Toxins - Diagnosis

Dr. Joseph Pizzorno, NDPresident Emeritus, Bastyr University

Editor-in-Chief, Integrative Medicine: A Clinician’s JournalChair, Scientific Advisory Board, Bioclinic Naturals

President, SaluGenecists, Inc.mail2@DrPizzorno.com

Copyright © 2015

1. Acute Exposure Versus Body Load2. Clinical Presentations3. Conventional Lab Tests4. Unconventional Lab Tests5. Monitoring

Overview

Acute Exposure versus Body Load• Must differentiate between acute exposure

and body load• Testing reveals exposure, not necessarily

toxicity• In general, serum and urine levels represent

acute exposure• Essentially no gold standard for body load• Serum, whole blood, hair, urine, feces, nails, and

adipose have all been used for assessment• Challenge testing can reveal body load of metals

DeVito MJ, Comparisons of estimated human body burdens of dioxinlike chemicals and TCDD body burdens in experimentally exposed animals. Environ Health Perspect. 1995Rooney JP. The role of thiols, dithiols, nutritional factors and interacting ligands in the toxicology of mercury. Toxicology. 2007

Early Clinical Presentations• Immunological Allergies, asthma, chemical sensitivity, chronic infections,

autoimmunity• Neurological Headache, brain fog, balance, memory, mood lability,

parkinsonism• Endocrine Hypothyroid, infertility, temperature dysregulation

Crinnion Wy. Tanking an Environmental History. AANP 2015

Sample Questions for Toxic Metal Exposure1. Has the patient knowingly been exposed to metals?2. What is patient’s occupation (dentist, welder, ship builder, etc.)?3. How frequently does the patient eat tuna, swordfish or shark?4. Does the patient have mercury amalgam fillings?5. If the patient is taking any dietary supplements, do they have

certificates of analysis that they are free of contaminants?6. Is the patient taking any Ayurvedic or traditional Chinese medicine

dietary supplements?7. Does the patient experience a metallic taste in their mouth and have

not recently been taking medications documented to cause metallic taste?

8. Does the patient have a history of smoking (particularly high in cadmium)?

Neustadt J, Pieczenik S. Mercury—an example of heavy metal toxicity. IMCJ 2007;6:1

Clinical - Arsenic• The most common

neurologic effect of chronic arsenic intoxication is a sensory-predominant peripheral neuropathy in a “stocking-glove” pattern

• Mechanism similar to neuropathy of thiamine deficiency: arsenic inhibits conversion of pyruvate to acetyl coenzyme A thus blocking Krebs cycle.

• Skin lesions: Hyperkeratosis, Hyperpigmentation, Skin cancer

http://www.atsdr.cdc.gov/csem/arsenic/docs/arsenic.pdf (accessed 2015-08-18)

Cadmium Exposure SymptomsAcute Exposure• Virtually all industrial Battery manufacture Pigment manufacture

• Route important with air being common and especially toxic

• "the cadmium blues:” chills, fever, and muscle ache

• More severe exposures can cause tracheo-bronchitis, pneumonitis, and pulmonary edema

Chronic Exposure• Few symptoms until

significant kidney damage

• Osteoporosis and osteomyelitis

• Joint pain• Hypertension• Albuminuria• Gout

Lead Toxicity Symptoms• Blood levels limited to acute toxicity• Symptoms correlate with degree of elevation

Gracia RC, Snodgrass WR. Lead toxicity and chelation therapy. Am J Health Syst Pharm. 2007 Jan 1;64(1):45-53

Mercury Neurological Symptoms

S Langworth, O Almkvist, E Söderman, and B O Wikström. Effects of occupational exposure to mercury vapour on the central nervous system. Br J Ind Med. 1992 August; 49(8): 545–555

