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Arsenic poisoning

January 26, 2023

Arsenic poisoning is a medical condition that occurs due to elevated levels of arsenic in the body.[6] If arsenic poisoning occurs over a brief period of time, symptoms may include vomiting, abdominal pain, encephalopathy, and watery diarrhea that contains blood.[3] Long-term exposure can result in thickening of the skin, darker skin, abdominal pain, diarrhea, heart disease, numbness, and cancer.[3]

Arsenic poisoning
Other namesArsenicosis
An 1889 newspaper advertisement for "arsenic complexion wafers".[1] Arsenic was known to be poisonous during the Victorian era.[2]
SpecialtyToxicology
SymptomsAcute: vomiting, abdominal pain, watery diarrhea[3]
Chronic: thickened skin, darker skin, cancer[3]
CausesArsenic[3]
Diagnostic methodUrine, blood, or hair testing[3]
PreventionDrinking water without arsenic[3]
TreatmentDimercaptosuccinic acid, dimercaptopropane sulfonate[4]
Frequency>200 million[5]

The most common reason for long-term exposure is contaminated drinking water.[5] Groundwater most often becomes contaminated naturally; however, contamination may also occur from mining or agriculture.[3] It may also be found in the soil and air.[7] Recommended levels in water are less than 10–50 µg/L (10–50 parts per billion).[3] Other routes of exposure include toxic waste sites and pseudo-medicine.[3][5] Most cases of poisoning are accidental.[3] Arsenic acts by changing the functioning of around 200 enzymes.[3] Diagnosis is by testing the urine, blood, or hair.[3]

Prevention is by using water that does not contain high levels of arsenic.[3] This may be achieved by the use of special filters or using rainwater.[3] There is not good evidence to support specific treatments for long-term poisoning.[3] For acute poisonings treating dehydration is important.[6] Dimercaptosuccinic acid or dimercaptopropane sulfonate may be used while dimercaprol (BAL) is not recommended.[4] Hemodialysis may also be used.[6]

Through drinking water, more than 200 million people globally are exposed to higher-than-safe levels of arsenic.[5] The areas most affected are Bangladesh and West Bengal.[5] Exposure is also more common in people of low income and minorities.[8] Acute poisoning is uncommon.[5] The toxicity of arsenic has been described as far back as 1500 BC in the Ebers papyrus.[9]

Signs and symptoms

Symptoms of arsenic poisoning begin with headaches, confusion, severe diarrhea, and drowsiness. As the poisoning develops, convulsions and changes in fingernail pigmentation called leukonychia striata (Mees's lines, or Aldrich-Mees's lines) may occur.[10] When the poisoning becomes acute, symptoms may include diarrhea, vomiting, vomiting blood, blood in the urine, cramping muscles, hair loss, stomach pain, and more convulsions. The organs of the body that are usually affected by arsenic poisoning are the lungs, skin, kidneys, and liver.[11] The final result of arsenic poisoning is coma and death.[12]

Arsenic is related to heart disease[13] (hypertension-related cardiovascular disease), cancer,[14] stroke[15] (cerebrovascular diseases), chronic lower respiratory diseases,[16] and diabetes.[17][18] Skin effects can include skin cancer in the long term, but often prior to skin cancer are different skin lesions.[7] Other effects may include darkening of skin and thickening of skin.[19]

Chronic exposure to arsenic is related to[clarification needed] vitamin A deficiency, which is related to heart disease and night blindness.[20] The acute minimal lethal dose of arsenic in adults is estimated to be 70 to 200 mg or 1 mg/kg/day.[21]

Cancer

Arsenic increases the risk of cancer.[22] Exposure is related to skin, lung, liver, and kidney cancer among others.[3]

Its comutagenic effects may be explained by interference with base and nucleotide excision repair, eventually through interaction with zinc finger structures.[23] Dimethylarsinic acid, DMA(V), caused DNA single strand breaks resulting from inhibition of repair enzymes at levels of 5 to 100 mM in human epithelial type II cells.[24][25]

MMA(III) and DMA(III) were also shown to be directly genotoxic by effectuating scissions in supercoiled ΦX174 DNA.[26] Increased arsenic exposure is associated with an increased frequency of chromosomal aberrations,[27] micronuclei[28][29] and sister-chromatid exchanges. An explanation for chromosomal aberrations is the sensitivity of the protein tubulin and the mitotic spindle to arsenic. Histological observations confirm effects on cellular integrity, shape and locomotion.[30]

DMA(III) is able to form reactive oxygen species by reaction with molecular oxygen. Resulting metabolites are the dimethylarsenic radical and the dimethylarsenic peroxyl radical.[31] Both DMA(III) and DMA(V) were shown to release iron from horse spleen as well as from human liver ferritin if ascorbic acid was administered simultaneously. Thus, formation of reactive oxygen species can be promoted.[32] Moreover, arsenic could cause oxidative stress by depleting the cell's antioxidants, especially the ones containing thiol groups. The accumulation of reactive oxygen species like that cited above and hydroxyl radicals, superoxide radicals and hydrogen peroxides causes aberrant gene expression at low concentrations and lesions of lipids, proteins and DNA in higher concentrations which eventually lead to cellular death. In a rat animal model, urine levels of 8-hydroxy-2'-deoxyguanosine (as a biomarker of DNA damage byreactive oxygen species) were measured after treatment with DMA(V). In comparison to control levels, they turned out to be significantly increased.[33] This theory is further supported by a cross-sectional study which found elevated mean serum lipid peroxides in the As exposed individuals which correlated with blood levels of inorganic arsenic and methylated metabolites and inversely correlated with nonprotein sulfhydryl (NPSH) levels in whole blood.[34] Another study found an association of As levels in whole blood with the level of reactive oxidants in plasma and an inverse relationship with plasma antioxidants.[35] A finding of the latter study indicates that methylation might in fact be a detoxification pathway with regard to oxidative stress: the results showed that the lower the As methylation capacity was, the lower the level of plasma antioxidant capacity. As reviewed by Kitchin (2001), the oxidative stress theory provides an explanation for the preferred tumor sites connected with arsenic exposure.[36] Considering that a high partial pressure of oxygen is present in lungs and DMA(III) is excreted in gaseous state via the lungs, this seems to be a plausible mechanism for special vulnerability. The fact that DMA is produced by methylation in the liver, excreted via the kidneys and later on stored in the bladder accounts for the other tumor localizations.

Regarding DNA methylation, some studies suggest interaction of As with methyltransferases which leads to an inactivation of tumor suppressor genes through hypermethylation; others state that hypomethylation might occur due to a lack of SAM resulting in aberrant gene activation.[37] An experiment by Zhong et al. (2001) with arsenite-exposed human lung A549, kidney UOK123, UOK109 and UOK121 cells isolated eight different DNA fragments by methylation-sensitive arbitrarily primed polymerase chain reactions.[38] It turned out that six of the fragments were hyper- and two of them were hypomethylated.[38] Higher levels of DNA methyltransferase mRNA and enzyme activity were found.[38]

Kitchin (2001) proposed a model of altered growth factors which lead to cell proliferation and thus to carcinogenesis.[36] From observations, it is known that chronic low-dose arsenic poisoning can lead to increased tolerance to its acute toxicity.[22][39] MRP1-overexpressing lung tumor GLC4/Sb30 cells poorly accumulate arsenite and arsenate. This is mediated through MRP-1 dependent efflux.[40] The efflux requires glutathione, but no arsenic-glutathione complex formation.[41]

Although many mechanisms have been proposed, no definite model can be given for the mechanisms of chronic arsenic poisoning. The prevailing events of toxicity and carcinogenicity might be quite tissue-specific. Current consensus on the mode of carcinogenesis is that it acts primarily as a tumor promoter. Its co-carcinogenicity has been demonstrated in several models. However, the finding of several studies that chronically arsenic-exposed Andean populations (as most extremely exposed to UV-light) do not develop skin cancer with chronic arsenic exposure, is puzzling.[42]

Causes

Organic arsenic is less harmful than inorganic arsenic. Seafood is a common source of the less toxic organic arsenic in the form of arsenobetaine. The arsenic reported in 2012 in fruit juice and rice by Consumer Reports was primarily inorganic arsenic.[43][44] Because of its high toxicity, arsenic is seldom used in the Western world, although in Asia it is still a popular pesticide. Arsenic is mainly encountered occupationally in the smelting of zinc and copper ores.

