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Mercury a heavy metal, exists in the environment in 3 forms: Organic, Inorganic and
elemental. It is toxic in any of these forms. Neurological manifestations involving the central
nervous system are seen with chronic mercury intoxication. The largest out breaks of mercury
toxicity have occurred with the ingestion of fish and seafood contaminated with methyl
mercury by industrial pollution and by the consumption of grains for seeds treated with
Symptoms of mercury toxicity include lethargy, confusion, stomatitis, vomiting, colitis.
Early in the disease it may be confused with viral, respiratory infection or flu.
When fish or other foods contaminated with methyl mercury are consumed, approximately
95% of the methyl mercury is absorbed through the stomach and intestinal tract, ten
transferred to the blood stream and distributed throughout the body. It readily passes the
blood brain barrier and enters the brain. In pregnant women, it readily passes the placental
barrier and moves into the blood of the developing child and subsequently into the child’s
brain and other tissues.
Methyl mercury can be changes into inorganic mercury within the body, when it happens in
the brain, mercury can remain there for a long time.
After stopping exposure to methyl mercury, it takes between 45 and 70 days to decrease
methyl mercury concentrations by half in a person’s blood and slightly longer in the whole
A wide range of adverse health effects have been observed with methyl mercury
poisoning.----Devastating neurological damage, and death, adverse effects on other organs in
the body, parathesia, Malaise, Dysarthia, Ataxia, etc.
If the level of mercury in the blood or urine is considered high, a doctor might prescribe
chelating agents that bind mercury ions. The mercury and chelating agents are then excreted
from the body together. A number of chelating agents that bind to mercury are available and
can increase the excretion rate upto threefold.
DMSA is the first treatment of choice in children with methyl mercury poisoning.
BRITISH MEDICAL JOURNAL 11 MARCH 1978
Methylmercury poisoning in Iraqi children: clinical observations over two years
L AMIN-ZAKI, M A MAJEED, T W CLARKSON, British Medical_7ournal, 1978, 1,
Summary and conclusions
The clinical features of 49 children who had eaten bread contaminated with methylmercury in
rural Iraq were reviewed. Symptoms and signs relating to the nervous system-varying degrees
of ataxia, weakness, and visual and sensory changes-dominated the clinical picture.
The severity of poisoning was related to the blood mercury concentration, as was the degree
of recovery. Follow-up over two years showed that children who had had mild or moderate
poisoning slowly but steadily improved, some of them recovering normal function, though all
had a residual generalised hyperreflexia. In some patients ataxia and motor weakness
Visual changes also improved, though less completely, and of 17 blind children, only five
had recovered partial sight by the end of two years. Seven of the 18 children who suffered
very severe poisoning were left physically and mentally incapacitated.
The degree of clinical progress shown by these children was better than that shown by some
other groups of patients, possibly because the poisoning was relatively acute and mercury
consumption was stopped immediately after its effects had become obvious.
Methylmercury compounds are highly neurotoxic. They are readily absorbed, slowly
metabolised, and pass the blood-brain barrier easily.' Several sporadic incidents2 3 and large
epidemics4-8 of methylmercury poisoning have been reported.
One such outbreak occurred in rural Iraq in the winter of 1971-2, when Iraqi farmers used a
mercury-treated seed grain to make bread.9 Analysis of the flour used gave an estimated
amount of 1 4 mg of mercury per loaf of bread. 9 The bread was eaten over two weeks to two
months. Many of the victims of this disaster were children.
We were actively engaged in the management of these patients both in hospital and in their
rural homes and had the opportunity to study the clinical manifestations. We describe here
the clinical picture at the outset of the disease and the clinical progress over two years in the
children who were old enough to have eaten the bread themselves. We have not included
infants who were exposed in utero or through their mother's milk.