Online Neurocognitive Testing

CNS Vital Signs Finger-tapping test

• Psychomotor speed Symbol digit substitution

test• Processing speed • Several cognitive

functions Verbal memory test

• Recognize, remember and retrieve words

Continuous performance test

• Sustained attention, vigilance, and choice reaction time

Gualtieri CT, Johnson LG. Reliability and validity of a computerized neurocognitive test battery, CNS Vital Signs. Arch Clin Neuropsychol. 2006 Oct;21(7):623-43

Conventional Laboratory Tests• Blood and urine levels of toxic metals• Surprising number show toxin exposure CBC: RBC, WBC, platelet count, hemoglobin, basophilic

stippling Liver enzymes: ALT, GGTP Inflammatory markers: CRP Lipids: LDL, oxLDL, triglycerides Blood sugar: insulin, FBS, 2-hour PP Metabolites: bilirubin, uric acid, 8-OHdG

• Within the “normal” range reflect toxin load• The historic “normal” range has been changing

as the population has become more toxic

Poor Hg Inter-Test Correlation

• Poor correlation between blood and urine , r = 0.30

• Better correlation between blood and hair, r = 0.56

Zimmera H, et al. Determination of mercury in blood, urine and saliva for the biological monitoring of an exposure from amalgam fillings in a group with self-reported adverse health effects. Int. J. Hyg. Environ. Health 2002;205(3):205-211Berglund M, et al. Inter-individual variations of human mercury exposure biomarkers: a cross-sectional assessment. Environ Health. 2005 Oct 3;4:20

Basophilic Stippling of Red Cells

Toxins• Arsenic• Lead

Diseases• Alpha-thalassemia, HbH Disease• Beta thalassemia • Hereditary pyrimidine 5'-

nucleotidase deficiency• Myelodysplastic syndrome• Sideroblastic anemia• Thrombotic thrombocytopenic

purpura

GGT: Indirect Measure of POPs• Glutathione is key intracellular defense against oxidative stress• Cellular GGT metabolizes extracellular GSH, allowing precursor

amino acids to be reutilized for intracellular GSH. • Exposure to POPs induces GGT as a defensive mechanism.• Within normal range predicts type 2 diabetes, coronary heart disease,

hypertension, stroke, dyslipidemia, chronic kidney disease and cancer.

• Men with GGT >50 U/I had ~26 fold risk for diabetes compared to those with <10. Those with 40-49 had a ~20 fold risk.

• Levels within normal range occur with obesity, xs alcohol, cigarette smoking, physical inactivity, high meat /low fruit and vegetable intake

• Cumulative biomarker for environmental pollutants.

Lee DH, et al (2003) Gamma-glutamyltransferase and diabetes—a 4 year follow-up study. Diabetologia 46:359–364Pamela A, et al. Serum gamma-glutamyltransferase: linking together environmental pollution, redox equilibria and progression of atherosclerosis? Clin ChemLab Med. 2009;47(12):1583-4. Lee DH, et al. Serum gamma-glutamyltransferase: new insights about an old enzyme. J Epidemiol Community Health. 2009 Nov;63(11):884-6. Lee DH, et al.Serum gamma-glutamyltransferase predicts non-fatal myocardial infarction and fatal coronary heart disease among 28,838 middle-aged men and women. Eur Heart J 2006;27:2170–6 Lee DH, et al. Gamma-glutamyltransferase and diabetes--a 4 year follow-up study. Diabetologia. 2003 Mar;46(3):359-64. Lee DH, et al. Can persistent organic pollutants explain the association between serum gamma-glutamyltransferase and type 2 diabetes? Diabetologia. 2008 Mar;51(3):402-7.

GGT and Alcohol Consumption• GGT directly correlates

with alcohol consumption• In a non-uniform

population, 40 g/d will elevate GGT ~15%

• Watch for false negatives• Genomic variation• Are these the ones most

sensitive to/damaged by chemical toxins?

• Could up-regulation of GGT in light alcohol consumption be reason for benefit?