Drinking water

Arsenic is naturally found in groundwater and presents serious health threats when high amounts exist.[45] Chronic arsenic poisoning results from drinking contaminated well water over a long period of time. Many aquifers contain high concentration of arsenic salts.[46] The World Health Organization (WHO) Guidelines for drinking water quality established in 1993 a provisional guideline value of 0.01 mg/L (10 parts per billion) for maximum contaminant levels of arsenic in drinking water.[47] This recommendation was established based on the limit of detection for most laboratories' testing equipment at the time of publication of the WHO water quality guidelines. More recent findings show that consumption of water with levels as low as 0.00017 mg/L (0.17 parts per billion) over long periods of time can lead to arsenicosis.[48][49]

From a 1988 study in China, the US protection agency quantified the lifetime exposure of arsenic in drinking water at concentrations of 0.0017 mg/L (1.7 ppb), 0.00017 mg/L, and 0.000017 mg/L are associated with a lifetime skin cancer risk of 1 in 10,000, 1 in 100,000, and 1 in 1,000,000 respectively. WHO asserts that a water level of 0.01 mg/L (10 ppb) poses a risk of 6 in 10,000 chance of lifetime skin cancer risk and contends that this level of risk is acceptable.[50]

One of the worst incidents of arsenic poisoning via well water occurred in Bangladesh, which the World Health Organization called the "largest mass poisoning of a population in history"[51] recognized as a major public health concern. The contamination in the Ganga-Brahmaputra fluvial plains in India and Padma-Meghna fluvial plains in Bangladesh demonstrated adverse impacts on human health.[52]

Mining techniques such as hydraulic fracturing may mobilize arsenic in groundwater and aquifers due to enhanced methane transport and resulting changes in redox conditions,[53] and inject fluid containing additional arsenic.[54]

Groundwater

Main article: Arsenic contamination of groundwater

In the US, the U.S. Geological Survey estimates that the median groundwater concentration is 1 μg/L or less, although some groundwater aquifers, particularly in the western United States, can contain much higher levels. For example, median levels in Nevada were about 8 μg/L[55] but levels of naturally occurring arsenic as high as 1000 μg/L have been measured in the United States in drinking water.[56]

Geothermally active zones occur at hotspots where mantle-derived plumes ascend, such as in Hawaii and Yellowstone National Park, US. Arsenic is an incompatible element (does not fit easily into the lattices of common rock-forming minerals). Concentrations of arsenic are high mainly in geothermal waters that leach continental rocks. Arsenic in hot geothermal fluids was shown to be derived mainly from leaching of host rocks at Yellowstone National Park, in Wyoming, US, rather than from magmas.[57]

In the western US, there are As (arsenic) inputs to groundwater and surface water from geothermal fluids in and near Yellowstone National Park,[58] and in other western mineralized areas.[59] Groundwater associated with volcanics in California contain As at concentrations ranging up to 48,000 μg/L, with As-bearing sulfide minerals as the main source.[60] Geothermal waters on Dominica in the Lesser Antilles also contain concentrations of As >50 μg/L.[61]

In general, because arsenic is an incompatible element, it accumulates in differentiated magmas,[58] and in other western mineralized areas.[59] Weathering of pegmatite veins in Connecticut, US, was thought to contribute As to groundwater.[citation needed]

Arsenic poisoning from exposure to groundwater is believed to be responsible for the illness experienced by those that witnessed the 2007 Carancas impact event in Peru, as local residents inhaled steam which was contaminated with arsenic, produced from groundwater which boiled from the intense heat and pressure produced by a chondrite meteorite impacting the ground.[62]

In Pennsylvania, As concentrations in water discharging from abandoned anthracite mines ranged from <0.03 to 15 μg/L and from abandoned bituminous mines, from 0.10 to 64 μg/L, with 10% of samples exceeding the United States Environmental Protection Agency MLC of 10 μg/L.[63]

In Wisconsin, As concentrations of water in sandstone and dolomite aquifers were as high as 100 μg/L. Oxidation of pyrite hosted by these formations was the likely source of the As.[64]

In the Piedmont of Pennsylvania and New Jersey, groundwater in Mesozoic age aquifers contains elevated levels of As—domestic well waters from Pennsylvania contained up to 65 μg/L,[65] whereas in New Jersey the highest concentration measured recently was 215 μg/L.[66]

Food

In the United States, Schoof et al. estimated an average adult intake of 3.2 μg/day, with a range of 1–20 μg/day.[67] Estimates for children were similar.[68] Food also contains many organic arsenic compounds. The key organic arsenic compounds that can be routinely found in food (depending on food type) include monomethylarsonic acid (MMAsV), dimethylarsinic acid (DMAsV), arsenobetaine, arsenocholine, arsenosugars, and arsenolipids. DMAsV or MMAsV can be found in various types of fin fish, crabs, and mollusks, but often at very low levels.[69]

Arsenobetaine is the major form of arsenic in marine animals, and, by all accounts, it is considered a compound that is nontoxic under conditions of human consumption. Arsenocholine, which is mainly found in shrimp, is chemically similar to arsenobetaine, and is considered to be "essentially nontoxic".[70] Although arsenobetaine is little studied, available information indicates it is not mutagenic, immunotoxic, or embryotoxic.[71]

Arsenosugars and arsenolipids have recently been identified. Exposure to these compounds and toxicological implications are currently being studied. Arsenosugars are detected mainly in seaweed but are also found to a lesser extent in marine mollusks.[72] Studies addressing arsenosugar toxicity, however, have largely been limited to in vitro studies, which show that arsenosugars are significantly less toxic than both inorganic arsenic and trivalent methylated arsenic metabolites.[73]

It has been found that rice is particularly susceptible to accumulation of arsenic from soil.[74] Rice grown in the United States has an average 260 ppb of arsenic, according to a study; but U.S. arsenic intake remains far below World Health Organization-recommended limits.[75] China has set a standard for arsenic limits in food (150 ppb),[76] as levels in rice exceed those in water.[77]

Arsenic is a ubiquitous element present in American drinking water.[78] In the United States, levels of arsenic that are above natural levels, but still well below danger levels set in federal safety standards, have been detected in commercially raised chickens.[79] The source of the arsenic appears to be the feed additives roxarsone and nitarsone, which are used to control the parasitic infection coccidiosis as well as to increase weight and skin coloring of the poultry.[80][81]

High levels of inorganic arsenic were reportedly found in 83 California wines in 2015.[82]

Soil

Exposure to arsenic in soil can occur through multiple pathways. Compared with the intake of naturally occurring arsenic from water and the diet, soil arsenic constitutes only a small fraction of intake.[83]

Air

The European Commission (2000) reports that levels of arsenic in air range 0–1 ng/m3 in remote areas, 0.2–1.5 ng/m3 in rural areas, 0.5–3 ng/m3 in urban areas, and up to about 50 ng/m3 in the vicinity of industrial sites. Based on these data, the European Commission (2000) estimated that in relation to food, cigarette smoking, water, and soil, air contributes less than 1% of total arsenic exposure.

Pesticides

The use of lead arsenate pesticides has been effectively eliminated for over 50 years. However, because of the pesticide's environmental persistence, it is estimated that millions of acres of land are still contaminated with lead arsenate residues. This presents a potentially significant public health concern in some areas of the United States (e.g., New Jersey, Washington, and Wisconsin), where large areas of land used historically as orchards have been converted into residential developments.[84]

Some modern uses of arsenic-based pesticides still exist. Chromated copper arsenate has been registered for use in the United States since the 1940s as a wood preservative, protecting wood from insects and microbial agents. In 2003, manufacturers of chromated copper arsenate instituted a voluntary recall of residential uses of wood treated with the chemical. The Environmental Protection Agency Act2008 final report stated that chromated copper arsenate is still approved for use in nonresidential applications, such as in marine facilities (pilings and structures), utility poles, and sand highway structures.

Copper smelting

Exposure studies in the copper smelting industry are much more extensive and have established definitive links between arsenic, a by-product of copper smelting, and lung cancer via inhalation.[85] Dermal and neurological effects were also increased in some of these studies.[86] Although as time went on, occupational controls became more stringent and workers were exposed to reduced arsenic concentrations, the arsenic exposures measured from these studies ranged from about 0.05 to 0.3 mg/m3 and are significantly higher than airborne environmental exposures to arsenic (which range from 0 to 0.000003 mg/m3).[87]

Pathophysiology

Arsenic interferes with cellular longevity by allosteric inhibition of an essential metabolic enzyme pyruvate dehydrogenase complex, which catalyzes the oxidation of pyruvate to acetyl-CoA by NAD+. With the enzyme inhibited, the energy system of the cell is disrupted resulting in cellular apoptosis. Biochemically, arsenic prevents use of thiamine resulting in a clinical picture resembling thiamine deficiency. Poisoning with arsenic can raise lactate levels and lead to lactic acidosis. Low potassium levels in the cells increases the risk of experiencing a life-threatening heart rhythm problem from arsenic trioxide.[citation needed] Arsenic in cells clearly stimulates the production of hydrogen peroxide (H2O2). When the H2O2 reacts with certain metals such as iron or manganese it produces a highly reactive hydroxyl radical. Inorganic arsenic trioxide found in ground water particularly affects voltage-gated potassium channels,[88] disrupting cellular electrolytic function resulting in neurological disturbances, cardiovascular episodes such as prolonged QT interval, neutropenia, high blood pressure,[89] central nervous system dysfunction, anemia, and death.