Department of Paediatrics, Medical College, University of Baghdad, Iraq
LAMAN AMIN-ZAKI, DCH, MRCP, professor and chairman, department of paediatrics
MUHAMMAD A MAJEED, MB, CHB, DCH Environmental Health Sciences Centre,
University of Rochester
Medical Centre, Rochester, New York 14642, USA
THOMAS W CLARKSON, BSC, PHD, professor of radiation biology and biophysics and of
pharmacology and toxicology MICHAEL R GREENWOOD, BSC, MSC, instructor and
assistant lecturer in radiation biology and biophysics and in environmental studies
M R GREENWOOD
Patients and methods
Forty-nine children, all of whom had eaten homemade bread prepared from grain treated with
a methyl mercury compound, were included. All belonged to families whose members were
affected by severe poisoning and who reported to the hospital asking for help.
Their age and sex distributions are shown in table I. The children were admitted to hospital
for periods of six to 12 months. After discharge they were visited in their homes at least once
every six months and their progress was evaluated by standard clinical and neurological tests.
Because of the youth of most of the patients the examination
often had to be limited to basic neurological tests, and such sensory tests as the tuning fork
test, two-point discrimination, and hot and cold discrimination were omitted. Visual changes
were evaluated by a consultant ophthalmologist and hearing changes by a consultant
TABLE I-Age and sex distribution in 49 children who were observed over two years Age
(years): 2-4 5-9 10-16
With symptoms and signs:
Boys 3 3 10 16
Girls 6 11 7 24
Without symptoms and signs:
Boys 2 3 5
Girls 3 1 4
Blood samples were collected in heparinised vacuum containers to prevent coagulation and
were refrigerated or kept on ice until assayed for mercury within 48 hours. Mercury
concentrations were determined in the blood by selective cold vapour atomic absorption.'0
Results and comment
SIGNS AND SYMPTOMS
Onset-As reported,9 the first symptoms often did not appear until up to six weeks after the
patient had stopped eating the contaminated bread. But 22 patients stopped eating the bread
because of the appearance of the clinical manifestations. The onset was always gradual and
the early signs consisted of malaise or a feeling of severe
bodily discomfort without clear signs of a particular illness, often associated with headache
and insornnia in children old enough to describe what they felt. Of the 49 patients admitted to
the hospital, nine were asymptomatic. The incidence of symptoms and signs in the 40 patients
with neurological manifestations is given in table II.
TABLE iI-Prevalence of neurological manifestations in 40 children exposed to
methylmercury. Manifestations were those observed shortly after admission to hospital
No of patients
Ataxia . .22
Visual disturbance ..30
Hearing disturbance .. 24
Sensory changes . .12
Babinski's sign . .18
Changes in muscle tone . .24
Incontinence .. 13
Priapism. . 4
Involuntary movements . .27
Ataxia and dysarthria-Ataxia was found in 22 out of the 40 children with symptoms. The
remaining 18 were too severely affected or too young to perform the clinical tests, which
included: the fingernose test, walking on a straight line, and picking up and drinking from a
glass of water. The ataxia varied in severity from clumsiness in the handling of objects to
broad-based gait, staggering, falling, and inability to stand or even sit. Thirty-four of the
children had speech disturbances, which varied from slow, slurred, and explosive speech to
an inability to utter clear, comprehensible words.
Visual and hearing disturbances-Visual disturbances ranged from blurred or hazy vision
through various degrees of constricted visual fields to complete blindness. In all cases the
constriction of visual fields was bilateral. The patients themselves described their constricted
fields of vision as being "like a horse with blinkers." Auditory
disturbances varied from reduced hearing to complete deafness. No other lesion that might
cause constriction of the visual fields or bilateral loss of hearing could be identified except
exposure to methylmercury.
Visual changes were found in 30 and auditory changes in 24 of the 40 children.