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Adapted from: Nagaya T, et al. Dose-response relationships between drinking and serum tests in Japanese men aged 40–59 years. Alcohol 1999 Feb. 17(2): 133–8.

GGT Correlates With Toxic Metal Levels

Lee DH, et al. Graded associations of blood lead and urinary cadmium concentrations with oxidative-stress-related markers in theU.S. population: results from the third National Health and Nutrition Examination Survey. Environ Health perspect. 2006 Mar;114(3):350-4

• GGT over 50 associated with tripling of death rate!

• 30-40 associated with doubling

GGT Levels Correlate with Risk of Death

Brenner H, et al. Distribution, determinants, and prognostic value of gamma-glutamyltransferase for all-cause mortality in a cohort of construction workers from southern Germany. Prev Med 1997; 26: 305–10.

GGT Data from Canadian Oil Field Workers

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20-fold increased risk of diabetes

GGT From Small US Company with Young Workers

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POPs and CRP Interact to Increase Insulin Resistance

Kim KS, et al. Interaction Between Persistent Organic Pollutants and C‐reactive Protein in Estimating Insulin Resistance Among Non‐diabetic Adults. J Prev Med Public Health. 2012 Mar;45(2):62‐9

Uric Acid: Indirect Measure of POPs• Poly-fluorinated hydrocarbons (PFOA and PFOS) associated

with increased serum uric acid

Lin CY, et al. Association among serum perfluoroalkyl chemicals, glucose homeostasis, and metabolic syndrome in adolescents and adults. Diabetes Care. 2009 Apr;32(4):702-7.Steenland K et al. Association of perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) with uric acid among adults with elevated community exposure to PFOA. Environ Health Perspect. 2010 Feb;118:229-33.

Steenland 2010: Open Access

ALT: Indirect Measure of POPs• ALT (proxy marker) elevation in 10.4% (not including viral

hepatitis, hemochromatosis, or alcoholic liver disease) of NHANES 03-04 subset

• Risk of elevated ALT increased dose-dependently with cadmium, lead, mercury, and PCB exposure

• 100% of individuals had detectable PCBs, 92.5% mercury, and 99.6% had detectable lead

• In 2005-08, prevalence of NAFLD in US was 11%, a growing cause of chronic liver disease.

Cave M, et al. Polychlorinated biphenyls, lead, and mercury are associated with liver disease in American adults: NHANES 2003-2004. Environ Health Perspect. 2010 Dec;118(12):1735-42.Younossi ZM et al. Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008. Clin Gastroenterol Hepatol. 2011 Jun;9(6):524-530.e1;

Bilirubin as a marker of POPs• Degree of serum bilirubin increase is

prognostically significant in chronic liver dysfunction

• Mono-ortho PCB TEQ values were found to be significantly positively associated with bilirubin (β=0.71, P=0.008) following adjustment for multiple potential confounders.

• Bilirubin levels significantly correlated with PCBs -105,-118,-126, and -194

• Smoking appears to be the biggest confounder

Dufour, D.R., et al., 2000. Diagnosis and monitoring of hepatic injury. II. Recommendations for use of laboratory tests in screening, diagnosis, and monitoring. Clin. Chem. 46, 2050–68.Kumar J, et al. Persistent organic pollutants and liver dysfunction biomarkers in a population-based human sample of men and women. Environ Res. 2014;134:251-256

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Gleason JA, et al. Associations of perfluorinated chemical serum concentrations and biomarkers of liver function and uric acid in the US population (NHANES), 2007-2010. Environ Res. 2015;136:8-14

Liver Enzymes Reflect Toxic Load• AST, ALT and

GGT increase with body load of PCBs and OCPs

• Some non-linear• Oxychlordane

top quartile: ALT 10% GGT 25%

Serdar B, et al. Potential effects of polychlorinated biphenyls (PCBs) and selected organochlorine pesticides (OCPs) on immune cells and blood biochemistry measures: a cross-sectional assessment of the NHANES 2003-2004 data. Environ Health. 2014;13:114.

