==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2633602510.5144/0256-4947.2015.165asm-2-165Case ReportUnusual presentation of arsenic poisoning in a case of celiac disease Hasanato Rana M. aAlmomen AbdulKareem M. b a Division of Clinical Biochemistry, Department of Pathology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia b Division of Hematology-Oncology, Department of Medicine, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi ArabiaCorrespondence: AbdulKareem M. Almomen, MD, Division of Hematology-Oncology, Department of Medicine, College of Medicine and KKUH, King Saud University, PO BOX 66533, Riyadh 11586, Saudi Arabia, T: +966 11 4692697, F: +966 11 4671032, akalmomen@gmail.comMar-Apr 2015 35 2 165 167 Copyright © 2015, Annals of Saudi Medicine2015This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Arsenic poisoning may occur from sources other than drinking water such as rice, seafood, or insecticides. Symptoms and signs can be insidious, non-specific, atypical, and easily overlooked. We present a 39-year-old woman with celiac disease who was on gluten-free diet for 8 years and presented with diarrhea, headache, insomnia, loss of appetite, abnormal taste, and impaired short-term memory and concentration, but with no skin lesions. Arsenic concentration in her 24-hour urine was 682.77 μg/g creatinine (normal <15). She responded very well to chelation therapy with dimercaptosuccinic acid given orally and recovered within 2 weeks. The suspected source of arsenic poisoning was rice, as drinking contaminated ground water is not known in Saudi Arabia and she had not taken seafood. Therefore, arsenic poisoning should be suspected based on the meticulous medical history in cases of patients with celiac disease whose main food is rice and who present with unusual symptoms. ==== Body Arsenic poisoning is known to occur in areas with contaminated drinking ground water such as Bangladesh, India, Taiwan, and United States.1–4 Other sources may include certain industries, particularly, carpenters dealing with pressure-treated wood that has been treated with arsenic-containing wood preservative. Other sources include food (sea food and rice), insecticides, and drugs.5–17 Arsenic poisoning can easily be overlooked because of atypical symptoms and signs, lack of awareness, and unavailability of the arsenic level test. We present a case of arsenic poisoning who presented with atypical signs and symptoms and was overlooked, and treatment was delayed for several months. We present this case to illustrate that such cases can be easily diagnosed and treated if arsenic poisoning is suspected and not overlooked. CASE Our case is a 39-year-old housewife, known with celiac disease for 8 years, who presented with progressive fatigue, profound watery diarrhea (12 times/d), palpitation, dry mouth, poor appetite, poor taste, sleeplessness, impaired concentration, and short-term memory. She was on gluten-free diet (mainly rice and corn derivatives) and vitamin and mineral supplements. She had not eaten sea food for almost 1 month prior to this admission. She continued to have regular menstrual periods. She was married with 4 healthy children. She had no other illnesses, and her medical history was unremarkable. No other family members had celiac disease or similar symptoms. On physical examination, she looked ill, exhausted, and anxious. Her height was 160 cm, weight 47 kg, pulse 110/min, regular, and blood pressure 110/70 mm Hg. No pallor or skin lesions were observed, and her abdominal, cardiovascular, and neurological examinations were normal. At this point, we thought that she was not compliant with her gluten-free diet, and probably she had a mixture of multiple deficiencies (e.g., calcium, magnesium, zinc, iron, vitamin B12) and depression. Laboratory tests were as follows: white blood cells 8.9×109/L, Hb 94 g/L, mean corpuscular volume 76.6 fl, platelets 397×106/L, erythrocyte sedimentation rate 41 mm, fasting glucose 4.7 mmol/L, urea 3.6 mmol/L, creatinine 40 μmol/L, albumin 31 g/L, globulins 36 g/L, total bilirubin 5 μmol/L, alkaline phosphatase 153 U/L, alanine aminotransferase 70 U/L, aspartate aminotransferase 30 U/L, gamma glutamyl transferase 25 U/L, zinc 7.3 μmol/L (normal 7.65–22.9), corrected calcium 2.29 mmol/L, magnesium 0.9 mmol/L, ferritin 97.2 ng/mL, vitamin B12 157.8 pmol/L, gliadin antibodies immunoglobulin (Ig) G 114 (positive >20), and anti-human tissue transglutaminase