Sensory changes-On admission 14 children were too severely affected and eight children
were too young to be able to give information about paraesthesiae. Of the remaining 18
children, 12 complained of numbness in the glove-and-stocking areas and four had perioral
paraesthesia as well. Sensory changes were commonly associated with motor weakness so
that the complaint was usually "a feeling of numbness and ants moving under the skin; my
hands are weak and do not obey me to do my work." All 40 patients could feel pin pricks
easily, including those with paraesthesia.
Changes in motor power, muscle tone, and deep tendoni reflexes- Varying degrees of
weakness were found in 34 patients; 18 patients suffered complete paralysis and helplessness.
Muscle tone was increased in 21 children, decreased in three, and normal in 16. There
was obvious muscle wasting in the 18 patients who were paralysed.
Deep tendon reflexes were exaggerated in all patients and Babinski's sign was extensor in 18.
Clonus was present in only four cases.
Disturbances of autonomic nervous system-Excessive salivation and drooling were found in
10 cases. Thirteen children who had previously had normal toilet habits had incontinence of
urine and faeces.
Priapism was found in four boys.
Involuntary movements-Twenty-seven children had involuntary movements. Coarse tremors
that became more pronounced during voluntary movements were the most common finding.
Twitching was also present in four children and myoclonic jerks in three. Athetotic
movements were found in only two cases.
Deaths-Our policy was to keep a clear airway; maintain the patients' nutrition through
nasogastric feeding and, when necessary, intravenous infusions; and treat promptly any
intercurrent infections during the critical period. As a result none of the patients died during
the period of observation.
The severity of each patient's clinical disease was classified according to the following
definitions adapted from Damluji (see table III)."
Asymptomatic children were free from any signs or symptoms on admission but had raised
blood mercury concentrations. They were admitted with affected members of their families
and were considered to be at risk.
Mild poisoning was present in six children who had no or very little impairment of
physiological function. The findings were mainly subjective and included symptoms such as
malaise, headache, insomnia, TABLE III-Clinical progress over two years according to
severity of poisoning Degree of improvement No of Physical Severity* patients Greatly
Improved, and Recovery improved, function mental function fair incapacigoodtation
Mild 6 6
Moderate 10 7 2 1
Severe 13 1 4 8
Very severe 11 1 3 7
Total 40 14 7 12 7
*Nine were asymptomatic.
BRITISH MEDICAL JOURNAL 11 MARCH 1978
paraesthesia, weakness, blurring of vision, and gastrointestinal disturbance. Hyperreflexia
was present in all cases. Moderate poisoning was present in 10 patients who had some
impairment of physiological function. The most common findings, in addition to those seen
in mild poisoning, were: ataxia elicited by tests such as the finger-nose test and walking on a
straight line; mild dysarthria; paresis; tremor; and some visual and auditory impairment.
Severe poisoning affected 13 patients, who all had gross impairment of physiological
function. The most common findings were stupor, gross ataxia, spastic paralysis, severe
bilateral visual or auditory impairment, severe dysarthria, and incontinence.
Very severe poisoning affected 11 patients; all were physically and mentally incapacitated.
The most common findings were blindness, deafness, decerebrate posture, bouts of severe
excitement and crying, and spastic paralysis.
BLOOD MERCURY CONCENTRATION
The blood concentrations of total mercury at the time of admission to hospital are shown in
the figure. There was no apparent relation between the severity of signs and symptoms and
the mercury concentrations, but it was clear that blood concentrations were falling during
this period (March to August 1972). This was to be expected. According to the clinical
histories of the patients, the consumption of contaminated bread had stopped before
admission to hospital. We therefore compared the severity of poisoning with the blood
concentrations at a common point in time.
Total mercury concentrations in first sample of whole blood collected after admission. (A)
Mercury concentrations plotted according to date of sample collection. (B) Mercury
concentrations extrapolated to 1 March 1972 using half time of 73 days.. Mercury values are
grouped according to severity of poisoning.
o Asymptomatic. * = Mild. A = Moderate. *= Severe. O=Very severe.
