitive decline. Children chronically exposed to lead have been reported to show a drop in mean verbal IQ score of 4.5 points. Primary school children with high lead levels in teeth, but without a history of lead exposure, had larger deficits in speech and language processing, psychometric intelligence scores, and classroom performance than did children with lower levels of lead. Children with high lead levels in their teeth are sevenfold more likely not to graduate from high school. They have a greater prevalence of poor eye-hand coordination, reading disabilities, poor fine motor skills, and poor reaction time.9–11
At present, acute lead encephalopathy resulting from industrial exposure is not common. Signs and symptoms generally include delirium, combative irrational behavior, sleep disturbances, decreased libido, increased distractibility, increased irritability, and mental status changes marked by psychomotor slowing, memory dysfunction, and seizures.12
Manganese
Clinical Features and Diagnosis
The onset of manganese toxicity depends on the intensity of exposure and on individual susceptibility. Symptoms may appear as soon as 1 or 2 months or as late as 20 years after exposure. The earliest symptoms of manganism include anorexia, apathy, hypersomnolence, and headaches. Neurobehavioral changes include irritability, emotional lability, and, after continued exposure, psychosis and speech abnormalities that sometimes lead to mutism. Other signs and symptoms include masklike facies, bradykinesia, micrographia, retropulsion and propulsion, fine or coarse tremor of the hands, and gross rhythmical movements of the trunk and head.13
Mercury
Inorganic Mercury
Management and Prognosis
Removal of the patient from the sources of exposure and chelation with N-acetyl-D-penicillamine are recommended. Long-term computed tomographic follow-up of survivors of Minamata disease revealed decreased bilateral attenuation in the visual cortex and diffuse atrophy of the cerebellum, especially the vermis.13a
Organic Mercury
Cause and Pathogenesis
Intoxications can be caused by ingestion of fish containing methyl mercury, homemade bread prepared from seed treated with methyl mercury–containing fungicide, or meat from livestock fed grain treated with mercury-containing fungicides. Organic mercury is absorbed via the gastrointestinal tract and is slowly excreted through the kidneys; the half-life ranges from 40 to 105 days. Mercury readily crosses the placenta, and the blood concentrations in the fetus are equal to or greater than those in the maternal blood. Fetal methyl mercury poisoning can occur in asymptomatic mothers. Because methyl mercury can also be secreted in breast milk, mercury poisoning can also occur in breastfed children.
ORGANIC SOLVENTS (Table 111-2)
n-Hexane and Methyl-N-Butyl Ketone
Exposure to n-hexane occurs from recreational use. Acute exposure to n-hexane causes euphoria, but chronic intoxication is associated with peripheral neuropathy. n-Hexane is metabolized to 2,5-hexanedione, which is responsible for much of the neurotoxicity of the parent compound.
Methyl Alcohol
Methyl alcohol (methanol, wood alcohol) is used as a solvent and is a component of antifreeze fluids. Although only mildly toxic, methanol is oxidized to formaldehyde and formic acid, which can produce severe acidosis and are responsible for the clinical symptoms associated with its abuse. The oxidation and excretion of methyl alcohol are slow; toxic symptoms develop over 12 to 48 hours. Methanol toxicity involves the gastrointestinal and respiratory tracts, the visual system, and the CNS. Toxicity is manifested by nausea, vomiting, abdominal pain, headache, and vertigo. Patients may also become restless, uncoordinated, weak, or delirious. More severe cases can manifest with visual loss, parkinsonism, convulsions, stupor, or coma. Death can also occur as a result of respiratory failure. Methanol-induced neuropathological abnormalities include neuronal degeneration, primarily in the parietal cortex.14
Mixed Solvents
Clinical Features and Diagnosis
A rating scale was developed in 1985 to classify patients who had been exposed to solvents:



Toluene (Methyl Benzene)
Toluene is a used as paint, lacquer thinner, or a dyeing agent. It is also found in fuels. Because toluene is also part of the glue used by paint huffers, it has been suggested as a potential cause of the neurotoxic syndrome observed in these individuals. Although similar to the neurobehavioral changes of benzene-induced toxic effects, those of toluene toxicity are more severe. Acute exposure causes fatigue, mild confusion, ataxia, and dizziness. Chronic use is associated with euphoria, disinhibition, and tremor. Neurobehavioral effects include decreases in performance IQ, memory abnormalities, poor motor control, decreased visuospatial functioning, and dementia.15 Treatment consists of removal from the source of toluene exposure.
