Chromium toxicity: Difference between revisions
 
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===Toxicokinetics===
===Toxicokinetics===
*Absorption
**Cr<sup>3+</sup>
***Limited oral absorption with 98% recovered in feces
**Cr<sup>6+</sup>
***Modestly absorbed
****10% orally
****50-85% inhalational
*Distribution
**Cr<sup>6+</sup> is rapidly converted to Cr<sup>3+</sup> in the blood
**50% total body burden is localized to the kidney and liver
***With additional stores in bone marrow, lymph nodes, spleen, and testes
*Elimination
**Urinary excretion of Cr<sup>3+</sup> form
*Cr<sup>6+</sup>
**Oxidative agent producing oxidative DNA damage
**Main cause of toxicity
*Cr<sup>3+</sup>
**Rarely develops toxicity
{| {{table}}
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Form'''
| align="center" style="background:#f0f0f0;"|'''Form'''
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| align="center" style="background:#f0f0f0;"|'''Elimination'''
| align="center" style="background:#f0f0f0;"|'''Elimination'''
|-
|-
| Cr3+||Rarely develops toxicity||Limited oral absorption with 98% recovered in feces||Cr6+ is rapidly converted to Cr3+ in the blood||Urinary excretion
| Cr<sup>3+</sup>||
*Rarely develops toxicity
||
*Limited oral absorption with 98% recovered in feces
||
||
*Urinary excretion
|-
|-
| Cr6+||Main cause of toxicity *Oxidative agent producing oxidative DNA damage||Modestly absorbed **10% orally **50-85% inhalational||||50% total body burden is localized to the kidney and liver *With additional stores in bone marrow, lymph nodes, spleen, and testes
| Cr<sup>6+</sup>||
*Main cause of toxicity  
*Oxidative agent producing oxidative DNA damage
||
*Modestly absorbed  
**10% orally  
**50-85% inhalational
||
*50% total body burden is localized to the kidney and liver  
**With additional stores in bone marrow, lymph nodes, spleen, and testes
||
*Cr6+ is rapidly converted to Cr3+ in the blood
|}
|}


==Clinical Features==
==Clinical Features==
*'''Acute'''
===Acute===
**Similar to corrosive metal ingestions
*Similar to corrosive metal ingestions
**GI hemorrhage
*[[Gastrointestinal bleeding]]
**Vomiting
*[[Vomiting]]
**Bowel perforation
*[[Bowel perforation]]
**Intravascular hemolysis with [[DIC]]
*Intravascular hemolysis with [[DIC]]
**[[Acute tubular necrosis]] and [[Renal failure]]
*[[Acute tubular necrosis]] and [[Renal failure]]
**[[Metabolic acidosis]]
*[[Metabolic acidosis]]
**[[Hyperkalemia]]
*[[Hyperkalemia]]
**[[Acute lung injury]]
*[[Acute lung injury]]
**Skin inflammation and ulcerations
*Skin inflammation and ulcerations
***Dermal chromic acid (H<sub>2</sub>CrO<sub>4</sub>) can lead to systemic toxicity with as little as 10% BSA
**Dermal chromic acid (H<sub>2</sub>CrO<sub>4</sub>) can lead to systemic toxicity with as little as 10% [[BSA]]
*'''Chronic'''
 
**Most are occupational inhalation exposures
===Chronic===
**Chrome holes
*Most are occupational inhalation exposures
***Nasal septal perforation
*Chrome holes
***Skin ulcerations
**Nasal septal perforation
**Chronic cough
**Skin ulcerations
**Dyspnea and bronchospasm
*Chronic cough
**Anaphylactoid-like reactions
*Dyspnea and bronchospasm
**Pneumoconicosis
*Anaphylactoid-like reactions
**Increase risk of lung cancer
*Pneumoconicosis
***Small cell lung cancer, however all types are associated with Cr<sup>6+</sup> exposure
*Increase risk of lung cancer
**[[Contact dermatitis]] and [[Type IV hypersensitivity reaction]]
**Small cell lung cancer, however all types are associated with Cr<sup>6+</sup> exposure
*[[Contact dermatitis]] and [[Type IV hypersensitivity reaction]]
 
==Differential Diagnosis==
==Differential Diagnosis==
===[[Heavy metal]] toxicity===
{{Heavy metals list}}
*[[Aluminum toxicity]]
 
*[[Antimony toxicity]]
*[[Arsenic toxicity]]
*[[Barium toxicity]]
*[[Bismuth toxicity]]
*[[Cadmium toxicity]]
*[[Chromium toxicity]]
*[[Cobalt toxicity]]
*[[Copper toxicity]]
*[[Gold toxicity]]
*[[Iron toxicity]]
*[[Lead toxicity]]
*[[Lithium toxicity]]
*[[Manganese toxicity]]
*[[Mercury toxicity]]
*[[Nickel toxicity]]
*[[Phosphorous toxicity]]
*[[Platinum toxicity]]
*[[Selenium toxicity]]
*[[Silver toxicity]]
*[[Thallium toxicity]]
*[[Tin toxicity]]
*[[Zinc toxicity]]
==Evaluation==
==Evaluation==
*BMP
*BMP
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*EKG
*EKG
*If toxicity present add coagulation factors
*If toxicity present add coagulation factors
*Chromium levels
 