LDL-Cholesterol as Measure of POPs?

• 5-year study to determine if POP levels predict future elevation in LDL-cholesterol

• 598 subjects initially at age 70

• Looked at 23 POPs

• Best correlation with PCB 194

Penell J, Lind L, Salihovic S, et al. Persistent organic pollutants are related to change in circulating lipid levels during a 5 year follow-up. Environ Res 134(2014)190–197

oxLDL as Measure of POPs?• 992 70-year old individuals (50% women)• Sum of PCBs showed strong, significant positive

associations with ox-LDL, and significant negative associations with glutathione-related markers (GSSG and GSSG/GSH)

• A number of POPs (PCB-99, 138, 153, 156, 170, 180, 194, 206 and 209) showed strong significant positive association with ox-LDL

Kumar J, et al. Influence of persistent organic pollutants on oxidative stress in population-based samples. Chemosphere. 2014;114:303-309.

WBC and PCB and OCP Exposure

Serdar B, et al. Potential effects of polychlorinated biphenyls (PCBs) and selected organochlorine pesticides (OCPs) on immune cells and blood biochemistry measures: a cross-sectional assessment of the NHANES 2003-2004 data. Environ Health. 2014;13:114.

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WBC• Strong inverse correlation with PCBs and OCPs and CBC

• Linear with almost all PCBs

• High variability with OCPs

• Within “normal” range!

Solvents Decrease Platelet Count• Compared workers exposed 2.3 hr/day to those

exposed most of day to toluene• All wore face masks and protective gear• Platelet count 14% lower: 252 versus 216/ml• Impairment of sympathetic nerves (OR = 4.13)• Impairment of peripheral nerves (OR = 6.94)• Positive relationship between neurological

abnormalities and a self-reported neuropsychiatric measurement (r = 0.35-0.66)

Shih HT, et al. Subclinical abnormalities in workers with continuous low‐level toluene exposure. Toxicol Ind Health. 2011 Sep;27(8):691‐9

Insightful 23-Year Prospective Study1. < 50, there is no difference

between those with the lowest and highest PCBs

2. In youngest group, insulin production increases in response to toxin level As expected since blocking of

insulin receptor sites by PCBs requires more insulin

3. That adaptive ability decreases with aging

4. At age 50, all the measures show very strong toxin-dose response.

Cumulative damage impairs ability to adapt

Suarez‐Lopez JR, et al. Persistent organic pollutants in young adults and changes in glucose related metabolism over a 23‐year follow‐up. Environ Res. 2015 Feb;137:485‐94

“Unconventional” Laboratory Tests• Challenge testing• Hair analysis• Direct measures of POPs in blood, urine,

adipose tissue

Evaluation of Metal Exposure – Provocation

• Provocation – the use of a chelating agent – before urine collection often done clinically, but several limitations No “official” reference range for provoked urine Most chelating agents do not extract metals from all tissues, thus

does not necessarily represent total body burden• Example: Brain is one of the main target organs for both elemental and organic

mercury, yet agents do not chelate brain mercury

• Despite limitations, widely used and advocated by clinicians, in part, to see efficacy of chelating agent as a guide to treatment, and based on empirical evidence

Rooney JP. The role of thiols, dithiols, nutritional factors and interacting ligands in the toxicology of mercury. Toxicology. 2007

Is Challenge Testing Valid?• Poor correlations of standard tests for mercury• Unpublished research from corporate wellness

project• Published amalgam number correlation• Published fish consumption correlation

What We Found In Canada

• Deviations from the mean of 14%, 29% and 91% respectively

• DMPS is spreading distribution, suggesting that it is better at differentiating mercury body load

