Copper toxicity

Copperiedus

A Kayser-Fleischer ring, copper deposits found in the cornea, is an indication the body is not metabolizing copper properly.
Classification and external resources
Specialty emergency medicine
ICD-10 T56.4
ICD-9-CM 985.8
MedlinePlus 002496

Copper toxicity, also called copperiedus, refers to the consequences of an excess of copper in the body. Copperiedus can occur from eating acid foods cooked in uncoated copper cookware, or from exposure to excess copper in drinking water or other environmental sources.

Representation in ICD-9-CM, ICD-10-CM and SNOMED-CT

ICD-9-CM 985.8 Toxic effect of other specified metals

ICD-9-CM code 985.8 Toxic effect of other specified metals includes acute & chronic copper poisoning (or other toxic effect) whether intentional, accidental, industrial etc.

ICD-10-CM

Header text code term
T56.4X1D Toxic effect of copper and its compounds, accidental (unintentional), subsequent encounter
T56.4X1S Toxic effect of copper and its compounds, accidental (unintentional), sequela
T56.4X2D Toxic effect of copper and its compounds, intentional self-harm, subsequent encounter
T56.4X2S Toxic effect of copper and its compounds, intentional self-harm, sequela
T56.4X3D Toxic effect of copper and its compounds, assault, subsequent encounter
T56.4X3S Toxic effect of copper and its compounds, assault, sequela
T56.4X4D Toxic effect of copper and its compounds, undetermined, subsequent encounter
T56.4X4S Toxic effect of copper and its compounds, undetermined, sequela

SNOMED-CT 46655005 Copper poisoning (disorder)

concept id term
46655005 Copper
43098002 Copper fever
49443005 Phytogenous chronic copper poisoning
50288007 Chronic copper poisoning
73475009 Hepatogenous chronic copper poisoning
875001 Chalcosis of eye
90632001 Acute copper poisoning

Toxicity

Copper in the blood and blood stream exists in two forms: bound to ceruloplasmin (85–95%), and the rest "free", loosely bound to albumin and small molecules. Free copper normally reduces oxidative stress, as it is involved in the metabolic elimination of reactive oxygen species, such as with the superoxide radical through Cu-Zn dependent superoxide dismutase.[1] Excessive free copper impairs zinc homeostasis, and vice versa, which in turn impairs antioxidant enzyme function, increasing oxidative stress.[1] Chronically elevated levels of copper intake produces zinc deficiency.[1]

Nutritionally, there is a distinct difference between organic and inorganic copper, according to whether the copper ion is bound to an organic ligand.[2][3] Organic copper, like that found in food, is a beneficial micronutrient needed for good health.[4] Inorganic metallic copper, like that found in electrical wire, plumbing pipes, brass fittings, redox water filters, sheet metal, cooking utensils, jewelry and pennies, is a neurotoxic heavy metal linked to physical and psychiatric symptoms on par with mercury and lead.[5][6][7][8]

Symptoms and presentation

Acute symptoms of copper poisoning by ingestion include vomiting, hematemesis (vomiting of blood), hypotension (low blood pressure), melena (black "tarry" feces), coma, jaundice (yellowish pigmentation of the skin), and gastrointestinal distress.[9] Individuals with glucose-6-phosphate deficiency may be at increased risk of hematologic effects of copper.[9] Hemolytic anemia resulting from the treatment of burns with copper compounds is infrequent.[9]

Chronic (long-term) effects of copper exposure can damage the liver and kidneys.[10] Mammals have efficient mechanisms to regulate copper stores such that they are generally protected from excess dietary copper levels.[10][11]

Those same protection mechanisms can cause milder symptoms, which are often misdiagnosed as psychiatric disorders. There is a lot of research going on regarding the function of the Cu/Zn ratio in many conditions, neurological, endocrinological and psychological.[12][13][14] The diagnostic difficulties arise from the fact that many of the substances that protect us from excess copper perform important functions in our neurological and endocrine systems. When they are used to bind copper in the plasma, to prevent it from being absorbed in the tissues, their own function may go unfulfilled. Such symptoms often include mood swings, irritability, depression, fatigue, excitation, difficulty focusing, feeling out of control, etc. To further complicate diagnosis, some symptoms of excess copper are similar to those of a copper deficit.