Arsenic exposure plays a key role in the pathogenesis of vascular endothelial dysfunction as it inactivates endothelial nitric oxide synthase, leading to reduction in the generation and bioavailability of nitric oxide. In addition, the chronic arsenic exposure induces high oxidative stress, which may affect the structure and function of cardiovascular system. Further, the arsenic exposure has been noted to induce atherosclerosis by increasing the platelet aggregation and reducing fibrinolysis. Moreover, arsenic exposure may cause arrhythmia by increasing the QT interval and accelerating the cellular calcium overload. The chronic exposure to arsenic upregulates the expression of tumor necrosis factor-α, interleukin-1, vascular cell adhesion molecule and vascular endothelial growth factor to induce cardiovascular pathogenesis.

— Pitchai Balakumar and Jagdeep Kaur, "Arsenic Exposure and Cardiovascular Disorders: An Overview", Cardiovascular Toxicology, December 2009[90]

Arsenic has also been shown to induce cardiac hypertrophy by activating certain transcription factors involved in pathologically remodeling the heart.[91] Tissue culture studies have shown that arsenic compounds block both IKr and Iks channels and, at the same time, activate IK-ATP channels. Arsenic compounds also disrupt ATP production through several mechanisms. At the level of the citric acid cycle, arsenic inhibits pyruvate dehydrogenase and by competing with phosphate it uncouples oxidative phosphorylation, thus inhibiting energy-linked reduction of NAD+, mitochondrial respiration, and ATP synthesis. Hydrogen peroxide production is also increased, which might form reactive oxygen species and oxidative stress. These metabolic interferences lead to death from multi-system organ failure, probably from necrotic cell death, not apoptosis. A post mortem reveals brick red colored mucosa, due to severe hemorrhage. Although arsenic causes toxicity, it can also play a protective role.[92]

Mechanism

Arsenite inhibits not only the formation of acetyl-CoA but also the enzyme succinic dehydrogenase. Arsenate can replace phosphate in many reactions. It is able to form Glc-6-arsenate in vitro; therefore it has been argued that hexokinase could be inhibited.[93] (Eventually this may be a mechanism leading to muscle weakness in chronic arsenic poisoning.) In the glyceraldehyde 3-phosphate dehydrogenase reaction arsenate attacks the enzyme-bound thioester. The formed 1-arseno-3-phosphoglycerate is unstable and hydrolyzes spontaneously. Thus, ATP formation in glycolysis is inhibited while bypassing the phosphoglycerate kinase reaction. (Moreover, the formation of 2,3-bisphosphoglycerate in erythrocytes might be affected, followed by a higher oxygen affinity of hemoglobin and subsequently enhanced cyanosis.) As shown by Gresser (1981), submitochondrial particles synthesize adenosine-5'-diphosphate-arsenate from ADP and arsenate in presence of succinate. Thus, by a variety of mechanisms arsenate leads to an impairment of cell respiration and subsequently diminished ATP formation.[94] This is consistent with observed ATP depletion of exposed cells and histopathological findings of mitochondrial and cell swelling, glycogen depletion in liver cells and fatty change in liver, heart and kidney.

Experiments demonstrated enhanced arterial thrombosis in a rat animal model, elevations of serotonin levels, thromboxane A[2] and adhesion proteins in platelets, while human platelets showed similar responses.[95] The effect on vascular endothelium may eventually be mediated by the arsenic-induced formation of nitric oxide. It was demonstrated that +3 As concentrations substantially lower than concentrations required for inhibition of the lysosomal protease cathepsin L in B cell line TA3 were sufficient to trigger apoptosis in the same B cell line, while the latter could be a mechanism mediating immunosuppressive effects.[96]

Kinetics

The two forms of inorganic arsenic, reduced (trivalent As(III)) and oxidized (pentavalent As(V)), can be absorbed, and accumulated in tissues and body fluids.[97] In the liver, the metabolism of arsenic involves enzymatic and non-enzymatic methylation; the most frequently excreted metabolite (≥ 90%) in the urine of mammals is dimethylarsinic acid or cacodylic acid, DMA(V).[98] Dimethylarsenic acid is also known as Agent Blue and was used as herbicide in the American war in Vietnam.

In humans inorganic arsenic is reduced nonenzymatically from pentoxide to trioxide, using glutathione or it is mediated by enzymes. Reduction of arsenic pentoxide to arsenic trioxide increases its toxicity and bio availability, Methylation occurs through methyltransferase enzymes. S-adenosylmethionine (SAM) may serve as methyl donor. Various pathways are used, the principal route being dependent on the current environment of the cell.[99] Resulting metabolites are monomethylarsonous acid, MMA(III), and dimethylarsinous acid, DMA(III).

Methylation had been regarded as a detoxification process,[by whom?] but reduction from +5 As to +3 As may be considered as a bioactivation[clarification needed] instead.[100] Another suggestion is that methylation might be a detoxification if "As[III] intermediates are not permitted to accumulate" because the pentavalent organoarsenics have a lower affinity to thiol groups than inorganic pentavalent arsenics.[99] Gebel (2002) stated that methylation is a detoxification through accelerated excretion.[101] With regard to carcinogenicity it has been suggested that methylation should be regarded as a toxification.[36][102][103]

Arsenic, especially +3 As, binds to single, but with higher affinity to vicinal sulfhydryl groups, thus reacts with a variety of proteins and inhibits their activity. It was also proposed that binding of arsenite at nonessential sites might contribute to detoxification.[104] Arsenite inhibits members of the disulfide oxidoreductase family like glutathione reductase[105] and thioredoxin reductase.[106]

The remaining unbound arsenic (≤ 10%) accumulates in cells, which over time may lead to skin, bladder, kidney, liver, lung, and prostate cancers.[98] Other forms of arsenic toxicity in humans have been observed in blood, bone marrow, cardiac, central nervous system, gastrointestinal, gonadal, kidney, liver, pancreatic, and skin tissues.[98]

Heat shock response

Another aspect is the similarity of arsenic effects to the heat shock response. Short-term arsenic exposure has effects on signal transduction inducing heat shock proteins with masses of 27, 60, 70, 72, 90, and 110 kDa as well as metallothionein, ubiquitin, mitogen-activated [MAP] kinases, extracellular regulated kinase [ERK], c-jun terminal kinases [JNK] and p38.[30][107] Via JNK and p38 it activates c-fos, c-jun and egr-1 which are usually activated by growth factors and cytokines.[30][108][109] The effects are largely dependent on the dosing regime and may be as well inversed.

As shown by some experiments reviewed by Del Razo (2001), reactive oxygen species induced by low levels of inorganic arsenic increase the transcription and the activity of the activator protein 1 (AP-1) and the nuclear factor-κB (NF-κB) (maybe enhanced by elevated MAPK levels), which results in c-fos/c-jun activation, over-secretion of pro-inflammatory and growth promoting cytokines stimulating cell proliferation.[107][110] Germolec et al. (1996) found an increased cytokine expression and cell proliferation in skin biopsies from individuals chronically exposed to arsenic-contaminated drinking water.[111]

Increased AP-1 and NF-κB obviously also result in an up-regulation of mdm2 protein, which decreases p53 protein levels.[112] Thus, taking into account p53's function, a lack of it could cause a faster accumulation of mutations contributing to carcinogenesis. However, high levels of inorganic arsenic inhibit NF-κB activation and cell proliferation. An experiment of Hu et al. (2002) demonstrated increased binding activity of AP-1 and NF-κB after acute (24 h) exposure to +3 sodium arsenite, whereas long-term exposure (10–12 weeks) yielded the opposite result.[113] The authors conclude that the former may be interpreted as a defense response while the latter could lead to carcinogenesis.[113] As the contradicting findings and connected mechanistic hypotheses indicate, there is a difference in acute and chronic effects of arsenic on signal transduction which is not clearly understood yet.[citation needed]

Oxidative stress

Studies have demonstrated that the oxidative stress generated by arsenic may disrupt the signal transduction pathways of the nuclear transcriptional factors PPARs, AP-1, and NF-κB,[98][113][114] as well as the pro-inflammatory cytokines IL-8 and TNF-α.[98][113][114][115][116][117][118][119] The interference of oxidative stress with signal transduction pathways may affect physiological processes associated with cell growth, metabolic syndrome X, glucose homeostasis, lipid metabolism, obesity, insulin resistance, inflammation, and diabetes-2.[120][121][122] Recent scientific evidence has elucidated the physiological roles of the PPARs in the ω- hydroxylation of fatty acids and the inhibition of pro-inflammatory transcription factors (NF-κB and AP-1), pro-inflammatory cytokines (IL-1, -6, -8, -12, and TNF-α), cell4 adhesion molecules (ICAM-1 and VCAM-1), inducible nitric oxide synthase, proinflammatory nitric oxide (NO), and anti-apoptotic factors.[98][115][120][122][123]

Epidemiological studies have suggested a correlation between chronic consumption of drinking water contaminated with arsenic and the incidence of type 2 diabetes.[98] The human liver after exposure to therapeutic drugs may exhibit hepatic non-cirrhotic portal hypertension, fibrosis, and cirrhosis.[98] However, the literature provides insufficient scientific evidence to show cause and effect between arsenic and the onset of diabetes mellitus Type 2.[98]