IgA 53 (positive >20). IgA anti-gliadin, anti-endothelium, and anti-reticulin were negative. Patient was started on intravenous fluids and 24-hour urine were collected and sent to Micro Trace Minerals (Micro Trace Minerals GmbH, Rohrenstrasse-91217, Hersbruck, Germany, www.microtrace.de) for metal analysis. The results of the 24-hour urine showed arsenic concentration 682.77 μg/g creatinine (normal <15). Therefore, the diagnosis of arsenic poisoning was made, and the patient was started on chelation therapy with dimercaptosuccinic acid 30 mg/kg orally every 8 hours along with multivitamin and mineral supplements for 3 days. Her chemistry tests (liver functions, kidney functions, calcium, magnesium, zinc, and copper) were monitored twice/d. She showed a rapid response with gradual improvement of her symptoms over the next 2 weeks, and a repeat of arsenic concentration in the 24-hour urine was 26 μg/g and 12 μg/g creatinine after 7 days and 2 weeks, respectively. The source of arsenic poisoning could not be identified, but rice was the suspected source. Other possible sources could be insecticides, pressure-wood furniture, supplements, or cosmetics. Drinking water is not suspected because the main water supply is desalination or mineral water. Arsenic is not known in well water in Saudi Arabia. DISCUSSION Arsenic is a naturally occurring toxic metalloid that combines with other elements such as oxygen, sulfur, chloride, hydrogen, and carbon.18 Due to its poisonous properties, arsenic has been used throughout the history as a homicidal and suicidal poison.19,20 In the past century, arsenic became very important insecticide, herbicide, and algaecide.7 Besides, arsenic is used in several industries such as copper smelting, wood preservation, and medicine. Arsenic trioxide is currently used in the treatment of acute promyelocytic leukemia.9,10 Exposure to arsenic occurs through drinking water from contaminated wells, inhaling smoke from pressure-treated wood, or inhaling vapors from insecticides, herbicides, algaecides or drugs. High levels of arsenic has been found recently in seafood, particularly bivalves and rice. Exposure to arsenic leads to several health problems that affect the gastrointestinal tract, respiratory system, cardiovascular system, nervous system, and skin.18–26 Several malignancies have been attributed to arsenic such as cancer of the skin, bladder, and lung; cancers are caused due the strong carcinogenicity of arsenic.21–26 Patients with celiac disease are at a high risk of arsenic exposure, because their gluten-free diet is composed mainly of rice.13–17,27 Our patient is known with celiac disease who is compliant with gluten-free diet, consuming abundance of rice. Arsenic from seafood was excluded, because she had a poor appetite and did not take any seafood for 1 month prior to admission. Other causes cannot be excluded such as inhalation of vapors from insecticides, pressure-treated wood, and may be some cosmetics. In addition, arsenic may contaminate other grains and supplements. Our patient was unusual, because she lacked classical skin lesions, and the other symptoms were non-specific. Arsenic concentration in the urine is more reliable because blood levels are normal in persons with chronic arsenic poisoning.28,29 She responded very well and rapidly to chelation therapy with oral DMSA, which is a safe agent for chelation therapy of heavy metals.30–32 We conclude that exposure to arsenic may not be rare, and that it has to be suspected and looked for in high risk persons In conclusion, chronic arsenic poisoning can present with atypical signs and symptoms. It should be suspected in high risk persons based on their health status, occupation, diet, and life style. Conflict of interest None. ==== Refs REFERENCES 1 Argos M Kalra T Rathouz P Chen Y Pierce B Parvez F 2010 Arsenic exposure from drinking water, and all-cause and chronic-disease mortalities in Bangladish (HEALS): a prospective cohort study Lancet 376 252 8 20646756 2 Mitra S Guha Mazumder D Basu A Block G Haque R Samanta S 2004 Nutritional factors and susceptibility to arsenic-caused skin lesions in West Bengal, India Environ Health Perspect 112 1104 9 15238285 3 Chang C Ho S Tsai S Yang C 2004 Ischemic heart disease mortality reductuion in an arsenosis-endemic area in Southwestern Taiwan after a switch in the tap-water supply system J Toxicol Environ Health 67 1353 61 4 United States Geological Survey 2005 