The U.S. Environmental Protection Agency's Maximum Contaminant Level (MCL) in drinking water is 1.3 milligrams per liter.[9][15] The MCL for copper is based on the expectation that a lifetime of consuming copper in water at this level is without adverse effect (gastrointestinal). The US EPA lists copper as a micronutrient and a toxin.[16] Toxicity in mammals includes a wide range of animals and effects such as liver cirrhosis, necrosis in kidneys and the brain, gastrointestinal distress, lesions, low blood pressure, and fetal mortality.[17][18][19] The Occupational Safety and Health Administration (OSHA) has set a limit of 0.1 mg/m3 for copper fumes (vapor generated from heating copper) and 1 mg/m3 for copper dusts (fine metallic copper particles) and mists (aerosol of soluble copper) in workroom air during an eight-hour work shift, 40-hour work week.[20] Toxicity to other species of plants and animals is noted to varying levels.[16]

EPA cancer data

The EPA lists no evidence for human cancer incidence connected with copper, and lists animal evidence linking copper to cancer as "inadequate". Two studies in mice have shown no increased incidence of cancer. One of these used regular injections of copper compounds, including cupric oxide. One study of two strains of mice fed copper compounds found a varying increased incidence of reticulum cell sarcoma in males of one strain, but not the other (there was a slightly increased incidence in females of both strains). These results have not been repeated.[21]

Treatment

In cases of suspected copper poisoning, penicillamine is the drug of choice, and dimercaprol, a heavy metal chelating agent, is often administered. Vinegar is not recommended to be given, as it assists in solubilizing insoluble copper salts. The inflammatory symptoms are to be treated on general principles, as are the nervous ones.

There is some evidence that alpha-lipoic acid (ALA) may work as a milder chelator of tissue-bound copper.[22] Alpha lipoic acid is also being researched for chelating other heavy metals, such as mercury.[23]

Cookware

When acidic foods are cooked in unlined copper cookware, or in lined cookware where the lining has worn through, toxic amounts of copper can leach into the foods being cooked.[24] This effect is exacerbated if the copper has corroded, creating reactive salts.[25] Actual cooking may not be required for copper to leach into acidic liquids if they are stored in copper for a period of time.[26]

Non-sparking tools

OSHA has set safety standards for grinding and sharpening copper and copper alloy tools, which are often used in nonsparking applications. These standards are recorded in the Code of Federal Regulations 29 CFR 1910.134 and 1910.1000.[27]

Note: The most important nonsparking copper alloy is beryllium copper, and can lead to beryllium poisoning.

Drinking water

With an LD50 of 30 mg/kg in rats, "gram quantities" of copper sulfate are potentially lethal in humans.[28] The suggested safe level of copper in drinking water for humans varies depending on the source, but tends to be pegged at 2.0 mg/l.[29]

Birth Control

Estrogen birth control pills and copper intrauterine devices are known to increase the amount of copper in humans.[30] Estrogen increases the absorption of copper, making women more likely to carry excess copper even when no birth control is used.

The amount of estrogen (or copper) contained in these modern forms of contraception are generally considered safe, and the former restrictions for estrogen use (not to be used by women older than 40, 35 for smokers) were lifted in 1989.

There are conditions in which an individual's copper metabolism is compromised to such an extent that birth control may cause an issue with copper accumulation. They include toxicity or just increased copper from other sources, as well as the increased copper level of the individual's mother via the placenta before birth.[31] The two hormones commonly used in birth control, estrogen and progestin, protect from each other's complications, so a combination method may work best. At least when existing imbalances have been treated.

Pathophysiology

A significant portion of the toxicity of copper comes from its ability to accept and donate single electrons as it changes oxidation state. This catalyzes the production of very reactive radical ions, such as hydroxyl radical in a manner similar to Fenton chemistry.[32] This catalytic activity of copper is used by the enzymes with which it is associated, thus is only toxic when unsequestered and unmediated. This increase in unmediated reactive radicals is generally termed oxidative stress, and is an active area of research in a variety of diseases where copper may play an important but more subtle role than in acute toxicity.

Some of the effects of aging may be associated with excess copper.[33]

Indian childhood cirrhosis

One manifestation of copper toxicity, cirrhosis of the liver in children (Indian childhood cirrhosis), has been linked to boiling milk in copper cookware. The Merck Manual states recent studies suggest that a genetic defect is associated with this particular cirrhosis.[34]

Wilson's disease

An inherited condition called Wilson's disease causes the body to retain copper, since it is not excreted by the liver into the bile. This disease, if untreated, can lead to brain and liver damage, and bis-choline tetrathiomolybdate is under investigation as a therapy against Wilson's disease.