Diagnosis

Arsenic may be measured in blood or urine to monitor excessive environmental or occupational exposure, confirm a diagnosis of poisoning in hospitalized victims or to assist in the forensic investigation in a case of fatal over dosage. Some analytical techniques are capable of distinguishing organic from inorganic forms of the element. Organic arsenic compounds tend to be eliminated in the urine in unchanged form, while inorganic forms are largely converted to organic arsenic compounds in the body prior to urinary excretion. The current biological exposure index for U.S. workers of 35 µg/L total urinary arsenic may easily be exceeded by a healthy person eating a seafood meal.[124]

Tests are available to diagnose poisoning by measuring arsenic in blood, urine, hair, and fingernails. The urine test is the most reliable test for arsenic exposure within the last few days. Urine testing needs to be done within 24–48 hours for an accurate analysis of an acute exposure. Tests on hair and fingernails can measure exposure to high levels of arsenic over the past 6–12 months. These tests can determine if one has been exposed to above-average levels of arsenic. They cannot predict, however, whether the arsenic levels in the body will affect health.[125] Chronic arsenic exposure can remain in the body systems for a longer period of time than a shorter term or more isolated exposure and can be detected in a longer time frame after the introduction of the arsenic, important in trying to determine the source of the exposure.

Hair is a potential bioindicator for arsenic exposure due to its ability to store trace elements from blood. Incorporated elements maintain their position during growth of hair. Thus for a temporal estimation of exposure, an assay of hair composition needs to be carried out with a single hair which is not possible with older techniques requiring homogenization and dissolution of several strands of hair. This type of biomonitoring has been achieved with newer microanalytical techniques like synchrotron radiation based X-ray fluorescence spectroscopy and microparticle induced X-ray emission. The highly focused and intense beams study small spots on biological samples allowing analysis to micro level along with the chemical speciation. In a study, this method has been used to follow arsenic level before, during and after treatment with arsenious oxide in patients with acute promyelocytic leukemia.[126]

Treatment

Chelation

Dimercaprol and dimercaptosuccinic acid are chelating agents that sequester the arsenic away from blood proteins and are used in treating acute arsenic poisoning. The most important side effect is hypertension. Dimercaprol is considerably more toxic than succimer.[citation needed][127] dimercaptosuccinic acid monoesters, e.g. MiADMSA, are promising antidotes for arsenic poisoning.[128]

Nutrition

Supplemental potassium decreases the risk of experiencing a life-threatening heart rhythm problem from arsenic trioxide.[129]

History

See also: Arsenic poisoning cases

Beginning in about 3000 BC arsenic was mined and added to copper in the alloying of bronze, but the adverse health effects of working with arsenic led to it being abandoned when a viable alternative, tin, was discovered.[130]

In addition to its presence as a poison, for centuries arsenic was used medicinally. It has been used for over 2,400 years as a part of traditional Chinese medicine.[131] In the western world, arsenic compounds, such as salvarsan, were used extensively to treat syphilis before penicillin was introduced. It was eventually replaced as a therapeutic agent by sulfa drugs and then by other antibiotics. Arsenic was also an ingredient in many tonics (or "patent medicines").

In addition, during the Elizabethan era, some women used a mixture of vinegar, chalk, and arsenic applied topically to whiten their skin. This use of arsenic was intended to prevent aging and creasing of the skin, but some arsenic was inevitably absorbed into the blood stream.[citation needed]

During the Victorian era (late 19th century) in the United States, U.S. newspapers advertised "arsenic complexion wafers" that promised to remove facial blemishes such as moles and pimples.[2]

Some pigments, most notably the popular Emerald Green (known also under several other names), were based on arsenic compounds. Overexposure to these pigments was a frequent cause of accidental poisoning of artists and craftsmen.

Arsenic became a favored method for murder of the Middle Ages and Renaissance, particularly among ruling classes in Italy allegedly. Because the symptoms are similar to those of cholera, which was common at the time, arsenic poisoning often went undetected.[132]: 63  By the 19th century, it had acquired the nickname "inheritance powder," perhaps because impatient heirs were known or suspected to use it to ensure or accelerate their inheritances.[132]: 21  It was also a common murder technique in the 19th century in domestic violence situations, such as the case of Rebecca Copin, who attempted to poison her husband by "putting arsenic in his coffee".[133]

In post-WW1 Hungary, arsenic extracted by boiling fly paper was used in an estimated 300 murders by the Angel Makers of Nagyrév.

In imperial China, arsenic trioxide and sulfides were used in murder, as well as for capital punishment for members of the royal family or aristocracy. Forensic studies have determined that the Guangxu Emperor (d. 1908) was murdered by arsenic, most likely ordered by the Empress Dowager Cixi or Generalissimo Yuan Shikai. Likewise, in ancient Korea, and particularly in the Joseon Dynasty, arsenic-sulfur compounds have been used as a major ingredient of sayak (사약; 賜藥), which was a poison cocktail used in capital punishment of high-profile political figures and members of the royal family.[134] Due to social and political prominence of the condemned, many of these events were well-documented, often in the Annals of Joseon Dynasty; they are sometimes portrayed in historical television miniseries because of their dramatic nature.[135]

Legislation

In the U.S. in 1975, under the authority of the Safe Drinking Water Act, the U.S. Environmental Protection Agency determined the National Interim Primary Drinking Water Regulation levels of arsenic (inorganic contaminant – IOCs) to be 0.05 mg/L (50 parts per billion – ppb).[136]

Throughout the years, many studies reported dose-dependent effects of arsenic in drinking water and skin cancer. In order to prevent new cases and death from cancerous and non-cancerous diseases, the Safe Drinking Water Act directed the Environmental Protection Agency to revise arsenic's levels and specified the maximum contaminant level (MCL). MCLs are set as close to the health goals as possible, considering cost, benefits and the ability of public water systems to detect and remove contaminants using suitable treatment technologies.[136][137]

In 2001, Environmental Protection Agency adopted a lower standard of MCL 0.01 mg/L (10 ppb) for arsenic in drinking water that applies to both community water systems and non-transient non-community water systems.[136]

In some other countries, when developing national drinking water standards based on the guideline values, it is necessary to take account of a variety of geographical, socio-economic, dietary and other conditions affecting potential exposure. These factors lead to national standards that differ appreciably from the guideline values. That is the case in countries such as India and Bangladesh, where the permissible limit of arsenic in absence of an alternative source of water is 0.05 mg/L.[47][138]

Challenges to implementation

Arsenic removal technologies are traditional treatment processes which have been tailored to improve removal of arsenic from drinking water. Although some of the removal processes, such as precipitative processes, adsorption processes, ion exchange processes, and separation (membrane) processes, may be technically feasible, their cost may be prohibitive.[136]

For underdeveloped countries, the challenge is finding the means to fund such technologies. The Environmental Protection Agency, for example, has estimated the total national annualized cost of treatment, monitoring, reporting, record keeping, and administration to enforce the MCL rule to be approximately $181 million. Most of the cost is due to the installation and operation of the treatment technologies needed to reduce arsenic in public water systems.[139]

Pregnancy

Arsenic exposure through groundwater is highly concerning throughout the perinatal period. Pregnant women are a high-risk population because not only are the mothers at risk for adverse outcomes, but in-utero exposure also poses health risks to the infant.

There is a dose-dependent relationship between maternal exposure to arsenic and infant mortality, meaning that infants born to women exposed to higher concentrations, or exposed for longer periods of time, have a higher mortality rate.[140]

Studies have shown that ingesting arsenic through groundwater during pregnancy poses dangers to the mother including, but not limited to abdominal pain, vomiting, diarrhea, skin pigmentation changes, and cancer.[141] Research has also demonstrated that arsenic exposure also causes low birth weight, low birth size, infant mortality, and a variety of other outcomes in infants.[141][142] Some of these effects, like lower birth-rate and size may be due to the effects of arsenic on maternal weight gain during pregnancy.[142]

See also

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Further reading

  • Atlas (color) of Chronic Arsenic Poisoning (2010), Nobuyuki Hotta, Ichiro Kikuchi, Yasuko Kojo, Sakuragaoka Hospital, Kumamoto, ISBN 978-4-9905256-0-6.
  • A 2011 article in the journal Social Medicine discusses community interventions to combat arsenic poisoning: Beyond medical treatment, arsenic poisoning in rural Bangladesh.
  • D. J. Vaughan and D. A. Polya (2013): Arsenic – the great poisoner revisited. Elements 9, 315–316. (update on the world situation in 2013)

