Extremely high urine arsenic level after remote seafood ingestion

Urine testing for heavy metal concentrations is increasingly performed in the outpatient setting as a part of laboratory evaluation for neuropathy. Abnormal urine arsenic levels due to dietary intake of organic arsenic can lead to unnecessary chelation therapy. A 54-year-old man underwent a 24-hour urine collection for heavy metal concentrations in evaluation of paresthesia of the right foot. The total arsenic level was 8880 μg/d with concentrations of 4749 μg/L and 3769 μg/g creatinine. He was urgently referred to the toxicology clinic for consideration of chelation therapy. History revealed consumption of 2 lobster tails 5 days before the testing. Speciation was then performed on the original urine specimen and revealed an organic arsenic concentration of 4332 μg/L. No inorganic or methylated arsenic was detected. Repeat testing after abstaining from seafood demonstrated a total arsenic level of 50 μg/d with concentrations of 30 μg/L and 21 μg/g creatinine. Our patient demonstrates the highest level of arsenobetaine reported in the literature, and this level is higher than expected for a person who had not consumed seafood for 5 days before testing. The high levels may be due to consumption of food that he did not recognize as containing arsenobetaine or that his clearance of arsenobetaine from the ingested lobster is slower than published ranges. This case demonstrates the importance of speciation when measuring urine arsenic levels to avoid unnecessary chelation therapy.