Disseminated pulmonary emboli caused by mercury: A rare cons
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A 25-year-old asymptomatic woman was referred with diffuse, high-density opacities in a chest radiograph and disseminated, metallic dots in the lung parenchyma on 3D-reconstructed CT. Her oxygen saturation was 98%. These unusual appearances prompted serum calcium (normal) and heavy metal testing; serum mercury levels were raised at 13.5 ng/mL (normal: less than 4 ng/mL).

Disseminated mercury in the lungs was diagnosed, but the origin of the mercury remained uncertain. The patient denied self-harm or mercury exposure. However, on further questioning, her family revealed that she had received previous surgery to remove mercury from her left arm 2 years previously, with an X-ray at that time showing high-density soft tissue opacities in her left forearm consistent with mercury self-injection.

There were no obvious financial or emotional rewards from self?harming, and depression and acute psychosis were excluded. Munchausen's syndrome (factitious disorder) was suspected, with disseminated mercury deposition apparently an unintended consequence of fabricating illness through peripheral mercury injection. She was referred to the Psychology Department while receiving chelation therapy. Regrettably, she was lost to follow-up after 3 months, which is not unusual for patients with Munchausen's syndrome.

Munchausen's syndrome is a factitious disorder imposed on the self and usually difficult to identify due to deceptive misrepresentation. Patients intentionally fake or cause symptoms of an illness and/or injury in themselves, even in the absence of obvious external rewards. Self-injection of mercury has been reported as a rare complication of psychiatric diseases, including Munchausen's syndrome.

Exposure to elemental mercury is usually by inhalation of its vapor, and it is poorly absorbed via intact skin. In our case, the patient subcutaneously injected mercury, however, even after surgical clearance, the residue at injection sites still permeated into the circulation and led to mercury embolization to the lungs, which she did not expect and revealed the underlying diagnosis.

Source: https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.3435?af=R
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