There was a six-day delay after acute inhalation exposure with regard to the treatment with dimercaprol in all four patients and systemic corticosteroids in case 1 and case 2. Whether this delay in therapy played a role on outcomes is highly speculative. As discussed previously, there is no evidence in the literature to support a relationship between pulmonary toxicity and serum mercury concentration. Earlier therapy with dimercaprol and the resultant clearing of mercury ions would not necessarily have lessened lung damage or affected outcome. The evidence in the literature relating to the use of systemic corticosteroids in patients with acute lung injury is quite definitive. There is no improvement in outcome of patients with acute lung injury when treated with corticosteroids. Thus, we believe that even if the patients had given an honest account of the events that precipitated the inhalation, the initiation of therapy earlier in their course would probably not have improved the outcome. canadian family pharmacy com
All four cases underwent autopsies and the findings were quite consistent with those described in the past.2 The histologic changes of acute lung injury seemed to correlate directly with survival time. Early changes of acute lung injury were seen in case 4 who died 11 days after exposure. The lungs of case 1, who survived 24 days after exposure, demonstrated endstage lung injury. The histologic changes seen in case 2 and case 3 were intermediate within this spectrum and related to survival days after exposure. These histologic changes are similar to changes described in the adult respiratory distress syndrome from other causes. The kidneys of all four patients demonstrated acute tubular necrosis of the proximal tubules, although only case 3 and case 4 demonstrated transient clinical signs of renal failure. These postmortem findings may be related to the immediate premorbid hypotensive and hypoxemic episodes they experienced prior to expiration.