External links

January 26, 2023
arsenic, poisoning, medical, condition, that, occurs, elevated, levels, arsenic, body, arsenic, poisoning, occurs, over, brief, period, time, symptoms, include, vomiting, abdominal, pain, encephalopathy, watery, diarrhea, that, contains, blood, long, term, exp. Arsenic poisoning is a medical condition that occurs due to elevated levels of arsenic in the body 6 If arsenic poisoning occurs over a brief period of time symptoms may include vomiting abdominal pain encephalopathy and watery diarrhea that contains blood 3 Long term exposure can result in thickening of the skin darker skin abdominal pain diarrhea heart disease numbness and cancer 3 Arsenic poisoningOther namesArsenicosisAn 1889 newspaper advertisement for arsenic complexion wafers 1 Arsenic was known to be poisonous during the Victorian era 2 SpecialtyToxicologySymptomsAcute vomiting abdominal pain watery diarrhea 3 Chronic thickened skin darker skin cancer 3 CausesArsenic 3 Diagnostic methodUrine blood or hair testing 3 PreventionDrinking water without arsenic 3 TreatmentDimercaptosuccinic acid dimercaptopropane sulfonate 4 Frequency gt 200 million 5 The most common reason for long term exposure is contaminated drinking water 5 Groundwater most often becomes contaminated naturally however contamination may also occur from mining or agriculture 3 It may also be found in the soil and air 7 Recommended levels in water are less than 10 50 µg L 10 50 parts per billion 3 Other routes of exposure include toxic waste sites and pseudo medicine 3 5 Most cases of poisoning are accidental 3 Arsenic acts by changing the functioning of around 200 enzymes 3 Diagnosis is by testing the urine blood or hair 3 Prevention is by using water that does not contain high levels of arsenic 3 This may be achieved by the use of special filters or using rainwater 3 There is not good evidence to support specific treatments for long term poisoning 3 For acute poisonings treating dehydration is important 6 Dimercaptosuccinic acid or dimercaptopropane sulfonate may be used while dimercaprol BAL is not recommended 4 Hemodialysis may also be used 6 Through drinking water more than 200 million people globally are exposed to higher than safe levels of arsenic 5 The areas most affected are Bangladesh and West Bengal 5 Exposure is also more common in people of low income and minorities 8 Acute poisoning is uncommon 5 The toxicity of arsenic has been described as far back as 1500 BC in the Ebers papyrus 9 Contents 1 Signs and symptoms 1 1 Cancer 2 Causes 2 1 Drinking water 2 1 1 Groundwater 2 2 Food 2 3 Soil 2 4 Air 2 5 Pesticides 2 6 Copper smelting 3 Pathophysiology 3 1 Mechanism 3 2 Kinetics 3 3 Heat shock response 3 4 Oxidative stress 4 Diagnosis 5 Treatment 5 1 Chelation 5 2 Nutrition 6 History 7 Legislation 7 1 Challenges to implementation 8 Pregnancy 9 See also 10 References 11 Further reading 12 External linksSigns and symptoms EditSymptoms of arsenic poisoning begin with headaches confusion severe diarrhea and drowsiness As the poisoning develops convulsions and changes in fingernail pigmentation called leukonychia striata Mees s lines or Aldrich Mees s lines may occur 10 When the poisoning becomes acute symptoms may include diarrhea vomiting vomiting blood blood in the urine cramping muscles hair loss stomach pain and more convulsions The organs of the body that are usually affected by arsenic poisoning are the lungs skin kidneys and liver 11 The final result of arsenic poisoning is coma and death 12 Arsenic is related to heart disease 13 hypertension related cardiovascular disease cancer 14 stroke 15 cerebrovascular diseases chronic lower respiratory diseases 16 and diabetes 17 18 Skin effects can include skin cancer in the long term but often prior to skin cancer are different skin lesions 7 Other effects may include darkening of skin and thickening of skin 19 Chronic exposure to arsenic is related to clarification needed vitamin A deficiency which is related to heart disease and night blindness 20 The acute minimal lethal dose of arsenic in adults is estimated to be 70 to 200 mg or 1 mg kg day 21 Cancer Edit Arsenic increases the risk of cancer 22 Exposure is related to skin lung liver and kidney cancer among others 3 Its comutagenic effects may be explained by interference with base and nucleotide excision repair eventually through interaction with zinc finger structures 23 Dimethylarsinic acid DMA V caused DNA single strand breaks resulting from inhibition of repair enzymes at levels of 5 to 100 mM in human epithelial type II cells 24 25 MMA III and DMA III were also shown to be directly genotoxic by effectuating scissions in supercoiled FX174 DNA 26 Increased arsenic exposure is associated with an increased frequency of chromosomal aberrations 27 micronuclei 28 29 and sister chromatid exchanges An explanation for chromosomal aberrations is the sensitivity of the protein tubulin and the mitotic spindle to arsenic Histological observations confirm effects on cellular integrity shape and locomotion 30 DMA III is able to form reactive oxygen species by reaction with molecular oxygen Resulting metabolites are the dimethylarsenic radical and the dimethylarsenic peroxyl radical 31 Both DMA III and DMA V were shown to release iron from horse spleen as well as from human liver ferritin if ascorbic acid was administered simultaneously Thus formation of reactive oxygen species can be promoted 32 Moreover arsenic could cause oxidative stress by depleting the cell s antioxidants especially the ones containing thiol groups The accumulation of reactive oxygen species like that cited above and hydroxyl radicals superoxide radicals and hydrogen peroxides causes aberrant gene expression at low concentrations and lesions of lipids proteins and DNA in higher concentrations which eventually lead to cellular death In a rat animal model urine levels of 8 hydroxy 2 deoxyguanosine as a biomarker of DNA damage byreactive oxygen species were measured after treatment with DMA V In comparison to control levels they turned out to be significantly increased 33 This theory is further supported by a cross sectional study which found elevated mean serum lipid peroxides in the As exposed individuals which correlated with blood levels of inorganic arsenic and methylated metabolites and inversely correlated with nonprotein sulfhydryl NPSH levels in whole blood 34 Another study found an association of As levels in whole blood with the level of reactive oxidants in plasma and an inverse relationship with plasma antioxidants 35 A finding of the latter study indicates that methylation might in fact be a detoxification pathway with regard to oxidative stress the results showed that the lower the As methylation capacity was the lower the level of plasma antioxidant capacity As reviewed by Kitchin 2001 the oxidative stress theory provides an explanation for the preferred tumor sites connected with arsenic exposure 36 Considering that a high partial pressure of oxygen is present in lungs and DMA III is excreted in gaseous state via the lungs this seems to be a plausible mechanism for special vulnerability The fact that DMA is produced by methylation in the liver excreted via the kidneys and later on stored in the bladder accounts for the other tumor localizations Regarding DNA methylation some studies suggest interaction of As with methyltransferases which leads to an inactivation of tumor suppressor genes through hypermethylation others state that hypomethylation might occur due to a lack of SAM resulting in aberrant gene activation 37 An experiment by Zhong et al 2001 with arsenite exposed human lung A549 kidney UOK123 UOK109 and UOK121 cells isolated eight different DNA fragments by methylation sensitive arbitrarily primed polymerase chain reactions 38 It turned out that six of the fragments were hyper and two of them were hypomethylated 38 Higher levels of DNA methyltransferase mRNA and enzyme activity were found 38 Kitchin 2001 proposed a model of altered growth factors which lead to cell proliferation and thus to carcinogenesis 36 From observations it is known that chronic low dose arsenic poisoning can lead to increased tolerance to its acute toxicity 22 39 MRP1 overexpressing lung tumor GLC4 Sb30 cells poorly accumulate arsenite and arsenate This is mediated through MRP 1 dependent efflux 40 The efflux requires glutathione but no arsenic glutathione complex formation 41 Although many mechanisms have been proposed no definite model can be given for the mechanisms of chronic arsenic poisoning The prevailing events of toxicity and carcinogenicity might be quite tissue specific Current consensus on the mode of carcinogenesis is that it acts primarily as a tumor promoter Its co carcinogenicity has been demonstrated in several models However the finding of several studies that chronically arsenic exposed Andean populations as most extremely exposed to UV light do not develop skin cancer with chronic arsenic exposure is puzzling 42 Causes EditOrganic arsenic is less harmful than inorganic arsenic Seafood is a common source of the less toxic organic arsenic in the form of arsenobetaine The arsenic reported in 2012 in fruit juice and rice by Consumer Reports was primarily inorganic arsenic 43 44 Because of its high toxicity arsenic is seldom used in the Western world although in Asia it is still a popular pesticide Arsenic is mainly encountered occupationally in the smelting of zinc and copper ores Drinking water Edit Arsenic is naturally found in groundwater and presents serious health threats when high amounts exist 45 Chronic arsenic poisoning results from drinking contaminated well water over a long period of time Many aquifers contain high concentration of arsenic salts 46 The World Health Organization WHO Guidelines for drinking water quality established in 1993 a provisional guideline value of 0 01 mg L 10 parts per billion for maximum contaminant levels of arsenic in drinking water 47 This recommendation was established based on the limit of detection for most laboratories testing equipment at the time of publication of the WHO water quality guidelines More recent findings show that consumption of water with levels as low as 0 00017 mg L 0 17 parts per billion over long periods of time can lead to arsenicosis 48 49 From a 1988 study in China the US protection agency