GASES (Table 111-3)
Carbon Monoxide
Clinical Features and Diagnosis
Neurological signs of mild carbon monoxide poisoning include headache, dizziness, and impaired vision, which can progress to convulsions and coma. Persistent chronic exposure from inadequately vented heaters in the home can cause blindness, deafness, pyramidal signs, extrapyramidal signs, and convulsive disorders.
Mild neurological effects may be transient or persistent and may appear immediately or days to weeks after exposure. Neuropsychiatric changes include irritability, violent behavior, euphoria, confusion, and impaired judgment. Cognitive symptoms include difficulties with visual and verbal memory, spatial deficits, and decline in cognitive efficiency and flexibility.16 Parkinsonism has also been reported after acute and chronic exposure. Imaging studies reveal lucency in the globus pallidus and atrophy.
PESTICIDES (See Table 111-3)
Organochlorine Insecticides
Cause and Pathogenesis
Chlorinated hydrocarbon insecticides are fat soluble. They can last for a long time in the environment and contribute to long-term clinical toxicity. These organochlorine insecticides include aldrin, chlordane, dichlorodiphenyltrichloroethane (DDT), endrin, heptachlor, chlordecone (Kepone), and lindane.17 Most of them have been banned or restricted in the United States because of their deleterious effects on wildlife. However, some are still used in less industrialized countries. Absorption may occur through oral, respiratory, or dermal routes.
Organophosphate Insecticides
Cause and Pathogenesis
Organophosphates are absorbed through the dermal and respiratory routes, but small amounts may also be ingested with foods that have been sprayed. Organophosphate insecticides are highly toxic to insects but less so to humans and domestic animals.18 Organophosphates such as triorthocresyl phosphate, mipafox, and trichlorfon compounds can be neurotoxic. Persons at high risk for organophosphate poisoning include factory workers involved in the production of these compounds and agricultural workers who use them to spray crops. Epidemics of organophosphate poisoning have been reported in some developing countries. In 1987, there were reports of 1754 pesticide-related cases in California.
Clinical Features and Diagnosis
Affected patients often complain of a vague sense of fatigue, increased salivation, nausea and vomiting, diaphoresis, abdominal cramps, headaches, and dizziness. Symptoms develop within 24 hours of exposure. Difficulty with speaking or swallowing, shortness of breath, and muscle fasciculations can be seen in patients with moderate levels of exposure. More severely affected patients have depressed levels of consciousness and marked myosis with no pupillary response. After initial recovery from acute intoxication, a delayed polyneuropathy (organophosphate insecticide delayed polyneuropathy [OPIDP]) may develop. OPIDP is a distal dying-back axonopathy characterized by cramping muscle pain in the legs, paresthesias, and motor weakness beginning 10 days to 3 weeks after the initial exposure. OPIDP-associated signs include footdrop, weakness of intrinsic hand muscles, absence of ankle jerk reflexes, and weakness of hip and knee flexors. Chronic low-level exposure is associated with weakness, malaise, headache, and lightheadedness. Anxiety, irritability, altered sleep, tremor, numbness and tingling of the extremities, and miosis may also be observed.19 Cognitive abnormalities include decreased capacity for information processing, decreased memory and learning abilities, and poor visuoconstructional skills.
ANIMAL TOXINS
Snake, Scorpion, and Spider Venoms
Cause and Pathogenesis
Poisonous snakes include vipers, rattlesnakes, cobras, kraits, mambas, and the American coral snake.20,21 The black widow probably accounts for most of the neurotoxic syndromes that occur after spider bites. Fatalities associated with spider bites occur in approximately 2.5% to 6% of cases.
