Case Report Diagram (Timeline)
Figure-1 shows the treatment details and treatment results described in the Case Report, automatically extracted and auto-illustrated.
Each box in the upper part of the figure shows the treatment details.
Each box in the middle part of the figure shows the treatment result.
(▲, ■, ▼) in each box in the lower part of the figure indicates the status of the treatment results.
▲ : better
■ : No change
▼ : worse
Figure-1
Case Report
Case Presentation
YA, a 48-year-old previously healthy woman, was referred to the University of ABC.
Occupational and Environmental Medicine Clinic with a 2-year history of wors- ening alopecia and memory loss. Her symp- toms began in October 2005 with minor memory loss and fatigue. Her primary care physician conducted a thorough physical exam, which showed no abnormality; all laboratory studies (complete blood count, electrolytes, thyroid-stimulating hormone) were also nor- mal. YA’s physician believed her symptoms were related to menopause. With no specific diagnosis or treatment recommendations, our patient started taking a variety of herbal thera- pies including kelp supplement, fish oil, ginkgo biloba, and grape seed extract. The kelp supple- ment was the only herbal therapy taken regu- larly throughout the course of her illness. She initially took two tablets of Kelp sup- plement per day (41 mg kelp, 66 mg calcium, 225 µg iodine). Over the next few months, she subjectively noticed new and progressively worsening symptoms. During her exam, it was noted that her short- and long- term memory had become impaired to the point where she could no longer remember her home address, a location where she had lived for the previous 5 years. She also began having difficulties functioning at work, where she did intake for a mental health facility.
YA’s gynecologist believed her symptoms were likely due to a relative estrogen defi- ciency and adjusted her estrogen dose. This resulted in no change in symptoms. Ancillary testing included a brain magnetic resonance image showing nonspecific changes. Further complete blood count, chemistry panel, and thyroid studies were also normal. Still lacking a clear diagnosis, YA decided to increase her daily kelp supplementation to at least four pills per day. At this point, she first noticed gastrointestinal (GI) symptoms including diarrhea, nausea, and vomiting without hematemesis. She developed daily pressure headaches as if “there was a band around her head.”
Additionally, she became excessively weak and fatigued as the day progressed, requiring more sleep than previously. By the summer of 2006, she noticed a lacy, erythe- matous rash on her lower legs bilaterally. Other dermatologic findings included onchyolysis. Physical findings were confirmed on dermatologic assessment, which yielded a diagnosis of onchomycosis. An antifungal was prescribed but was of no benefit to her condi- tion. By the summer of 2006, the debilitating nature of her symptoms forced her to leave her full-time job and take part-time work.
Her physician believed that her symptoms resembled those of a patient he had previously seen with arsenic toxicity. On 9 October 2006, a spot urine sample showed an arsenicconcentration of 83.6 µg/g creatinine (normal < 50 µg/g creatinine). No lead or mercury was detected.
A detailed exposure history focusing on potential sources of arsenic was conducted. YA’s home water is from a deep well that was found to contain arsenic below detectable lev- els. Her diet consisted of less than one serving of seafood/fish per week. A sample of the kelp supplement was analyzed by Super Services and showed an arsenic concentration of 8.5 mg/kg. No arsenic was detected in the fish oil she had been tak- ing. The ginkgo biloba and grape seed extract were not analyzed.
Given the arsenic contamination in the kelp supplement, her physician recommended that she stop taking the supplement. She noted a dramatic improvement in her neurologic, GI, and dermatologic symptoms. Three weeks after stopping supplement use, YA returned to full-time work on 1 November 2006, with nearly complete resolution of symptoms. Repeat spot urine arsenic on 10 December 2006, was 25 µg/L (normal 0–50 µg/L), down over one-third from 2 months before. In a urine sample analyzed on 26 February 2007, arsenic was undetectable. Blood arsenic on 26 February 2007, was 8 g/L (normal for reporting laboratory, 2–23).
