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• W4387248755 abstract "SESSION TITLE: Critical Care Case Report Posters 43 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Respiratory disease from acute inhalation of mercury can be fatal. The following case describes a patient with mercury inhalation induced acute respiratory distress syndrome (ARDS) who survived after veno-venous extracorporeal membrane oxygenation (VV ECMO) was initiated, allowing time for pneumonitis to resolve and chelation therapy to limit systemic damage. CASE PRESENTATION: A 56-year-old male presented with dyspnea and dry cough for two days after a mercury spill at work. His medical history was significant for COVID-19 ARDS but was discharged without oxygen. Physical exam on admission was notable for mild respiratory distress, respiratory rate of 22/min and with an oxygen saturation of 83% on room air. Computed tomography of the chest revealed diffuse ground glass opacities. Infectious workup was negative. Despite diuresis, broad spectrum antibiotics, methylprednisolone 2 mg/kg IV daily, the patient's hypoxemia worsened, and he required mechanical ventilation. Even with paralysis and proning, ABG revealed 7.30/62/69/30/93.7% on a FiO2 100%. The decision was made to initiate VV-ECMO for severe ARDS. His initial serum and urine mercury levels were elevated at 373 ug/L and 272 mcg/g, respectively. Chelation therapy was started with dimercaptosuccinic acid and dimercaprol. In less than 2 weeks, the patient was decannulated from VV-ECMO, extubated and discharged on 6 liters nasal cannula with a prednisone taper. DISCUSSION: Most commonly part of industrial accidents (1), mercury disrupts normal cell physiology primarily through covalent binding to intracellular sulfhydryl-containing enzymes and proteins, inactivating them and exposing cells to oxidant injury (2, 3). Mercury inhalation can lead to pulmonary injury due to the high temperature of the vapor causing thermal damage, along with direct oxidant injury to the alveoli (1,2). Inhalation leads to rapid systemic absorption through the alveolar membrane (1). Lung illness severity ranges from mild lung dysfunction to severe pneumonitis and ARDS (4). Typical treatment regimens include steroids for pneumonitis and chelating agents to bind mercury to prevent further systemic toxicity (1, 4-8). However, chelating agents will not treat pneumonitis (1, 5, 9, 10). Most salient in this case is the decision to initiate VV-ECMO. Although there have been other cases of mercury toxicity transferred to ECMO centers, our case appears to be a rare case of a patient being stabilized with VV-ECMO and surviving to discharge (4, 11, 12). We believe that VV-ECMO allowed for lung rest and steroids to treat acute mercury pneumonitis, and for early chelation therapy to limit systemic toxicity and multi-organ failure. CONCLUSIONS: Patients with acute mercury pneumonitis may benefit from early VV-ECMO to allow for lung protective ventilation and lung rest, steroids to treat pneumonitis, and for chelation therapy to limit systemic toxicity and organ damage. REFERENCE #1: 1. Rowens B, Guerrero-Betancourt D, Gottlieb CA, Boyes RJ, Eichenhorn MS. Respiratory failure and death following acute inhalation of mercury vapor. Chest. 1991;99(1):185-190. doi:10.1378/chest.99.1.185 REFERENCE #2: 2. Glezos J, Albrecht J, Gair R. Pneumonitis after inhalation of mercury vapours. Canadian Respiratory Journal. 2006;13(3):150-152. doi:10.1155/2006/898120 REFERENCE #3: 3. Sue Y. Mercury. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank's Toxicologic Emergencies, 11e. McGraw Hill; 2019. Accessed March 31, 2023.4. Hammerling J, Kanters A, Jacobs B, Franzblau A, Park PK, Napolitano LM. An unusual cause of severe hypoxemia and acute respiratory distress syndrome. Chest. 2020;158(2):e71-e77. doi:10.1016/j.chest.2019.11.058 5. Lim HE, Shim JJ, Lee SY, et al. Mercury inhalation poisoning and acute lung injury. Korean J Intern Med. 1998;13(2):127-130. doi:10.3904/kjim.1998.13.2.127 6. Seaton A, Bishop CM. Acute mercury pneumonitis. Occupational and Environmental Medicine. 1978;35(3):258-261. doi:10.1136/oem.35.3.258 7. Lien DC, Todoruk DN, Rajani HR, Cook DA, Herbert FA. Accidental inhalation of mercury vapour: respiratory and toxicologic consequences. Can Med Assoc J. 1983;129(6):591-595. 8.Lilis R, Miller A, Lerman Y. Acute mercury poisoning with severe chronic pulmonary manifestations. Chest. 1985;88(2):306-309. doi:10.1378/chest.88.2.306 9. Cortes J, Peralta J, Díaz-Navarro R. Acute respiratory syndrome following accidental inhalation of mercury vapor. Clin Case Rep. 2018;6(8):1535-1537. doi:10.1002/ccr3.1656 10. Agocs, M. (1992). Case studies in environmental medicine: Mercury toxicity. Toxic substances and disease registry, (17). 11. Jung RC, Aaronson J. Death following inhalation of mercury vapor at home. West J Med. 1980;132(6):539-543. 12. Kim HS, Han SJ, Hong KS, et al. Acute respiratory failure treated with veno-venous extracorporeal membrane oxygenation. Tuberc Respir Dis. 2010;68(2):62. doi:10.4046/trd.2010.68.2.62 DISCLOSURES: No disclosure on file for Eric Gottesman No relevant relationships by Zubair Hasan No relevant relationships by William Heuser No relevant relationships by Simon Kashfi No relevant relationships by Henry Mayo-Malasky No relevant relationships by George Mundanchira No relevant relationships by Dimple Shah No relevant relationships by Adit Singhal" @default.
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• W4387248755 title "VENO-VENOUS ECMO AS RESCUE THERAPY FOR ACUTE MERCURY PNEUMONITIS" @default.
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