PLANT TOXINS
Chickpea (Lathyrism)
Lathyrism is related to a neurotoxin that acts on glutaminergic system. Spastic paraplegia has been observed in Europe and India after consumption of different varieties of chickpea.22 Development of human lathyrism is associated with two potent neurotoxins found in the peas: α-amino-β-oxalylaminopropionic acid and α-amino-γ-oxalylaminobutyric acid. Toxic neurological signs are seen when 30% or more of the diet consists of chickpeas. Men tend to be affected more than are women. The onset is subtle, with pain in the lumbar region and with stiffness and weakness of the lower extremities on awakening in the morning. The legs may become spastic and exhibit clonic tremor. Other patients complain of tremulousness, numbness, paresthesias, formication, and sphincteric spasms. Some patients complain of pain and cramps in the calf muscles. The upper extremities may also be involved in patients with severe disease. The pain and paresthesias usually disappear within 1 to 2 weeks after chickpeas are removed from the diet, but relapses may occur. Lathyrism has been classified on a 4-point scale: no-stick (mild), one-stick (moderate), two-stick (severe), and crawler-stage (very severe) cases. In the latter cases, victims are unable to move their legs and depend on their arms to move the body on their rumps. Neurological examination reveals no involvement of the cranial nerves, the sensory system, or the cerebellum.
BACTERIAL TOXINS
Botulism
Cause and Pathogenesis
Botulism results from the ingestion of one of the most potent poisons in existence.23 The toxin made by the spores of C. botulinum is a potent inhibitor of acetylcholine release. Three distinct forms of botulism exist. Foodborne botulism occurs after the ingestion of contaminated home-canned fruits and vegetables, which contain already-formed spores. This syndrome appears rapidly, usually between 8 and 36 hours after ingestion. Neurological signs appear within hours or, at most, 1 week after ingestion of the toxin. Wound-induced botulism results from the entry of the organism into the blood stream through the wound site. Spores may germinate locally in the tissues and cause a toxic syndrome. Infantile botulism usually occurs in the first 6 months after birth.24,25 It is caused by the absorption of C. botulinum from the gastrointestinal tract.
Clinical Features and Diagnosis
The diagnosis is confirmed by detecting the toxin either in the patient (blood) or in the implicated food products.26 A stool culture is also recommended.
Diphtheria
Cause and Pathogenesis
The bacterium Corynebacterium diphtheriae is the causative agent of diphtheria. It is acquired through respiratory droplets from infected persons or asymptomatic carriers. There are two forms, oropharyngeal and cutaneous, with incubation periods lasting 1 to 4 days. The bacterium affects the respiratory tract, heart, kidneys, and nervous system through a toxin that causes tissue damage in the vicinity of affected areas and is transported to other organs via the blood stream. Muscle and myelin are preferentially affected by this powerful toxin. Neurological symptoms result either from direct damage to muscle and peripheral nerve or from indirect damage caused by hypoxia and airway obstruction. The CNS is not directly affected because the toxin does not cross the blood-brain barrier.
ACKNOWLEDGMENT
The authors thanks Maryann Carrigan for her assistance in the preparation of this chapter.
Branchi I, Capone F, Alleva E, et al. Polybrominated dephenyl ethers: neurobehavioral effects following developmental exposure. Neurotoxicology. 2003;24:449-462.
Davidson PW, Weiss B, Myers GJ, et al. Evaluation of techniques for assessing neurobehavioral development in children. Neurotoxicology. 2000;21:957-972.
Josko D. Botulin toxin: a weapon in terrorism. Clin Lab Sci. 2004;17:30-34.
Levy BS, Nassetts WJ. Neurologic effects of manganese in humans: a review. Int J Occup Environ Health. 2003;9:153-163.
Rhee P, Nunley MK, Demetriades D, et al. Tetanus and trauma: a review and recommendations. J Trauma. 2005;58:1082-1088.
1 Goetz CG. Neurotoxins in Clinical Practice. New York: Spectrum, 1985.
2 Carpenter DO. Effects of metal on the nervous system of humans and animals. Int J Occup Med Environ Health. 2001;14:209-218.