• Some VERY high

Hg Assessment Correlations• Extensive measurements in 65

Whole blood Hg Oral DMPS challenge Amalgam surfaces

• Correlations Whole blood w pre urine: r = 0.40 Whole blood w post urine: r = 0.57 Pre urine w post urine: r = 0.68 Amalgams w pre urine: r = 0.26 Amalgams w whole blood: r = 0.36 Amalgams with post urine: 0.44

• Clear documentation that challenge testing is better

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Modest Correlation with # of Fillings

• Very large study• Surprisingly only

reported none versus 1 or more fillings

• Huge overlap!• Not controlled for fish

consumption

Dutton DJ, et al. The association between amalgam dental surfaces and urinary mercury levels in a sample of Albertans, a prevalence study. J Occup Med Toxicol. 2013;8(1):22

Strong Correlation with Fish Consumption

• Compared 0 to 1-2 to 3 or more servings per week

• First urine showed essentially no differentiation

• Challenge testing showed clear correlation

• Still a lot of variation

Ruha AM, et al. Urine mercury excretion following meso-dimercaptosuccinic acid challenge in fish eaters. Arch Pathol Lab Med. 2009;133(1):87-92.

Cadmium

• Blood cadmium - a marker of current exposure but may also reflect body burden from long-term retention of cadmium in the liver and kidney Assessed as whole blood

• Urinary cadmium is thought to more specifically be a marker of cumulative exposure

Järup L, Akesson A. et al. Current status of cadmium as an environmental health problem. Toxicol Appl Pharmacol. 2009 Aug 1;238(3):201-8.

Arsenic Evaluation • Blood arsenic not a good marker for long term exposure

• May not be a sensitive marker for acute exposure

• Urinary arsenic used as a marker for acute exposure Variety of arsenic compounds in urine, may reflect toxicity

• Urinary levels also used for chronic exposure, but may only be relevant if exposure has stayed constant (and still present)

• Other tissues (hair, nails) may reflect chronic exposure Hair & toenails do reflect past exposure, but susceptible to external contamination

and lack standard ranges

Orloff K, et al. Biomonitoring for environmental exposures to arsenic. J Toxicol Environ Health B Crit Rev. 2009 Aug;12(7):509-24.

Toxic Metal Assessment Recommendation• Acute exposure

First morning urine• Body load

300 mg DMPS (Hg) + 500 mg DMSA (Pb,Hg, Cd)

6 hour collection

• 50 yo Japanese man• Smoked and ate a lot

of sushi• Did not follow advice• Cancer 2 years later

POPs – Laboratory Tests• Urine, blood, adipose tissue and breath• Can be directly measured, but expensive and only a

few of the about 100 most important of the thousands in the environment

Directly Measure POPs and Solvents

Monitoring -- 8-OHdG• Oxidized nucleoside • Direct measure of

DNA damage• Indirect measure of

oxidative stress and toxin load

• Correlates with: Multiple cancers Mitochondrial damage Rate of aging Smoking Etc.

8-OHdG Correlates with Pack-Years of Smoking

Yano T, et al. Significance of the urinary 8-OHdG level as an oxidative stress marker in lung cancer patients. Lung Cancer. 2009 Jan;63(1):111-4

8-OHdG Correlates with Mercury

Chen C, et al. Increased oxidative DNA damage, as assessed by urinary 8-hydroxy-2'-deoxyguanosine concentrations, and serum redox status in persons exposed to mercury. Clin Chem. 2005 Apr;51(4):759-67

Summary AssessmentBody chemical load: GGT: > 25 Uric acid: > 5.0 mg/dl ALT: >30 U/L Biirubin: >0.8 mg/dl CBC: < 6,000 Platelet: < 250,000

Total/Monitor: 8-OHdG: >4

Metal body load: First urine for current

exposure Cd (?), Hg, Pb:

• Oral:• DMPS: 300 mg• DMSA: 500 mg

• Collect urine for 6 hours

As: hair or nails Cd: urine