Alzheimer’s disease

Elevated free copper levels exist in Alzheimer's disease,[35] which has been hypothesized to be linked to inorganic copper consumption.[36] Copper and zinc are known to bind to amyloid beta proteins in Alzheimer's disease.[37] This bound form is thought to mediate the production of reactive oxygen species in the brain.[38]

Aquatic life

Too much copper in water may damage marine and freshwater organisms such as fish and molluscs.[39] Fish species vary in their sensitivity to copper, with the LD50 for 96-h exposure to copper sulphate reported to be in the order of 58 mg per litre for Tilapia (Oreochromis niloticus) and 70 mg per litre for catfish (Clarias gariepinus) [40] The chronic effect of sublethal concentrations of copper on fish and other creatures is damage to gills, liver, kidneys and the nervous system. It also interferes with the sense of smell in fish, thus preventing them from choosing good mates or finding their way to mating areas.[41]

Bacteria

Copper and copper alloys such as brass have been found to be toxic to bacteria via the oligodynamic effect. The exact mechanism of action is unknown, but common to other heavy metals. Viruses are less susceptible to this effect than bacteria. Associated applications include the use of brass doorknobs in hospitals, which have been found to self-disinfect after eight hours, and mineral sanitizers, in which copper can act as an algicide. Overuse of copper sulfate as an algicide has been speculated to have caused a copper poisoning epidemic on Great Palm Island in 1979.[42]

