454 Principles of Forensic Medicine and Toxicology

• Formication • Nails – become brittle and show Mees’ line. Mees’

• Delirium line are white transverse lines over nails
• Tenderness in muscle • Hairs – dry and may fall off; patchy or diffuse alopecia
• Paralysis • Arsenic dust – flexor eczema, painless perforation
• Hyperpyrexia of nasal septum.
• QT prolongation, tachyarrhythmia including torsades • Liver enlarged (hepatomegaly) and cirrhotic
de pointes may develop within first 24 hours after • Melanosis of neck, eyelids and nipples
ingestion.10 • Bowen’s disease.
3. Third stage
Subacute Poisoning • Headache
• Tingling and numbness of extremities
This results when arsenic is given in small doses at frequent
• Hyperasthesia of skin
intervals. The features are:
• Cramps in muscle and tenderness
• Dyspepsia
• Arthralgia
• Cough
• Knee jerk lost
• Tingling in throat followed by vomiting
• Impotence
• Diarrhea with tenesmus and abdominal pain
• Bone marrow depression with aplstic anemia
• Cramps in muscle
• Interference with folic acid metabolism with defi-
• Restlessness.
ciency
• Hematological abnormalities (Table 36.5).
Chronic Poisoning
4. Fourth stage
The features are exhibited in four stages6 • Peripheral neuropathy
1. First stage • Neuropathy is hallmark of arsenic poisoning. It is
• GIT symptoms dominate usually symmetrical sensorimotor polyneuropathy
• Malaise resembling Guillain-Barre syndrome
• Loss of appetite • Weakness of muscle and atrophy – extensor muscles
• Salivation more commonly affected resulting in wrist drop and
• Colicky abdominal pain foot drop
• Constipation (sometimes diarrhea) • Ataxia
• Vomiting • Tremors
• Gums – red and soft • Emaciation
• Circumscribed edema of ankle • Anemia
• Periorbital edema • Dysuria
2. Second stage • Delusion
• Cutaneous eruptions • Encephalopathy
• Voice – hoarse and husky • Death.
• Rhinorrhea
• Skin – generalized or localized fine mottled pigmenta-
tion of skin (Rain drop pigmentation, see Table 36.4)
Table 36.5: Showing hematological abnormalities
• Epithelial hyperplasia with keratosis – mostly on sole
in arsenic poisoning
and palms
Hematological abnormalities
Toxicology

• Leukopenia
Table 36.4: Displaying differential diagnosis of • Thrombocytopenia
raindrop pigmentation of arsenic • Mild eosinophilia
B Rain drop pigmentation may be mistaken for • Karyorrhexis – manifested by bizarre nuclear forms
• Megaloblastic anemia
Section 

1. Addison’s disease
2. Secondary syphilis • Basophilic stippling