3 Chang LW, Dyer RS, editors. Handbook of Neurotoxicology. New York: Marcel Dekker, 1995.
4 Krantz A, Dorevitch S. Metal exposure and common chronic diseases: a guide for the clinician. Dis Mon. 2004;50:220-262.
5 Hartman DE. Neuropsychological Toxicology: Identification and Assessment of Human Neurotoxic Syndromes. New York: Pergamon, 1988.
6 Bolla KI. Use of neuropsychological resting in idiopathic environmental testing. Occup Med. 2000;15:617-625.
7 Graeme KA, Pollack CVJr. Heavy metals toxicity, part I: arsenic and mercury. J Emerg Med. 1998;16:45-56.
8 National Advisory Council for Environmental Policy and Technology Report of Environmental Protection Agency. Washington, DC: U.S. Government Printing Office, 1993.
9 Bellinger D, Levinton A, Waternaux C, et al. Longitudinal analyses of prenatal and postnatal lead exposure and early cognitive development. N Engl J Med. 1987;316:1037-1043.
10 Bolla K, Rignani J. Clinical course of neuropsychological functioning after chronic exposure to organic and inorganic lead. Arch Clin Neuropsychol. 1997;12:123-131.
11 Schwartz BS, Bolla KI, Stewart W, et al. Decrements in neurobehavioral performance associated with mixed exposure to organic and inorganic lead. Am J Epidemiol. 1993;137:1006-1021.
12 Schwartz BS, Lee BBK, Bandeen-Roche K, et al. Occupational lead exposure and longitudinal decline in neurobehavioral test scores. Epidemiology. 2005;16:106-113.
13 Cotzias GC, Horiuchi K, Fuenzalida S, et al. Chronic manganese poisoning: clearance of tissue manganese concentrations with persistence of the neurological picture. Neurology. 1968;18:376-382.
13a Tokuomi H, Uchimo M, Imamura S, et al. Minamata disease (organic mercury poisoning): neuroradiologic and electro-physiologic studies. Neurology. 1982;32:1369-1375.
14 Mittal BV, Desai AP, Khade KR. Methyl alcohol poisoning: an autopsy study of 28 cases. J Postgrad Med. 1991;37:9-13.
15 Benignus VA. Neurobehavioral effects of toluene: a review. Neurobehav Toxicol Teratol. 1981;3:408-415.
16 Gordon MF, Mercandetti M. Carbon monoxide poisoning producing purely cognitive and behavioral sequelae. Neuropsychiatry Neuropsychol Behav Neurol. 1989;2:145-152.
17 Baker SR, Williamson CF. The Effects of Pesticides on Human Health. Advances in Modern Environmental Toxicology. Princeton, NJ: Princeton Scientific Co., 1990.
18 Wesseling C, Keifer M, Ahlbom A, et al. Long-term neurobehavioral effects of mild poisoning with organophosphate and N-methyl carbamate pesticides among banana workers. Int J Occup Environ Health. 2002;8:27-34.
19 Kamel F, Hoppin JA. Association of pesticide exposure with neurologic dysfunction and disease. Environ Health Perspect. 2004;112:950-958.
20 Seneviratne U, Dissanayake S. Neurological manifestations of snake bite in Sri Lanka. J Postgrad Med. 2002;48:227-275.
21 Gold BS, Barish RA, Dart RC. North American snake envenomation: diagnosis, treatment, and management. Emerg Med Clin North Am. 2004;2:423-443.
22 Getahun H, Lambein F, Vanhoorne M, et al. Neurolathyrism risk depends on type of grass pea preparation and on mixing with cereals and antioxidants. Trop Med Int Health. 2005;10:169-178.
23 Erbguth FJ. Hostorical notes on botulism, clostridium botulinum, botulinum toxin, and the idea of the therapeutic use of the toxin. Mov Disord. 2004;8:S2-S6.
24 Krishna S, Puri V. Infant botulism: case reports and review. J Ky Med Assoc. 2001;99:143-146.
25 Cox N, Hinkle R. Infant botulism. Am Fam Physician. 2002;65:1388-1392.
26 Sharma SK, Whiting RC. Methods for detection of Clostridium botulinum toxin in foods. J Food Prot. 2005;68:1256-1263.