References

  1. 1 2 3 Sandstead HH (1995). "Requirements and toxicity of essential trace elements, illustrated by zinc and copper". Am. J. Clin. Nutr. 61 (3 Suppl): 621S–624S. PMID 7879727.
  2. ↑ Batley, G. E., & Florence, T. M. (1976). Determination of the chemical forms of dissolved cadmium, lead and copper in seawater. Marine Chemistry, 4(4), 347-363.
  3. ↑ Van Den Berg, C. M. (1984). Organic and inorganic speciation of copper in the Irish Sea. Marine Chemistry, 14(3), 201-212.
  4. ↑ "Copper Toxicity". Retrieved 2015-11-24.
  5. ↑ "The Copper Toxicity Epidemic: Top 10 Health Conditions, Strategies & Solutions". Retrieved 2015-11-23.
  6. ↑ "Copper Toxicity Syndrome". Retrieved 2015-11-23.
  7. ↑ "Copper Toxicity". Analytical Research Labs. Retrieved 2015-11-24.
  8. ↑ Pfeiffer, Carl C. (1987). Nutrition and Mental Illness. Rochester, Vt.: Healing Arts Press.
  9. 1 2 3 4 Casarett & Doull's Toxicology, The Basic Science of Poisons, Fifth Edition, Edited by Curtis D. Klassen, Ph.D., McGraw-Hill, New York. pp 715.
  10. 1 2 Copper: Health Information Summary, Environmental Fact Sheet. New Hampshire Department of Environmental Services,ARD-EHP-9 2005, Available Online at: http://des.nh.gov/organization/commissioner/pip/factsheets/ard/documents/ard-ehp-9.pdf
  11. ↑ "Function and Regulation of Human Copper-Transporting ATPases". Physiological Reviews. Retrieved 20 December 2015.
  12. ↑ "Role of copper in human neurological disorders". American Society for Clinical Nutrition 2008. Retrieved 20 December 2015.
  13. ↑ "Treatment of Mood Lability and Explosive Rage with Minerals and Vitamins: Two Case Studies in Children". Journal of Child and Adolescent Psychopharmacology 2002. Retrieved 20 December 2015.
  14. ↑ "The plasma zinc/serum copper ratio as a biomarker in children with autism spectrum disorders". Taylor & Francis 2009. Retrieved 20 December 2015.
  15. ↑ Federal Register / Vol. 65, No. 8 / Wednesday, January 12, 2000 / Rules and Regulations. pp. 1976.
  16. 1 2 US EPA Region 5 (2011-12-28). "Ecological Toxicity Information". US EPA. Retrieved 17 June 2015.
  17. ↑ "Toxicological Profile for Copper". Agency for Toxic Substances and Disease Registry, U.S. Department of Health and Human Services. Retrieved 17 June 2015.
  18. ↑ Kabata-Pendias, Alina (2011). "Trace Elements in Soils and Plants, Fourth Edition". Taylor and Francis Group. Retrieved 17 June 2015.
  19. ↑ Ware, George W. (1983). Pesticides: Theory and application. New York: W.H. Freeman.
  20. ↑ Occupational Safety and Health Administration, U.S. Department of Labor, Copper, Available Online at: https://www.osha.gov/SLTC/metalsheavy/copper.html
  21. ↑ EPA results for copper and cancer. Accessed March 11, 2011
  22. ↑ "Comparison of the effect of α-lipoic acid and α-tocopherol supplementation on measures of oxidative stress". Elsevier, Free Radical Biology and Medicine 1999. Retrieved 20 December 2015.
  23. ↑ "Mercury toxicity and antioxidants: part I: role of glutathione and alpha-lipoic acid in the treatment of mercury toxicity. (Mercury Toxicity).". Thorne Research Inc. 2002. Retrieved 20 December 2015.
  24. ↑ "The Safe Use of Cookware". Health Canada. Retrieved 2009-04-30.
  25. ↑ "Cookware retinning and Copper Repair". Retrieved 2009-04-30.
  26. ↑ http://www.foodscience.csiro.au/fshbull/fshbull20f.htm
  27. ↑ "Occupational Safety and Health Standards". Retrieved 2012-09-18.
  28. ↑ "Pesticide Information Profile for Copper Sulfate". Cornell University. Retrieved 2008-07-10.
  29. ↑ http://www.opsi.gov.uk/si/si2000/20003184.htm#30
  30. ↑ "Effects of age and sex on copper absorption, biological half-life, and status in humans". The American Society for Clinical Nutrition, Inc. Retrieved 2015-12-20.
  31. ↑ "Copper and iron transport across the placenta: regulation and interactions". Journal of neuroendocrinology 2008. Retrieved 2015-12-20.
  32. ↑ Held KD; et al. (May 1996). "Role of Fenton chemistry in thiol-induced toxicity and apoptosis". Radiat Res. (Radiation Research Society) 145 (5): 542–53. doi:10.2307/3579272. JSTOR 3579272. PMID 8619019.
  33. ↑ Brewer GJ (February 2007). "Iron and copper toxicity in diseases of aging, particularly atherosclerosis and Alzheimer's disease". Exp. Biol. Med. (Maywood) 232 (2): 323–35. PMID 17259340.
  34. ↑ "Merck Manuals -- Online Medical Library: Copper". Merck. November 2005. Retrieved 2008-07-19.
  35. ↑ Brewer GJ. (2010). Copper toxicity in the general population. Clin Neurophysiol. 2010 Apr;121(4):459-60. doi:10.1016/j.clinph.2009.12.015 PMID 20071223
  36. ↑ Brewer GJ (June 2009). "The risk of copper toxicity contributing to cognitive decline in the aging population and to Alzheimer's disease". J. Am. Coll. Nutr. 28 (3): 238–42. PMID 20150596.
  37. ↑ Faller P (2009-12-14). "Copper and zinc binding to amyloid-beta: coordination, dynamics, aggregation, reactivity and metal-ion transfer". Chembiochem 10 (18): 2837–45. doi:10.1002/cbic.200900321. PMID 19877000.
  38. ↑ Hureau C, Faller P (October 2009). "Abeta-mediated ROS production by Cu ions: structural insights, mechanisms and relevance to Alzheimer's disease". Biochimie 91 (10): 1212–7. doi:10.1016/j.biochi.2009.03.013. PMID 19332103.
  39. ↑ Van Genderen EJ, Ryan AC, Tomasso JR, Klaine SJ (February 2005). "Evaluation of acute copper toxicity to larval fathead minnows (Pimephales promelas) in soft surface waters". Environ. Toxicol. Chem. 24 (2): 408–14. doi:10.1897/03-494.1. PMID 15720002.
  40. ↑ Ezeonyejiaku, CD, Obiakor, MO and Ezenwelu, CO (2011). "Toxicity of copper sulphate and behavioural locomotor response of tilapia (Oreochromis niloticus) and catfish (Clarias gariepinus) species.". Online J. Anim. Feed Res. 1 (4): 130–134.
  41. ↑ C. A. Flemming and J. T. Trevors (1989). "Copper toxicity and chemistry in the environment: a review". Water, Air, & Soil Pollution 44 (1-2): 143–158. doi:10.1007/BF00228784.
  42. ↑ Prociv P (September 2004). "Algal toxins or copper poisoning--revisiting the Palm Island "epidemic"". Med. J. Aust. 181 (6): 344. PMID 15377259.
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