Arsenic in ground water in the United States Reston, VA updated 2009 June 16 accessed 2009 September 14 Available from: http://water.usgs.gov/nawaqa/trace/pubs/geo-v46n11/fig3.html 5 Weis P Weis J Coohill 1991 Toxicity to estuarine organisms of leachates from chromated copper arsenate treated wood Arch Environ Contam Toxico 20 118 24 6 Baptist D Leslie N 2008 Children playing with poison: Arsenic exposure from CCA-treated wood J Nurse Practitioners 4 48 53 7 Jones K Huang WH 2003 Evaluation of toxicity of the pesticides, chlorpyrifos and arsenic, in the presence of compost humic substances in aqueous systems J Hazardous Materials B 103 93 105 8 Chakraborti D Mukherjee SC Saha KC Chaudhury UK Rahman MM Sengupta MK 2003 Arsenic toxicity from homeopathic treatment J Toxicol Clin Toxicol 41 963 7 14705842 9 Antman KH 2001 Introduction: the history of arsenic trioxide in cancer therapy The Oncologist 6 1 2 10 Iland HJ Seymour JF Role of arsenic trioxide in acute promyelocytic leukemia Curr Treat Options Oncol 2013 14 170 84 23322117 11 Liu J Lu Y Wu Q Goyer RA Waalkes MP 2008 Mineral arsenicals in traditional medicines: orpiment, realgar, and arsenolite JPET 326 363 8 12 Barak J Hosgood HD 2007 Seafood arsenic: implications for human risk assessment Regul Toxicol Pharmacol 47 204 12 17092619 13 Bae M Watanabe C Inaoka T Sekiyama M Sudo N Bokul MH Ohtsuka R 2002 Arsenic in cooked rice in Bangladesh Lancet 360 1839 40 12480363 14 Williams PN Raab A Feldmann J Meharg AA 2007 Market basket survey shows elevated levels of As in South Central U.S. processed rice compared to California: consequences for human dietary exposure Environ Sci Technol 41 2178 83 17438760 15 Jorhem L Astrand C Sundström B Baxter M Stokes P Lewis J Grawé KP 2008 Elements in rice from the Swedish market: 1. Cadmium, lead and arsenic (total and inorganic) Food Addit Contam Part A Chem Anal Control Expo Risk Assess 25 284 92 17906996 16 Sun GX Williams PN Carey AM Zhu YG Deacon C Raab A Feldmann J Islam RM Meharg AA 2008 Inorganic arsenic in rice bran and its products are an order of magnitude higher than in bulk grain Environ Sci Technol 42 7542 46 18939599 17 Rahman MA Hasegawa H 2011 High levels of inorganic arsenic in rice in areas where arsenic-contaminated water is used for irrigation and cooking Sci Total Environ 409 4645 55 21899878 18 U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry 2007 Toxicological profile for arsenic Atlanta GA Updated 2007 August accessed 2008 January 14 Available from: http://atsdr.cdc.gov/toxprofils/tp2.html 19 Massey EW Wold D Heyman A 1984 Arsenic: homicidal intoxication South Med J 77 848 51 6740352 20 Yilmaz Y Armagan E Olmez O Esen M Alkis N Dolar E 2009 Acute arsenic self-poisoning for suicidal purpose in a dentist: a case report Hum Exp Toxicol 28 63 5 19411562 21 Hughes MF Beck BD Chen Y Lewis AS Thomas DJ 2011 Arsenic Exposure and Toxicology: A Historical Perspective Toxicol Sci 123 305 32 21750349 22 Mazumder G 2003 Chronic arsenic toxicity: clinical features, epidemiology, and treatment: experience in West Bengal J Environ Sci Health 38 141 63 23 Tsuchiya K 1977 Various effects of arsenic in Japan depending on type of exposure Environ Health Perospect 19 35 42 24 Ratnaike RN Acute and chronic arsenic toxicity Postgrad Med J 2003 79 391 396 12897217 25 Chen CJ Chen CW Wu MM Kuo TL 1992 Cancer potential in liver, lung, bladder and kidney due to ingested inorganic arsenic in drinking water Br J Cancer 66 888 92 1419632 26 Binder HJ Solitare GB Spiro HM 1967 Neuromuscular disease in patients with steatorrhoea Gut 8 605 11 6079812 27 Murray JA 1999 The widening spectrum of celiac disease Am J Clin Nutr 69 354 65 10075317 28 Valentine JL Kang HK Spivey G 1979 Arsenic levels in human blood, urine, and hair in response to exposure via drinking water Environ Res 20 24 32 499171 29 Abdelghani AA Anderson AC Jaghabir M Mather F 1986 Arsenic levels in blood, urine, and hair of workers applying monosodium methanearsonate (MSMA) Arch Environ Health 41 163 9 3740956 30 Miller AL 1998 Dimercaptosuccinic Acid (DMSA), A non-toxic, water-soluble treatment for heavy metal toxicity Altern Med Rev 3 199 207 9630737 31 Shum S Whitehead J Vaughn L Shum S Hale 1995 Chelation of organoarsenate with dimercaptosuccinic acid Vet Hum Toxicol 37 239 42 7571355 32 Bradberry S Sheehan T Vale A 2009 Use of oral dimercaptosuccinic acid (succimer) in adult patients with inorganic lead poisoning Q J Med 102 721 32