quantified the lifetime exposure of arsenic in drinking water at concentrations of 0 0017 mg L 1 7 ppb 0 00017 mg L and 0 000017 mg L are associated with a lifetime skin cancer risk of 1 in 10 000 1 in 100 000 and 1 in 1 000 000 respectively WHO asserts that a water level of 0 01 mg L 10 ppb poses a risk of 6 in 10 000 chance of lifetime skin cancer risk and contends that this level of risk is acceptable 50 One of the worst incidents of arsenic poisoning via well water occurred in Bangladesh which the World Health Organization called the largest mass poisoning of a population in history 51 recognized as a major public health concern The contamination in the Ganga Brahmaputra fluvial plains in India and Padma Meghna fluvial plains in Bangladesh demonstrated adverse impacts on human health 52 Mining techniques such as hydraulic fracturing may mobilize arsenic in groundwater and aquifers due to enhanced methane transport and resulting changes in redox conditions 53 and inject fluid containing additional arsenic 54 Groundwater Edit Main article Arsenic contamination of groundwater In the US the U S Geological Survey estimates that the median groundwater concentration is 1 mg L or less although some groundwater aquifers particularly in the western United States can contain much higher levels For example median levels in Nevada were about 8 mg L 55 but levels of naturally occurring arsenic as high as 1000 mg L have been measured in the United States in drinking water 56 Geothermally active zones occur at hotspots where mantle derived plumes ascend such as in Hawaii and Yellowstone National Park US Arsenic is an incompatible element does not fit easily into the lattices of common rock forming minerals Concentrations of arsenic are high mainly in geothermal waters that leach continental rocks Arsenic in hot geothermal fluids was shown to be derived mainly from leaching of host rocks at Yellowstone National Park in Wyoming US rather than from magmas 57 In the western US there are As arsenic inputs to groundwater and surface water from geothermal fluids in and near Yellowstone National Park 58 and in other western mineralized areas 59 Groundwater associated with volcanics in California contain As at concentrations ranging up to 48 000 mg L with As bearing sulfide minerals as the main source 60 Geothermal waters on Dominica in the Lesser Antilles also contain concentrations of As gt 50 mg L 61 In general because arsenic is an incompatible element it accumulates in differentiated magmas 58 and in other western mineralized areas 59 Weathering of pegmatite veins in Connecticut US was thought to contribute As to groundwater citation needed Arsenic poisoning from exposure to groundwater is believed to be responsible for the illness experienced by those that witnessed the 2007 Carancas impact event in Peru as local residents inhaled steam which was contaminated with arsenic produced from groundwater which boiled from the intense heat and pressure produced by a chondrite meteorite impacting the ground 62 In Pennsylvania As concentrations in water discharging from abandoned anthracite mines ranged from lt 0 03 to 15 mg L and from abandoned bituminous mines from 0 10 to 64 mg L with 10 of samples exceeding the United States Environmental Protection Agency MLC of 10 mg L 63 In Wisconsin As concentrations of water in sandstone and dolomite aquifers were as high as 100 mg L Oxidation of pyrite hosted by these formations was the likely source of the As 64 In the Piedmont of Pennsylvania and New Jersey groundwater in Mesozoic age aquifers contains elevated levels of As domestic well waters from Pennsylvania contained up to 65 mg L 65 whereas in New Jersey the highest concentration measured recently was 215 mg L 66 Food Edit In the United States Schoof et al estimated an average adult intake of 3 2 mg day with a range of 1 20 mg day 67 Estimates for children were similar 68 Food also contains many organic arsenic compounds The key organic arsenic compounds that can be routinely found in food depending on food type include monomethylarsonic acid MMAsV dimethylarsinic acid DMAsV arsenobetaine arsenocholine arsenosugars and arsenolipids DMAsV or MMAsV can be found in various types of fin fish crabs and mollusks but often at very low levels 69 Arsenobetaine is the major form of arsenic in marine animals and by all accounts it is considered a compound that is nontoxic under conditions of human consumption Arsenocholine which is mainly found in shrimp is chemically similar to arsenobetaine and is considered to be essentially nontoxic 70 Although arsenobetaine is little studied available information indicates it is not mutagenic immunotoxic or embryotoxic 71 Arsenosugars and arsenolipids have recently been identified Exposure to these compounds and toxicological implications are currently being studied Arsenosugars are detected mainly in seaweed but are also found to a lesser extent in marine mollusks 72 Studies addressing arsenosugar toxicity however have largely been limited to in vitro studies which show that arsenosugars are significantly less toxic than both inorganic arsenic and trivalent methylated arsenic metabolites 73 It has been found that rice is particularly susceptible to accumulation of arsenic from soil 74 Rice grown in the United States has an average 260 ppb of arsenic according to a study but U S arsenic intake remains far below World Health Organization recommended limits 75 China has set a standard for arsenic limits in food 150 ppb 76 as levels in rice exceed those in water 77 Arsenic is a ubiquitous element present in American drinking water 78 In the United States levels of arsenic that are above natural levels but still well below danger levels set in federal safety standards have been detected in commercially raised chickens 79 The source of the arsenic appears to be the feed additives roxarsone and nitarsone which are used to control the parasitic infection coccidiosis as well as to increase weight and skin coloring of the poultry 80 81 High levels of inorganic arsenic were reportedly found in 83 California wines in 2015 82 Soil Edit Exposure to arsenic in soil can occur through multiple pathways Compared with the intake of naturally occurring arsenic from water and the diet soil arsenic constitutes only a small fraction of intake 83 Air Edit The European Commission 2000 reports that levels of arsenic in air range 0 1 ng m3 in remote areas 0 2 1 5 ng m3 in rural areas 0 5 3 ng m3 in urban areas and up to about 50 ng m3 in the vicinity of industrial sites Based on these data the European Commission 2000 estimated that in relation to food cigarette smoking water and soil air contributes less than 1 of total arsenic exposure Pesticides Edit The use of lead arsenate pesticides has been effectively eliminated for over 50 years However because of the pesticide s environmental persistence it is estimated that millions of acres of land are still contaminated with lead arsenate residues This presents a potentially significant public health concern in some areas of the United States e g New Jersey Washington and Wisconsin where large areas of land used historically as orchards have been converted into residential developments 84 Some modern uses of arsenic based pesticides still exist Chromated copper arsenate has been registered for use in the United States since the 1940s as a wood preservative protecting wood from insects and microbial agents In 2003 manufacturers of chromated copper arsenate instituted a voluntary recall of residential uses of wood treated with the chemical The Environmental Protection Agency Act2008 final report stated that chromated copper arsenate is still approved for use in nonresidential applications such as in marine facilities pilings and structures utility poles and sand highway structures Copper smelting Edit Exposure studies in the copper smelting industry are much more extensive and have established definitive links between arsenic a by product of copper smelting and lung cancer via inhalation 85 Dermal and neurological effects were also increased in some of these studies 86 Although as time went on occupational controls became more stringent and workers were exposed to reduced arsenic concentrations the arsenic exposures measured from these studies ranged from about 0 05 to 0 3 mg m3 and are significantly higher than airborne environmental exposures to arsenic which range from 0 to 0 000003 mg m3 87 Pathophysiology EditArsenic interferes with cellular longevity by allosteric inhibition of an essential metabolic enzyme pyruvate dehydrogenase complex which catalyzes the oxidation of pyruvate to acetyl CoA by NAD With the enzyme inhibited the energy system of the cell is disrupted resulting in cellular apoptosis Biochemically arsenic prevents use of thiamine resulting in a clinical picture resembling thiamine deficiency Poisoning with arsenic can raise lactate levels and lead to lactic acidosis Low potassium levels in the cells increases the risk of experiencing a life threatening heart rhythm problem from arsenic trioxide citation needed Arsenic in cells clearly stimulates the production of hydrogen peroxide H2O2 When the H2O2 reacts with certain metals such as iron or manganese it produces a highly reactive hydroxyl radical Inorganic arsenic trioxide found in ground water particularly affects voltage gated potassium channels 88 disrupting cellular electrolytic function resulting in neurological disturbances cardiovascular episodes such as prolonged QT interval neutropenia high blood pressure 89 central nervous system dysfunction anemia and death Arsenic exposure plays a key role in the pathogenesis of vascular endothelial dysfunction as it inactivates endothelial nitric oxide synthase leading to reduction in the generation and bioavailability of nitric oxide In addition the chronic arsenic exposure induces high oxidative stress which may affect the structure and function of cardiovascular system Further the arsenic exposure has been noted to induce atherosclerosis by increasing the platelet aggregation and reducing fibrinolysis Moreover arsenic exposure may cause arrhythmia by increasing the QT interval and accelerating the cellular calcium overload The chronic exposure to arsenic upregulates the expression of tumor necrosis factor a interleukin 1 vascular cell adhesion molecule and vascular