Bismuth Toxicity: A Rare Cause of Neurologic Dysfunction

Paul T. Reynolds, Kathleen C. Abalos, Jennifer Hopp, Mark E. Williams

.

DOI: 10.4236/ijcm.2012.31010                

Abstract

Bismuth subsalicylate (Pepto-Bismol^?) and other bismuth-containing compounds have been used for many years to treat gastroenterological complaints. Although safe in the majority of patients, bismuth can cause a well-described toxic state marked by progressive neurological decline. Features of bismuth toxicity include confusion, postural instability, myoclonus, and problems with language. This presentation can masquerade as other causes of progressive neurologic dysfunction including Creutzfeld-Jakob Disease (CJD), Hashimoto’s Encephalopathy, and others. In this case study, we present a patient who was using bismuth salicylate in toxic quantities to help control diarrhea. On initial presentation, several diagnoses were entertained before bismuth levels were obtained. This case study highlights the fact that bismuth toxicity, while rare, should be considered in a patient with progressive neurological decline. Also, we hope this case reminds physicians of a severe consequence of a common, readily available medication.

Keywords

Bismuth Toxicity; Creutzfeld-Jakob

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	P. Loiseau, P. Henry, P. Jallon and M. Legroux, “Iatrogenic Myoclonic Encephalopathies Caused by Bismuth Salts,” Journal of the Neurological Sciences, Vol. 27, No. 2, 1976, pp. 133-143. doi:10.1016/0022-510X(76)90056-3
[2]	M. Teepker, H. M. Hamer, S. Knake, O. Bandmann, W. H. Oertel and F. Rosenow, “Myoclonic Encephalopathy Caused by Chronic Bismuth Abuse,” Epileptic Disorders, Vol. 4, No. 4, 2002, pp. 229-233.
[3]	J. C. Hutson, “Effects of Bismuth Citrate on the Viability and Function of Leydig Cells and Testicular Macrophages,” Journal of Applied Toxicology, Vol. 25, No. 3, 2005, pp. 234-238. doi:10.1002/jat.1060
[4]	Micromedex, “Healthcare Series,” Thomson Reuters (Healthcare) Inc., Greenwood Village, Accessed 21 December 2011.
[5]	P. M. Le-Quesne, “Toxic Substances and the Nervous System: The Role of Clinical Observation,” Journal of Neurology, Neurosurgery, and Psychiatry, Vol. 44, No. 1, 1981, pp. 1-8. doi:10.1136/jnnp.44.1.1
[6]	I. Zerr, M. Pocchiari, S. Collins, et al., “Analysis of EEG and CSF 14-3-3 Proteins as Aids to the Diagnosis of Creutzfeldt-Jakob Disease,” Neurology, Vol. 55, No. 6, 2000, pp. 811-815.
[7]	I. Kothbauer-Margreiter, M. Sturzenegger, J. Komor, R. Baumgartner and C. W. Hess, “Encephalopathy Associated with Hashimoto Thyroiditis: Diagnosis and Treatment,” Journal of Neurology, Vol. 243, No. 8, 1996, pp. 585-593. doi:10.1007/BF00900946
[8]	F. Ferracci, G. Bertiato and G. Moretto, “Hashimoto’s Encephalopathy: Epidemiologic Data and Pathogenetic Considerations,” Journal of the Neurological Sciences, Vol. 217, No. 2, 2004, pp. 165-168. doi:10.1016/j.jns.2003.09.007
[9]	M. Borg, “Symptomatic Myoclonus,” Neurophysiologie Clinique, Vol. 36, No. 5-6, 2006, pp. 309-318. doi:10.1016/j.neucli.2006.12.006
[10]	C. D. Marsden, A. E. Harding, J. A. Obeso and C. S. Lu, “Progressive Myoclonic Ataxia (the Ramsay Hunt Syndrome),” Archives of Neurology, Vol. 47, No. 10, 1990, pp. 1121-1125. doi:10.1001/archneur.1990.00530100091019
[11]	P. Birmes, D. Coppin, L. Schmitt and D. Lauque, “Serotonin Syndrome: A Brief Review,” Canadian Medical Association Journal, Vol. 168, No. 11, 2003, pp. 1439-1442.
[12]	A. C. Ford, P. Malfertheiner, M. Giguere, J. Santana, M. Khan and P. Moayyedi, “Adverse Events with Bismuth Salts for Helicobacter Pylori Eradication: Systematic Review and Meta-Analysis,” World Journal of Gastroenterology, Vol. 14, No. 48, 2008, pp. 7361-7370. doi:10.3748/wjg.14.7361
[13]	M. D. Ioffreda, C. A. Gordon, D. R. Adams, S. J. Naides and J. J. Miller, “Black Tongue,” Archives of Dermatology, Vol. 137, No. 7, 2001, pp. 968-969.
[14]	M. F. Gordon, R. I. Abrams, D. B. Rubin, W. B. Barr and D. D. Correa, “Bismuth Subsalicylate Toxicity as a Cause of Prolonged Encephalopathy with Myoclonus,” Movement Disorders, Vol. 10, No. 2, 1995, pp. 220-222. doi:10.1002/mds.870100215
[15]	H. Ovaska, D. M. Wood, I. House, P. I. Dargan, A. L. Jones and S. Murray, “Severe Iatrogenic Bismuth Poisoning with BIsmuth Iodoform Paraffin Paste Treated with DMPS Chelation,” Clinical Toxicology, Vol. 46, No. 9, 2008, pp. 855-857. doi:10.1080/15563650801953182