Presentation Acute cases present with garlic breath, vomiting, watery diarrhea, and QTc prolongation. If severe, there can be pancytopenia and hepatitis. Chronic cases present with: sensorimotor neuropathy -- stocking glove distribution with burning sensation, distal weakness, hyporeflexia skin changes -- 1. first there is a change in skin color (hypo/hyperpigmentaiton), 2. later hyperkeratosis (scaling of palms/ soles), 3. Mees lines (horizontal lines on fingernails) Pathology Arsenic binds to sulfhydryl groups and disrupts cellular respiration and gluconeogenesis. Sources of arsenic include pesiticides/ insecticides, contaminated water (e.g. well water), and pressure treated wood (e.g. antique furniture). Diagnosis Urine arsenic levels Treatment Chelation therapy with: Dimercaprol (British anti-Lewisite, BAL) DMSA (meso-2,3-dimercaptosuccinic acid, succimer) Relevant Images Dimercaprol has sulfhydryl groups an...