Diagnostic problems in a case of arsenic encephalopathy in a schizophrenic patient: Case report and review of the literature

Although arsenic is the second most common cause of heavy metal intoxication in the United States today, its clinical presentation suggests a serious diagnostic challenge. A 58-year-old, chronic paranoid schizophrenic patient showed sudden clinical change heralded by flulike symptoms, followed by delirium, fever, scrotal candidiasis, and profound leukopenia. The presence of Guillain-Barre-like symptoms suggested a toxic polyneuropathy and the necessity of ruling out porphyria. Because of this suspicion, screening for heavy metals was performed, and revealed an urinary arsenic level of 124 μg/L. The patient's wife had reported being frightened by the patient's threatening demeanor for years. She subsequently committed suicide. Eventual investigation into the patient's illness concluded that his wife had been poisoning him. Review of historical and current literature shows that encephalopathy is a relatively common presentation of arsenic poisoning. Furthermore, it is associated with distinctive clinical and neuropathological features.