QUESTION: I have a 53 yo F patient who is ANA+ (homogeneous pattern – associated with SLE, drug induced SLE and connective tissue diseases), with progressively increasing liver enzymes (ALT and GGT > 200 U/L most recently), and a normal liver biopsy. CRP < 3 mg/l, rheumatoid factor wnl, and protein electrophoresis wnl. The gastroenterologist is ‘done with her’ and sees no problem with the trend in liver enzymes, but has recommended a rheumatologist. No polyarthritis, fever, or malar rash; however does report some fatigue. Urine toxic metals showed a significant elevation in bismuth (provocated with DMSA 500mg, DMPS 300mg). I’m thinking the source may be hair dye as she is a hairdresser – she is not a pepto bismol abuser. From what I’ve read, bismuth is thought to have a 5 day half-life but can accumulate in the liver and kidneys. Is bismuth a contributor here? Or is it just a red herring? Basically I’m wondering what your approach might be for this case.
ANSWER: In hair dressers the toxicity is epic regardless of testing, and the chemicals and mito damage are always 10X what metals are.
