Arsenic poisoning and Mees’ lines

Abstract

A 40-year-old male presented with 4 weeks’ history of numbness with painful paraesthesias in limbs. The paraesthesias (tingling and gnawing pain) and numbness started distally in hands and feet, almost simultaneously, and reached up till wrists and mid legs over 2 weeks. At this time, he noticed imbalance on walking which worsened in dark and some difficulty in gripping objects Examination revealed mild hand grip weakness, generalized areflexia, pansensory loss in glove and stocking distribution and sensory ataxia. He had antecedent fever, loose stools, transaminitis, right pleural effusion 2 weeks before the neurological symptoms, which recovered in 5 days. He had history of intake of indigenous medicines (herbal) during this febrile episode. Electrophysiology revealed demyelinating sensorimotor polyradiculoneuropathy with conduction blocks. Cerebrospinal fluid examination revealed albuminocytologic dissociation. Over the next 2 weeks he developed profound distal weakness, desquamating rash over trunk and limbs, rain drop pigmentation (Figure 1A) and Mees’ lines (Figure 1B). 24-h urine arsenic levels were 405.2 μg/l. Considering a diagnosis of arsenic induced subacute demyelinating polyradiculoneuropathy, he was treated symptomatically for pain. The neuropathy stabilized after 6 weeks of onset.