The encircled triangle is a sample from a patient who had extensive exfoliative dermatitis in
addition to other signs and symptoms of poisoning.
This was an atypical case. Mercury concentrations in blood were not available for nine
SI to traditional units-Mercury: 1 Humol/l 201 ng/ml.
Enough blood samples were collected from 14 children to allow the biological half time to be
estimated. The decline in blood concentration was exponential and could be adequately
described by a single biological half time, as reported.9 The average biological half time was
56 days (range 39 to 72 days). This did not differ significantly from an average biological
half time of 65 days (range 45 to 105) reported in 16 adult Iraqi patients9 and a value of 50
days computed for 16 volunteers who took tracer doses of radioactive methylmercury." We
decided to correct all the blood values shown in the figure (A) to 1 March 1972, the date
when the first patients were admitted to the hospital The individual's half time was used to
make this correction for the 14 children whose half time was known and the average half time
of 56 days was used for the rest of the children. The corrected mercury concentrations are
also shown in the figure, grouped according to the severity of poisoning. The severity of the
poisoning increased with increasing blood mercury concentrations. The asymptomatic group
had significantly lower concentrations than the severe and very severe groups (Mann
Whitney test: P < 0-01). One-way analysis of variance'3 showed highly significant (P <001)
differences between the mean concentrations of mercury in each clinical group, with the
value increasing according to the severity of poisoning. The individual variation in mercury
concentration in each group and the overlap between groups reflected both differences in
individual sensitivity to methylmercury'4 and differences in biological half time.15
Table III summarises the results of two years' follow-up. The degree of recovery was
generally inversely related to the severity of signs and symptoms. Hyperreflexia with or
without a bilaterally extensor Babinski's reflex remained in all patients, even after two
years. Patients shown in the tables as having regained normal function did have
hyperreflexia, but all coped well with their daily functions or school activities. All six
children who had mild poisoning were normal at the end of one year. Seven of the 10 who
had had moderate poisoning recovered normal function by the end of two years; two
improved greatly and were able to work with residual sequelae such as constriction
of visual fields, some slurring of speech, and a positive Babinski's sign; and one patient
showed improvement but retained some muscle weakness, abnormal gait, and slurring of
speech. Of the 13 patients who had had severe poisoning, one recovered her function, four
showed great improvement, and eight (three of whom remained blind) improved slightly but
did not regain full capacity to perform their previous activities. Of the 11 patients who had
had very severe poisoning, none recovered; seven remained with physical and mental
incapacity, and four showed some improvement. Table IV gives details of speech, ataxia,
walking, and visual changes observed over two years.
TABLE iv-Clinical progress over two years according to selected signs and symptoms
No of One year later Two years later patients
I1 1* 2 3 Normal 1 2133 Normal
Slurred (1)) 13 2 1 1 2 1 1
Severely slurred (2) 8 5 3 4 4
Lost (3) 13 2 2 9 4 2 6 1
Finger-nose (1) 22 10 12t 8 14§
Straight line (2) 21 10 11 8 13
Glass of water (3) 18 4 14 4 14
Without support (1) 11 2 9 1 10
With support (2) 7 7 4 3
Bedridden (3) 18 9 1 8 9 7 2
Blurred (1) 14 14 14
Constricted (2) 9 8 1 8 1
Blind (3) 17 5 12 5 12+|
*Numbers used as column headings refer to same numbers after clinical finding in each row.
±12 out of 22 patients had normal results on all three tests.
+Nine of these patients showed only perception of light.
§14 out of 22 patients had normal results on all three tests.
