Unexplained dyspnea in a patient of chronic arsenicosis: A diagnostic challenge and learning curve for physicians

Abstract

Chronic arsenic exposure causes cutaneous effects like hyperkeratosis, peripheral vascular disease, hypertension, ischemic heart disease, non-cirrhotic portal hypertension, hepatomegaly, peripheral neuropathy, respiratory involvement, bad obstetrical outcome, hematological disturbances, and diabetes mellitus. Here we present a case of a 24-year-old lady, with chronic exposure to arsenic, presenting to us with progressive dyspnea. We found pulmonary arterial hypertension (PAH) as a cause of her dyspnea. PAH can occur in arsenicosis, secondary to arsenic-induced chronic obstructive pulmonary disease (COPD), lung fibrosis, and portal hypertension, which we excluded by appropriate investigations in our case. We also excluded a familial or heritable form of PAH. Thus, with the exclusion of all these secondary causes of PAH, as well as a hereditary cause, we came to a conclusion that this PAH might be due to chronic arsenic exposure. To the best of our knowledge, no case of PAH in chronic arsenicosis has been reported to date.

Metal-Induced Pulmonary Fibrosis

“…A recent meta-analysis of 9 studies identified a strong, inverse link between lung function and arsenic intake, specifically noting the likelihood for development of a restrictive phenotype [21]. Residents of many parts of the world, particularly in India, Bangladesh, Taiwan, and Northern China ingest drinking water contaminated with arsenic and are at risk for arsenicosis, a multisystem disorder [22]. Respiratory manifestations of arsenicosis include not only pulmonary fibrosis but also chronic bronchitis and emphysema phenotypes of COPD, bronchiectasis, and secondary pulmonary hypertension [22].…”

“…Residents of many parts of the world, particularly in India, Bangladesh, Taiwan, and Northern China ingest drinking water contaminated with arsenic and are at risk for arsenicosis, a multisystem disorder [22]. Respiratory manifestations of arsenicosis include not only pulmonary fibrosis but also chronic bronchitis and emphysema phenotypes of COPD, bronchiectasis, and secondary pulmonary hypertension [22]. Given the presence of multiple concomitant lung diseases causing similar respiratory symptoms and decline in spirometric parameters, the prevalence of pulmonary fibrosis in epidemiological studies is difficult to estimate.…”