endothelial growth factor to induce cardiovascular pathogenesis Pitchai Balakumar and Jagdeep Kaur Arsenic Exposure and Cardiovascular Disorders An Overview Cardiovascular Toxicology December 2009 90 Arsenic has also been shown to induce cardiac hypertrophy by activating certain transcription factors involved in pathologically remodeling the heart 91 Tissue culture studies have shown that arsenic compounds block both IKr and Iks channels and at the same time activate IK ATP channels Arsenic compounds also disrupt ATP production through several mechanisms At the level of the citric acid cycle arsenic inhibits pyruvate dehydrogenase and by competing with phosphate it uncouples oxidative phosphorylation thus inhibiting energy linked reduction of NAD mitochondrial respiration and ATP synthesis Hydrogen peroxide production is also increased which might form reactive oxygen species and oxidative stress These metabolic interferences lead to death from multi system organ failure probably from necrotic cell death not apoptosis A post mortem reveals brick red colored mucosa due to severe hemorrhage Although arsenic causes toxicity it can also play a protective role 92 Mechanism Edit Arsenite inhibits not only the formation of acetyl CoA but also the enzyme succinic dehydrogenase Arsenate can replace phosphate in many reactions It is able to form Glc 6 arsenate in vitro therefore it has been argued that hexokinase could be inhibited 93 Eventually this may be a mechanism leading to muscle weakness in chronic arsenic poisoning In the glyceraldehyde 3 phosphate dehydrogenase reaction arsenate attacks the enzyme bound thioester The formed 1 arseno 3 phosphoglycerate is unstable and hydrolyzes spontaneously Thus ATP formation in glycolysis is inhibited while bypassing the phosphoglycerate kinase reaction Moreover the formation of 2 3 bisphosphoglycerate in erythrocytes might be affected followed by a higher oxygen affinity of hemoglobin and subsequently enhanced cyanosis As shown by Gresser 1981 submitochondrial particles synthesize adenosine 5 diphosphate arsenate from ADP and arsenate in presence of succinate Thus by a variety of mechanisms arsenate leads to an impairment of cell respiration and subsequently diminished ATP formation 94 This is consistent with observed ATP depletion of exposed cells and histopathological findings of mitochondrial and cell swelling glycogen depletion in liver cells and fatty change in liver heart and kidney Experiments demonstrated enhanced arterial thrombosis in a rat animal model elevations of serotonin levels thromboxane A 2 and adhesion proteins in platelets while human platelets showed similar responses 95 The effect on vascular endothelium may eventually be mediated by the arsenic induced formation of nitric oxide It was demonstrated that 3 As concentrations substantially lower than concentrations required for inhibition of the lysosomal protease cathepsin L in B cell line TA3 were sufficient to trigger apoptosis in the same B cell line while the latter could be a mechanism mediating immunosuppressive effects 96 Kinetics Edit The two forms of inorganic arsenic reduced trivalent As III and oxidized pentavalent As V can be absorbed and accumulated in tissues and body fluids 97 In the liver the metabolism of arsenic involves enzymatic and non enzymatic methylation the most frequently excreted metabolite 90 in the urine of mammals is dimethylarsinic acid or cacodylic acid DMA V 98 Dimethylarsenic acid is also known as Agent Blue and was used as herbicide in the American war in Vietnam In humans inorganic arsenic is reduced nonenzymatically from pentoxide to trioxide using glutathione or it is mediated by enzymes Reduction of arsenic pentoxide to arsenic trioxide increases its toxicity and bio availability Methylation occurs through methyltransferase enzymes S adenosylmethionine SAM may serve as methyl donor Various pathways are used the principal route being dependent on the current environment of the cell 99 Resulting metabolites are monomethylarsonous acid MMA III and dimethylarsinous acid DMA III Methylation had been regarded as a detoxification process by whom but reduction from 5 As to 3 As may be considered as a bioactivation clarification needed instead 100 Another suggestion is that methylation might be a detoxification if As III intermediates are not permitted to accumulate because the pentavalent organoarsenics have a lower affinity to thiol groups than inorganic pentavalent arsenics 99 Gebel 2002 stated that methylation is a detoxification through accelerated excretion 101 With regard to carcinogenicity it has been suggested that methylation should be regarded as a toxification 36 102 103 Arsenic especially 3 As binds to single but with higher affinity to vicinal sulfhydryl groups thus reacts with a variety of proteins and inhibits their activity It was also proposed that binding of arsenite at nonessential sites might contribute to detoxification 104 Arsenite inhibits members of the disulfide oxidoreductase family like glutathione reductase 105 and thioredoxin reductase 106 The remaining unbound arsenic 10 accumulates in cells which over time may lead to skin bladder kidney liver lung and prostate cancers 98 Other forms of arsenic toxicity in humans have been observed in blood bone marrow cardiac central nervous system gastrointestinal gonadal kidney liver pancreatic and skin tissues 98 Heat shock response Edit Another aspect is the similarity of arsenic effects to the heat shock response Short term arsenic exposure has effects on signal transduction inducing heat shock proteins with masses of 27 60 70 72 90 and 110 kDa as well as metallothionein ubiquitin mitogen activated MAP kinases extracellular regulated kinase ERK c jun terminal kinases JNK and p38 30 107 Via JNK and p38 it activates c fos c jun and egr 1 which are usually activated by growth factors and cytokines 30 108 109 The effects are largely dependent on the dosing regime and may be as well inversed As shown by some experiments reviewed by Del Razo 2001 reactive oxygen species induced by low levels of inorganic arsenic increase the transcription and the activity of the activator protein 1 AP 1 and the nuclear factor kB NF kB maybe enhanced by elevated MAPK levels which results in c fos c jun activation over secretion of pro inflammatory and growth promoting cytokines stimulating cell proliferation 107 110 Germolec et al 1996 found an increased cytokine expression and cell proliferation in skin biopsies from individuals chronically exposed to arsenic contaminated drinking water 111 Increased AP 1 and NF kB obviously also result in an up regulation of mdm2 protein which decreases p53 protein levels 112 Thus taking into account p53 s function a lack of it could cause a faster accumulation of mutations contributing to carcinogenesis However high levels of inorganic arsenic inhibit NF kB activation and cell proliferation An experiment of Hu et al 2002 demonstrated increased binding activity of AP 1 and NF kB after acute 24 h exposure to 3 sodium arsenite whereas long term exposure 10 12 weeks yielded the opposite result 113 The authors conclude that the former may be interpreted as a defense response while the latter could lead to carcinogenesis 113 As the contradicting findings and connected mechanistic hypotheses indicate there is a difference in acute and chronic effects of arsenic on signal transduction which is not clearly understood yet citation needed Oxidative stress Edit Studies have demonstrated that the oxidative stress generated by arsenic may disrupt the signal transduction pathways of the nuclear transcriptional factors PPARs AP 1 and NF kB 98 113 114 as well as the pro inflammatory cytokines IL 8 and TNF a 98 113 114 115 116 117 118 119 The interference of oxidative stress with signal transduction pathways may affect physiological processes associated with cell growth metabolic syndrome X glucose homeostasis lipid metabolism obesity insulin resistance inflammation and diabetes 2 120 121 122 Recent scientific evidence has elucidated the physiological roles of the PPARs in the w hydroxylation of fatty acids and the inhibition of pro inflammatory transcription factors NF kB and AP 1 pro inflammatory cytokines IL 1 6 8 12 and TNF a cell4 adhesion molecules ICAM 1 and VCAM 1 inducible nitric oxide synthase proinflammatory nitric oxide NO and anti apoptotic factors 98 115 120 122 123 Epidemiological studies have suggested a correlation between chronic consumption of drinking water contaminated with arsenic and the incidence of type 2 diabetes 98 The human liver after exposure to therapeutic drugs may exhibit hepatic non cirrhotic portal hypertension fibrosis and cirrhosis 98 However the literature provides insufficient scientific evidence to show cause and effect between arsenic and the onset of diabetes mellitus Type 2 98 Diagnosis EditArsenic may be measured in blood or urine to monitor excessive environmental or occupational exposure confirm a diagnosis of poisoning in hospitalized victims or to assist in the forensic investigation in a case of fatal over dosage Some analytical techniques are capable of distinguishing organic from inorganic forms of the element Organic arsenic compounds tend to be eliminated in the urine in unchanged form while inorganic forms are largely converted to organic arsenic compounds in the body prior to urinary excretion The current biological exposure index for U S workers of 35 µg L total urinary arsenic may easily be exceeded by a healthy person eating a seafood meal 124 Tests are available to diagnose poisoning by measuring arsenic in blood urine hair and fingernails The urine test is the most reliable test for arsenic exposure within the last few days Urine testing needs to be done within 24 48 hours for an accurate analysis of an acute exposure Tests on hair and fingernails can measure exposure to high levels of arsenic over the past 6 12 months These tests can determine if one has been exposed to above average levels of arsenic They cannot predict however whether the arsenic levels in the body will affect health 125 Chronic arsenic exposure can remain in the body systems for a longer period of time than a shorter term or more isolated exposure and can be detected in a longer time frame after the introduction of the arsenic important in trying to determine the