**Whole blood: 20-30 μg/L (380-580 nmol/L)
===Chromium levels===
**Serum: 0.05-2.86 μg/L (1-56 nmol/L)
''Baseline levels have varied over the past 50 years by 5000-fold, additionally it is difficult to establish standard reference range, use caution when interpreting these levels; phlebotomy needles and blood containers for storage can contain chromium''
**Urine: < 1μg/g creatinine (<19.2 nmol/g creatinine)
*Whole blood: 20-30 μg/L (380-580 nmol/L)
***Can reflect acute absorption of chromium over the past 1-2 days, however wide variation in metabolism and total body burden
*Serum: 0.05-2.86 μg/L (1-56 nmol/L)
**Baseline levels have varied over the past 50 years by 5000-fold, additionally it is difficult to establish standard reference range, use caution when interpreting these levels
*Urine: < 1μg/g creatinine (<19.2 nmol/g creatinine)
**Phlebotomy needles and blood containers for storage contain chromium
**Can reflect acute absorption of chromium over the past 1-2 days, however wide variation in metabolism and total body burden
 
==Management==
==Management==
*Decontamination
*Decontamination
**Activated charcoal not indicated
**[[Activated charcoal]] not indicated
**Consider NG lavage if Cr<sup>6+</sup> ingestion and presenting within 1-2 hours without signs of vomiting
**Consider [[NG lavage]] if Cr<sup>6+</sup> ingestion and presenting within 1-2 hours without signs of vomiting
**Consider oral N-acetylcysteine  
**Consider oral [[N-acetylcysteine]]
***Shown to increases renal elimination of chromium in rats
***Shown to increases renal elimination of chromium in rats
*Supportive care
*Supportive care
*Chelation
*Chelation
**Not effective in reducing chromium levels
**Not effective in reducing chromium levels
*Dialysis
*[[Dialysis]]
**Not effective in those with normal renal function
**Not effective in those with normal renal function
**Consider in those on chronic dialysis
**Consider in those on chronic dialysis
==Disposition==
==Disposition==
*Acute toxicity likely requires intensive care unit
*Acute toxicity likely requires intensive care unit
*Consult Toxicology or Poison Control Center
*Consult Toxicology or [[poison control]]
==See Also==
*[[Toxicology (main)]]
*[[Heavy Metals]]
 
==External Links==
 
==References==
==References==
<references/>
<references/>
Bird, S. Chromium. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1243-1247
*Bird, S. Chromium. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1243-1247


[[Category:Toxicology]]
[[Category:Toxicology]]

Latest revision as of 01:14, 9 March 2021

Background

  • Blue white metal
  • Essential in glucose and fat metabolism
  • The predominant forms are trivalent (Cr3+) and hexavalent (Cr6+)
  • Cr6+ is a carcinogen
  • Uses
    • Chrome platting
    • Component of making stainless steel
    • Used to make cement
    • Welding
    • Joint arthroplasty
    • Coronary artery stents
    • Tanned leather products

Toxicokinetics

Form Toxicity Absorption Distribution Elimination
Cr3+
  • Rarely develops toxicity
  • Limited oral absorption with 98% recovered in feces
  • Urinary excretion
Cr6+
  • Main cause of toxicity
  • Oxidative agent producing oxidative DNA damage
  • Modestly absorbed
    • 10% orally
    • 50-85% inhalational
  • 50% total body burden is localized to the kidney and liver
    • With additional stores in bone marrow, lymph nodes, spleen, and testes
  • Cr6+ is rapidly converted to Cr3+ in the blood

Clinical Features

Acute

Chronic

  • Most are occupational inhalation exposures
  • Chrome holes
    • Nasal septal perforation
    • Skin ulcerations
  • Chronic cough
  • Dyspnea and bronchospasm
  • Anaphylactoid-like reactions
  • Pneumoconicosis
  • Increase risk of lung cancer
    • Small cell lung cancer, however all types are associated with Cr6+ exposure
  • Contact dermatitis and Type IV hypersensitivity reaction

Differential Diagnosis

Evaluation

  • BMP
  • LFTs
  • CBC
  • CPK
  • EKG
  • If toxicity present add coagulation factors

Chromium levels

Baseline levels have varied over the past 50 years by 5000-fold, additionally it is difficult to establish standard reference range, use caution when interpreting these levels; phlebotomy needles and blood containers for storage can contain chromium

  • Whole blood: 20-30 μg/L (380-580 nmol/L)
  • Serum: 0.05-2.86 μg/L (1-56 nmol/L)
  • Urine: < 1μg/g creatinine (<19.2 nmol/g creatinine)
    • Can reflect acute absorption of chromium over the past 1-2 days, however wide variation in metabolism and total body burden

Management

  • Decontamination
    • Activated charcoal not indicated
    • Consider NG lavage if Cr6+ ingestion and presenting within 1-2 hours without signs of vomiting
    • Consider oral N-acetylcysteine
      • Shown to increases renal elimination of chromium in rats
  • Supportive care
  • Chelation
    • Not effective in reducing chromium levels
  • Dialysis
    • Not effective in those with normal renal function
    • Consider in those on chronic dialysis

Disposition

  • Acute toxicity likely requires intensive care unit
  • Consult Toxicology or poison control

See Also

External Links

References

  • Bird, S. Chromium. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1243-1247
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