Third-degree chemical burns: a consequence of subcutaneous metallic mercury injection

Perhaps the most colorful description of systemic mercury sequelae is the "Mad Hatter" in Alice in Wonderland, one whose personality was envisioned from the effects of illnesses seen in workers of the hat industry during the 19th century.2 These toxic effects of metallic mercury are characterized by renal· demise, pulmonary emboli, and central nervous system degeneration with progressive symptoms of paresthesia, ataxia, visual field deficits, dysarthria, hearing defects, and possible death.3 Although the potential toxic effects of mercury depend on the route of exposure with systemic effects typically related to intravenous injection or inhalation, subcutaneous injection is unpredictable and also potentially fatal through lymphatic or vascular spread with two deaths having been reported in the literature.1' 3 Mercury injection has been observed in those attempting suicide, psychiatric patients, accidental injections, athletes looking for performance improvement, and those with beliefs in ethnic folk medicine.4 Like in the case described, the injection of mercury is more common practice among those from Central or South America. Furthermore, as immigrant demographics continue to change and Latin American immigration rises, proper disposal of mercury and prevention of its sale are essential preventive health measures.4 After subcutaneous injection, we believe that early, massive excision of tissues affected with mercury deposits would prevent local damage as well as systemic absorption and embolism, therefore decreasing the risk of renal, neurological, or pulmonary complications through lymphatic or vascular spread.3 After operative intervention and excision, interval split-thickness skin grafting allows for wound closure and a decreased risk for secondary infection.