Ailing bones and failing kidneys: a case of chronic cadmium toxicity

Abstract

Heavy metal toxicity is often caused by occupational exposure. Chronic cadmium toxicity is a significant health concern among workers engaged in zinc smelting, battery production and silver jewellery industries, particularly in developing countries. We report the case of a 48-year-old man who presented with severe osteoporosis, impaired renal function and acquired Fanconi syndrome. He was finally diagnosed with chronic cadmium toxicity resulting from long-term occupational exposure. Cadmium has a long biological half-life and there is no effective treatment for people who are exposed to it. Therefore, an early diagnosis and prevention of further exposure are important. KeywordsDisease, bone disorders, toxicology Accepted: 12th February 2013 Case report A 48-year-old Indian non-smoker male patient presented with progressively worsening skeletal pain for the previous five years. X-rays of the lumbosacral spine and hip showed markedly reduced bone density with prominent trabecular markings. Dual-energy Xray absorptiometry (DEXA) confirmed the presence of severe osteoporosis (T score <À2.5 in the lumbar vertebrae and left femoral neck). He also had impaired renal function, with serum creatinine concentration of 250 mmol/L (reference interval 53-106 mmol/L) and serum urea concentration of 10 mmol/L (reference interval 2.5-7.5 mmol/L). He was referred to our hospital for further evaluation of his impaired renal function. The patient was not diabetic or hypertensive nor did he have any history of corticosteroid therapy. Full blood count showed mild normochromic normocytic anaemia: haemoglobin 10.9 g/dL (reference interval 12.0-15.0 g/dL). Total and differential white blood cell counts were within reference limits. Biochemical investigations showed hypophosphataemia (0.6 mmol/L, reference interval 0.8-1.5 mmol/L), hypouricaemia (100 mmol/L, reference interval 208-416 mmol/L) and increased alkaline phosphatase (412 U/L, reference Routine urinalysis showed trace albumin and 2þ glucose on urine dipstick but plasma glucose was normal. Fractional excretion of uric acid (18%, reference interval 5-11%) and phosphate (31%, reference interval 5-20%) were elevated. Urine protein:creatinine ratio was 310 mg/mmol (reference interval <22 mg/mmol), and urine albumin:creatinine ratio was 5.3 mg/mmol (reference interval <2.5 mg/mmol of creatinine). Urine and serum protein electrophoreses were unremarkable. Subsequently, the patient was re-evaluated. On further questioning, the patient gave an occupational history of working in a silver jewellery industry for the past 15 years.

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“…Chronic occupational poisoning may occur after long-lasting exposure to cadmium by inhalation or oral route. Unlike acute, chronic intoxication can lead to the development of certain diseases, for example, chronic obstructive pulmonary disease, lung emphysema, kidney disease (nephrotoxicity) and bone disease (arthritis, osteoporosis) [7], prostatic carcinoma, anaemia, alopecia, frequent migraines, growth disorder and cardiovascular diseases [8,9]. There is no medical chelation method that is completely effective for treating cadmium toxicity.…”

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