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case_images: Specification of the T&AM used:Classification of drugs by country of origin. In addition to Ayurvedic medicine, Indian drugs also include other Indian preparations for which it is not certain whether they can be classified as Ayurvedic drugs. The Mexican folk remedies are known as Azarcon and Greta.
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case_images: Fig5
case_images: Obtaining of the medication:Who or where did the patients turn to in order to acquire T&AM? Some patients obtained the T&AM without medical consultation, buying it over the counter or from traders, ordering it over the Internet, or making it themselves. But even in cases of consultation, the designation of the person or institution consulted does not necessarily indicate the level of medical qualification.
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case_images: Fig6
case_images: The graphical representation of all subcategorical symptoms is shown in the Supplementary Figures S6A-S6K.
case_images: Overview of the metals with which the T&AM were contaminated in the available case reports. Some T&AM were contaminated with more than one metal. This graph provides only an overview of the metals present and does not indicate any information about the metal concentration. Not all metals were present in the same concentration. Some metals were only detected at low levels.
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case_images: Fig7
case_images: Intake reasons for T&AM by main categories, each of which includes several intake reasons. The following reasons for intake were the most common in each category: Skin diseases: acne, dermatitis, psoriasis; Gastrointestinal complaints: abdominal colic, indigestion; Metabolic diseases: diabetes; Pain control: back pain, angina pectoris; Neurological and (neuro)muscular diseases: developmental delay, seizures, weakness; Cardiovascular and blood diseases: hypertension, atherosclerosis prevention; Respiratory diseases: rhinitis
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case_images: Fig8
case_images: Average patient age for selected intake reasons:We divided the age of all patients who reported a reason for taking T&AM in a particular category by the number of patients in that category.
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case_images: Fig9
case_images: At older ages, typical age-related illnesses such as arthritis (o 53 years) and cardiovascular diseases (o 61.2 years) become more frequent reasons for taking T&AM (Fig. 9).
case_images: Sex- and age-related comparison of intake duration (A) and time from first use of T&AM to first symptoms of intoxication (latency, B) using box plots; 10A: the following patients were excluded from these box plots: patients with unknown or unclear intake duration (N = 65), and patients with only indirect intake (N = 2); 10B: the following patients were excluded from these box plots: patients with unknown latency period (N = 72), patients whose first symptoms appeared only after cessation of the medication (N = 7), patients with only indirect intake (N = 2), and asymptomatic patients (N = 19); there is no separate box plot for patients whose sex is unknown
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case_images: Fig10
case_images: Box plots were used to compare different groups of patients with regard to the duration of T&AM use (Fig. 10A). The time between the first intake of T&AM and the onset of symptoms varies widely (Fig. 10B).
case_images: Differences in the frequency of various symptoms depending on sex (A) and the metal ingested (B); 11A: patients with unknown sex were excluded from this figure; 11B: this figure includes only cases of lead or arsenic poisoning and excludes poisoning with other or multiple metals
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case_images: Fig11
case_images: Within each symptom category, we calculated how many men out of all male patients and how many women out of all female patients were affected by a symptom in that symptom category (Fig. 11A). Comparing lead and arsenic poisoning, it is noticeable that some symptoms are typical of poisoning with each metal (Fig. 11B).
case_images: BLL:Sex comparison (highest measured BLL and BLL measured at the last check-up); the following patients were excluded from these box plots: patients with unknown BLL (N = 7), and patients with unknown sex (N = 10); there is no separate box plot for patients whose sex is unknown; since the BLL refers only to lead, these box plots include only patients who consumed lead-contaminated T&AM
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case_images: Fig12
case_images: When the highest BLLs measured in males and females are compared using a box plot (Fig. 12), it shows that males have a higher mean BLL (4.24 mumol/l) than females (3.85 mumol/l). Due to the more severe course of the disease, men also required chelation therapy more often, but even after chelation, the average BLL was still higher in men (1.36 mumol/l) than in women (1.23 mumol/l, Fig. 12).
case_images: Relationship between normal and low hemoglobin levels by sex in the form of a line chart, where the orange line represents female patients and the blue line represents male patients. The gray line represents patients whose sex is unknown. The percentages indicate the number of patients with normal, low, or unknown Hb compared by sex.
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case_images: Fig13
case_images: Instead, more men (62.2%) than women (53.9%) had low Hb levels, suggesting that men are more likely to develop metal-associated anemia than women (Fig. 13). South Korea (Fig. S13).
case_images: Correlation between BLL and quantity of anemia and basophilic stippling. The patients' BLLs were first divided into 3 groups according to their level (in mumol/l). The percentages indicate how many patients in each BLL group were diagnosed with anemia and/or basophilic stippling in addition to an elevated BLL.
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case_images: Fig14
case_images: In the highest measured BLLs of 5.01 to 7.5 mumol/l, 81.3% were diagnosed with anemia and 53.1% had basophilic stippling (Fig. 14).
case_images: This bar chart shows the absolute number of chelating agents used. The blue bars represent the cases where only one chelator was used (either in one or more cycles), and the orange bars represent the cases where multiple chelators were used during the course of chelation therapy.
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case_images: Fig15
case_images: D-penicillamine were the most commonly used. Dimercaprol and Dimercapto-propanesulfonic acid (DMPS), on the other hand, were rarely used, and when they were, they were usually used in combination with other chelators (Fig. 15).
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