From the Departments of Dermatology and Neurology, Cleveland Clinic Foundation, Cleveland, Ohio
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A 62-year-old Turkish man developed nausea and vomiting 1 h following a dinner with friends and business associates. In the following few days, he developed dark urine, anemia, and thrombocytopenia. Five of his dinner companions developed similar symptoms of varying degrees, and one died. It is unknown how their food and beverage consumption differed during the meal. During the subsequent month, the patient developed gait ataxia, leg weakness, and burning pain and numbness in a glove-and-stocking distribution. Six weeks later, he traveled to the USA and was evaluated by our Department of Neurology. An electromyogram demonstrated generalized peripheral polyneuropathy, with motor and sensory axon loss. The patient was referred to the Department of Dermatology for evaluation of possible arsenic poisoning.Cutaneous examination revealed one transverse white band on several fingernails approximately 3–4 mm distal to the proximal nail fold, consistent with Mees’ lines (Fig. 1 ). A plaque of confluent 3-mm hypopigmented macules was evident on the extensor aspect of the left forearm (Fig. 2 ). Hair, nail, and urine samples were obtained to rule out heavy metal poisoning; the arsenic levels obtained were 27.6 µg/g (normal, 0.03–3 µg/g), 2.98 µg/g (normal, 0.03–3 µg/g), and 82 µg/L (normal, < 81 µg/L), respectively.These laboratory findings were consistent with acute arsenic poisoning. The patient was treated with oral succimer (water-soluble analog of dimercaprol), 10 mg/kg every 8 h, for 14 days with improvement of his neurologic symptoms. It is unknown exactly how the arsenic poisoning occurred, or the motivation behind it; however, criminal intent was suspected and is under investigation by the Turkish authorities.