source of the exposure Hair is a potential bioindicator for arsenic exposure due to its ability to store trace elements from blood Incorporated elements maintain their position during growth of hair Thus for a temporal estimation of exposure an assay of hair composition needs to be carried out with a single hair which is not possible with older techniques requiring homogenization and dissolution of several strands of hair This type of biomonitoring has been achieved with newer microanalytical techniques like synchrotron radiation based X ray fluorescence spectroscopy and microparticle induced X ray emission The highly focused and intense beams study small spots on biological samples allowing analysis to micro level along with the chemical speciation In a study this method has been used to follow arsenic level before during and after treatment with arsenious oxide in patients with acute promyelocytic leukemia 126 Treatment EditChelation Edit Dimercaprol and dimercaptosuccinic acid are chelating agents that sequester the arsenic away from blood proteins and are used in treating acute arsenic poisoning The most important side effect is hypertension Dimercaprol is considerably more toxic than succimer citation needed 127 dimercaptosuccinic acid monoesters e g MiADMSA are promising antidotes for arsenic poisoning 128 Nutrition Edit Supplemental potassium decreases the risk of experiencing a life threatening heart rhythm problem from arsenic trioxide 129 History EditSee also Arsenic poisoning cases Beginning in about 3000 BC arsenic was mined and added to copper in the alloying of bronze but the adverse health effects of working with arsenic led to it being abandoned when a viable alternative tin was discovered 130 In addition to its presence as a poison for centuries arsenic was used medicinally It has been used for over 2 400 years as a part of traditional Chinese medicine 131 In the western world arsenic compounds such as salvarsan were used extensively to treat syphilis before penicillin was introduced It was eventually replaced as a therapeutic agent by sulfa drugs and then by other antibiotics Arsenic was also an ingredient in many tonics or patent medicines In addition during the Elizabethan era some women used a mixture of vinegar chalk and arsenic applied topically to whiten their skin This use of arsenic was intended to prevent aging and creasing of the skin but some arsenic was inevitably absorbed into the blood stream citation needed During the Victorian era late 19th century in the United States U S newspapers advertised arsenic complexion wafers that promised to remove facial blemishes such as moles and pimples 2 Some pigments most notably the popular Emerald Green known also under several other names were based on arsenic compounds Overexposure to these pigments was a frequent cause of accidental poisoning of artists and craftsmen Arsenic became a favored method for murder of the Middle Ages and Renaissance particularly among ruling classes in Italy allegedly Because the symptoms are similar to those of cholera which was common at the time arsenic poisoning often went undetected 132 63 By the 19th century it had acquired the nickname inheritance powder perhaps because impatient heirs were known or suspected to use it to ensure or accelerate their inheritances 132 21 It was also a common murder technique in the 19th century in domestic violence situations such as the case of Rebecca Copin who attempted to poison her husband by putting arsenic in his coffee 133 In post WW1 Hungary arsenic extracted by boiling fly paper was used in an estimated 300 murders by the Angel Makers of Nagyrev In imperial China arsenic trioxide and sulfides were used in murder as well as for capital punishment for members of the royal family or aristocracy Forensic studies have determined that the Guangxu Emperor d 1908 was murdered by arsenic most likely ordered by the Empress Dowager Cixi or Generalissimo Yuan Shikai Likewise in ancient Korea and particularly in the Joseon Dynasty arsenic sulfur compounds have been used as a major ingredient of sayak 사약 賜藥 which was a poison cocktail used in capital punishment of high profile political figures and members of the royal family 134 Due to social and political prominence of the condemned many of these events were well documented often in the Annals of Joseon Dynasty they are sometimes portrayed in historical television miniseries because of their dramatic nature 135 Legislation EditIn the U S in 1975 under the authority of the Safe Drinking Water Act the U S Environmental Protection Agency determined the National Interim Primary Drinking Water Regulation levels of arsenic inorganic contaminant IOCs to be 0 05 mg L 50 parts per billion ppb 136 Throughout the years many studies reported dose dependent effects of arsenic in drinking water and skin cancer In order to prevent new cases and death from cancerous and non cancerous diseases the Safe Drinking Water Act directed the Environmental Protection Agency to revise arsenic s levels and specified the maximum contaminant level MCL MCLs are set as close to the health goals as possible considering cost benefits and the ability of public water systems to detect and remove contaminants using suitable treatment technologies 136 137 In 2001 Environmental Protection Agency adopted a lower standard of MCL 0 01 mg L 10 ppb for arsenic in drinking water that applies to both community water systems and non transient non community water systems 136 In some other countries when developing national drinking water standards based on the guideline values it is necessary to take account of a variety of geographical socio economic dietary and other conditions affecting potential exposure These factors lead to national standards that differ appreciably from the guideline values That is the case in countries such as India and Bangladesh where the permissible limit of arsenic in absence of an alternative source of water is 0 05 mg L 47 138 Challenges to implementation Edit Arsenic removal technologies are traditional treatment processes which have been tailored to improve removal of arsenic from drinking water Although some of the removal processes such as precipitative processes adsorption processes ion exchange processes and separation membrane processes may be technically feasible their cost may be prohibitive 136 For underdeveloped countries the challenge is finding the means to fund such technologies The Environmental Protection Agency for example has estimated the total national annualized cost of treatment monitoring reporting record keeping and administration to enforce the MCL rule to be approximately 181 million Most of the cost is due to the installation and operation of the treatment technologies needed to reduce arsenic in public water systems 139 Pregnancy EditArsenic exposure through groundwater is highly concerning throughout the perinatal period Pregnant women are a high risk population because not only are the mothers at risk for adverse outcomes but in utero exposure also poses health risks to the infant There is a dose dependent relationship between maternal exposure to arsenic and infant mortality meaning that infants born to women exposed to higher concentrations or exposed for longer periods of time have a higher mortality rate 140 Studies have shown that ingesting arsenic through groundwater during pregnancy poses dangers to the mother including but not limited to abdominal pain vomiting diarrhea skin pigmentation changes and cancer 141 Research has also demonstrated that arsenic exposure also causes low birth weight low birth size infant mortality and a variety of other outcomes in infants 141 142 Some of these effects like lower birth rate and size may be due to the effects of arsenic on maternal weight gain during pregnancy 142 See also Edit2007 Peruvian meteorite event a meteorite impact believed to have caused arsenic poisoning Arsenic 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2605 PMID 10777704 R Baselt Disposition of Toxic Drugs and Chemicals in Man 8th edition Biomedical Publications Foster City CA 2008 pp 106 110 ToxFAQs for Arsenic Agency for Toxic Substances and Disease Registry Archived from the original on 15 January 2009 Retrieved 2009 01 06 Nicolis I Curis E Deschamps P Benazeth S October 2009 Arsenite medicinal use metabolism pharmacokinetics and monitoring in human hair Biochimie 91 10 1260 7 doi 10 1016 j biochi 2009 06 003 PMID 19527769 Dimercaprol medical facts from Drugs com Archived from the original on 2006 10 13 Kreppel H Reichl FX Kleine A Szinicz L Singh PK Jones MM Antidotal efficacy of newly synthesized dimercaptosuccinic acid DMSA monoesters in experimental arsenic poisoning in mice Fundamentals of Applied Toxicology 26 2 239 245 1995 Arsenic Trioxide Trisenox The Abramson Cancer Center of the University of Pennsylvania Last modified December 25 2005 Harper M 1987 Possible toxic metal exposure of prehistoric bronze workers British 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Mortality Archived 2019 03 04 at the Wayback Machine Epidemiology 21 6 797 804 Accessed on 24 May 2019 a b Bloom M S Surdu S Neamtiu I A amp Gurzau E S 2014 Maternal arsenic exposure and birth outcomes a comprehensive review of the epidemiologic literature focused on drinking water International journal of hygiene and environmental health 217 7 709 719 doi 10 1016 j ijheh 2014 03 004 a b Kile M L Cardenas A Rodrigues E Mazumdar M Dobson C Golam M amp Christiani D C 2016 Estimating effects of arsenic exposure during pregnancy on perinatal outcomes in a Bangladeshi cohort Epidemiology 27 2 173 doi 10 1097 EDE 0000000000000416 Further reading EditAtlas color of Chronic Arsenic Poisoning 2010 Nobuyuki Hotta Ichiro Kikuchi Yasuko Kojo Sakuragaoka Hospital Kumamoto ISBN 978 4 9905256 0 6 A 2011 article in the journal Social Medicine discusses community interventions to combat arsenic poisoning Beyond medical treatment arsenic poisoning in rural Bangladesh D J Vaughan and D A Polya 2013 Arsenic the great poisoner revisited Elements 9 315 316 PDF update on the world situation in 2013 External links EditArsenic poisoning at Curlie Retrieved from https en wikipedia org w index php title Arsenic poisoning amp oldid 1134033311, wikipedia, wiki, book, books, library,

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