Clinical effects of groundwater arsenic contamination in the GMB plain

Arsenical skin lesions

The following symptoms of arsenic dermopathy were observed during filed visits in affected areas of the GMB plain (Mandal et al 1996, Rahman et al 2001; Chakraborti et al 2004; Mukherjee et al 2005, and Saha 2003):

  1. Salient dermatological features are melanosis (pigmentation) and keratosis (rough, dry, papular skin lesions).  Both may be spotted or diffuse. Usually melanosis appears earlier than keratosis. 
  2. Melanosis is diffuse in palms, soles and later over whole body if arsenic exposure continues.  Melanosis may be spotted like raindrop pigmentation often noticed over chest, back and limbs. Leucomelanosis (pigmentation and depigmentation side by side) usually appears in later stages (after discontinuing consumption of contaminated water). Guttate melanosis (like black mole) may sometimes be found.  Buccal mucus membrane melanosis on the tongue, gums and lips (diffuse, patchy, and spotted) may also be observed. 
  3. Starting from palms and soles (palmo-plantar keratosis), in advanced cases, keratosis is often distributed over dorsum of hands and feet and even over other body parts. Early keratosis is better felt than noticed and may be missed unless palms and soles are carefully palpated.
  4. Large nodules are often pre-runners of cancer. 
  5. Bowen’s disease is a premalignant condition called intraepidermal carcinoma in situ, which may be noted as a complication in chronic arsenicosis.
  6. Skin ulcer is a late feature of cutaneous asenicosis that may turn into malignancy.
  7. Skin cancers are late complications. Arsenic may also cause lung, bladder and kidney cancers and perhaps other internal tumors.
  8. We noticed some other features not previously reported in arsenicosis cases. Almost 70-75% of the patients with arsenical skin lesions reported severe pruritus or prickly heat type of sensation on exposure to sunlight, even in winter (solar dermaception). Another unique finding was that face escaped from arsenical skin lesions except in some cases of diffuse melanosis. Burning sensation of eyes was noticed in ≈ 30% of cases.
  9. Detailed history and systemic examinations in arsenic exposed persons having a combination of pigmentation (melanosis) and nodular rough skin (spotted palmo plantar keratosis) almost always point to arsenic toxicity ruling out several isolated causes of melanosis or keratosis. However, as there are several diseases mimicking arsenic dermatosis, care should be taken in confirming the arsenical effect (Saha 2003).

Other symptoms sometimes found are conjunctional congestion and non-pitting swelling (solid edema) of the feet. 
We have observed that drinking water with more than 300μg/L arsenic for several years may cause arsenical skin lesions . However, nutritional factors, thus diet, have an influence on prevalence of skin lesions.

The figures below demonstrate some of the prominent dermatological symptoms of arsenical toxicity.
Aceities
Amputated due to Gangrene
Bowens
Multiple Sqamous Cell Carc
Mee S Line
Conjunctival Conjestion
Dorsal Keratosis
Gangrene
Leuco Melanosis
Diffuse and Spotted Keratos
Diffuse Melanosis
Squamous Cell Carcinoma
Spotted And Diffused Kerato
Spotted Keratosis
Spotted Melanosis
Non Pitting Oedema
Spotted Keratosis On Palm
Tongue Melanosis

 Arsenical neuropathy

Neurological examination was generally undertaken by us for arsenocosis patients whose skin lesions were already diagnosed by experienced dermatologist. The neurological part was conducted by the same experienced neurologist to obviate inter-observer variability for each patient of arsenocosis so tested. The items included to characterize neuropathy were (i) pain and paraesthesias (e.g., burning) in a stocking and glove distribution, (ii) numbness, (iii) hyperpathia/allodynia, (iv) distal hypesthesias (reduced perception of sensation to pinprick/reduced or absent vibratory perception/ affected joint-position sensation/ affected touch sensation), (v) calf tenderness, (vi) weakness/atrophy of distal limb muscles or gait disorder, and (vii) reduction or absence of tendonflexes. The figure below shows a patient with arsenic neuropathy.

Neuropathy

Arsenic in drinking water and obstetric outcome

Arsenic exposure during pregnancy can adversely affect several reproductive endpoints. In several studies we have investigated the association between arsenic exposure and adverse pregnancy outcome, including spontaneous abortion, preterm birth, stillbirths, low birth weight and neonatal and perinatal mortality . All these parameters were compared to those observed in the unexposed women group from a non-arsenic exposed district (Medinipur) of West Bengal. Adverse obstetric effects were observed in our studies (comprising around 56 adult women) with village women from Murshidabad district, West Bengal , Bhojpur district of Bihar , Ballia district of UP (Ahamed et al 2006a) or Comilla district, Bangladesh (Ahamed et al 2006b).

The figure below shows a patient of arsenical obstetric outcome.
Obstetric Outcome

 Dose response relationship for arsenic effects

 We could not carry out a dose response survey due to various reasons. Neither the time period of arsenic contamination in these tubewells, nor the duration that villagers have been drinking arsenic-contaminated water could be determined. From field experience we notice that the villagers normally do not drink from one tubewell, and that adults and children stay outside their home for 8-12 hours. Moreover, a few important interrelated factors also need to be emphasized: (i) duration of exposure, (ii) dosage, (iii) concentration of arsenic in drinking water, (iv) nutritional status, (v) inter - individual variability, and (vi) confounding factors like recreational habits (smoking, drinking, etc).  We could not conduct a thorough survey to cover all these factors.

Arsenic affected children

Infants and children are considered to be more susceptible to the adverse effects of some toxic substances (NRC 1993). From the field experience in West Bengal and Bangladesh we observed, normally children (<11 years age) do not show arsenical skin lesions although their biological samples may contain high levels of arsenic. However we noticed exceptions in cases when i) arsenic content in water consumed is very high (≥ 1000μg/L) and ii) arsenic content in drinking water is not so high (around 500μg/L), but the children’s nutrition is poor. If children face higher risk, the future of the next generation in arsenic affected villages in the GMB plain appears to be grim [(90% of 1600 hair and nail samples analysed from arsenic affected villages in West Bengal and Bangladesh showed arsenic much above normal level) (Chakraborti et al 2004). Screening around 19,000 children from, arsenic affected areas of West Bengal, Bangladesh, Bihar, Uttar Pradesh and Jharkhand we found nearly 1100 affected with arsenical skin lesions. Figure 6 shows a group of arsenic affected children.

Arsenic affected children

Reference
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(2) Some drinking water disinfectants and contaminations, including arsenic. In: IARC Monographs on the evaluation of carcinogenic risks to humans, Volume 84, 2004, World Health Organization, International Agency for Research on Cancer, Lyon, France.
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(4) Arsenic Exposure and Health Effects-Authors’ Reply. Kshitish Chandra Saha, Subhash Chandra Mukherjee, Mohammad Mahmudur Rahman, Dipankar Chakraborti. Letter to the Editor. Clinical Toxicology, 2002, 40(4), 529-530.
(5) Long-term changes in severity of arsenical skin lesions following intervention to reduce arsenic exposure. Shoko Oshikawa, Alan Geater, Virasakdi Chongsuvivatwong, Tada Piampongsan, Dipankar Chakraborti, Gautam Samanta, Badal Mandel, Nobuyuki Hotta, Yasuko Kojo, Hiromi Hironaka, Environmental Science, 8 (5), 2001, 435-448.
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