Many workers have taken a pessimistic outlook towards patients with methylmercury
poisoning, predicting either a fatal outcome or permanent and stable neurological
In Japan most patients were permanently affected, and, once methylmercury exposure was
stopped, their disease ran a progressive course. Harada22 described 30 patients who had
615 developed infantile Minamata disease in 1953-9 after eating fish from Minamata Bay
that had been contaminated with methylmercury compounds by industrial pollution. Ten of
Harada's group died. Thus many of his patients were more severely affected than ours, and
none were asymptomatic or had only mild poisoning. Of the 20 surviving patients, one
showed no improvement, three were lost to follow-up, and 16 improved very slightly. In the
original paper of Hunter et a12 four older patients were reported, all of whom showed
varying degrees of functional improvement, although "the actual neurological condition had
improved little, if at all,"2 and improvement was attributed to re-education and physical
treatment. Two years after the exposure their patient who showed the most recovery retained
many neurological deficits.
He still had gross ataxia; his visual fields were unaltered; his speech was explosive, and he
had fine tremor in the arms, head, and neck.
In Iraq the neurological symptoms and signs were grossly similar to those in Japan. But not
only did we observe functional recovery but in many cases the neurological condition also
improved. A preliminary report23 indicated that improvement had already started in our
cases by the end of 1972. Our twoyear follow-up study indicates that those who were initially
disabled, paralysed, and bedridden improved greatly with time and began to be independent
in caring for themselves and walking around. We have no doubt that physiological function
improves or even recovers completely.
Pierce et al,24 commenting on an outbreak in New Mexico, suggested that the recovery might
be related to the fact that ingestion of the mercury compounds occurred over a relatively
short period (three months) and then abruptly stopped when the symptoms appeared.
Exposure in Iraq9 was also short. In Minamata the ingestion of mercury-contaminated fish
probably supplied lower doses over longer periods, and even after the onset of symptoms.
Although the consumption of fish from Minamata Bay was supposed to have stopped,
occasional additional doses taken with fish meals, at long intervals, cannot be excluded in the
absence of laboratory data. The Iraqi outbreak was comparable with that in the family studied
by Pierce; hence the difference in the clinical picture and outlook.
Furthermore, the short exposure in Iraq was similar to that reported by Hunter et a12 3in
adults, although their patients showed poor recovery. This difference may reflect differences
in the sensitivity of children and of adults.
The young central nervous system, unaffected by aging and vascular change, might give a
pure clinical picture of methylmercury poisoning, in which recovery becomes evident.
Children do not seem to be more susceptible than adults to comparable methylmercury
exposure and their capacity to improve or recover appears to be greater.
Despite individual variation, the severity of the poisoning is related to blood concentrations
of mercury. Furthermore, the severity of poisoning seems to determine the extent of recovery.
Patients with mild poisoning completely recovered, while those with very severe poisoning
recovered only slightly.
Mild cases of poisoning are more difficult to diagnose as they manifest themselves mainly as
subjective complaints and usually disappear5l 24 over a few months. The proof that these
symptoms are caused by methylmercury depends on (a) a correlation of these complaints
with blood mercury concentrations9 25 and (b) the patient's history indicating that the onset
of symptoms coincided with exposure to methylmercury.
We thank the Minister of Health and the director of the Medical City, Baghdad, for supplying
the hospital facilities. We also thank the deans of the medical schools of the Universities of
Baghdad and Rochester for arranging the interuniversity collaboration. The cosponsored
analytical laboratory under the direction of Dr Hashim I Dhahir supplied the analytical data
on mercury. We are also indebted to the director general of the Mussayeb al-Kabeer
Irrigation Project for help in this area; Dr A Harith for help with the study of patients at
Salman Pak; and Dr S Sabelaish, consultant ophthalmologist, and Dr G Toma, consultant
otolaryngologist, for their help in assessing 616 visual and auditory effects. We also thank
Drs S F Damluji, L Magos, and D 0 Marsh for reading and criticising this paper.
The University of Rochester was supported in part by a National Science Foundation
(Research Applied to National Needs) Grant GI-300978, a Centre Grant (ES-01247), and a
Programme Project Grant (ES-01248) from the National Institute of Environmental
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(Accepted 53January 1978)