Objective: To describe the clinical features of a patient with selenium toxicity after ingesting Total Body Formula Peach Nectar liquid supplement with a selenium formulation error.

Case Report: A 55-year-old woman presented with a 6-week history of diarrhea followed by progressive hair loss 2 weeks later. The hair loss began on her head in a diffuse symmetrical distribution and progressed to her axillae, genitalia, and extremities. She also reported generalized muscle cramps, joint pain, fatigue, and difficulty with concentration. A week before the onset of diarrhea, she received the liquid supplement that she shared with her husband. The supplement’s stated ingredients included multiple vitamins and trace minerals and elements, including selenium.

On physical examination, the patient had alopecia throughout her body and Mees lines on her fingernails (Figure). Her serum selenium level was markedly elevated at 534 µg/L (6.76 µmol/L) (reference range, 80 to 150 µg/L [1.02 to 1.91 µmol/L]). Her spot urinary selenium level was also elevated at 220 µg/L (2.79 µmol/L) (reference range, <150 µg/L [<1.91 µmol/L]) (Quest Diagnostics, Madison, New Jersey). The patient’s husband had similar but less severe clinical and laboratory findings.

View larger version (89K): [in this window] [in a new window]   Figure. Hair and nail manifestations of selenium toxicity. A. The patient’s hair loss occurred in a diffuse and symmetrical distribution. B. Mees lines were present on her fingernails.

The nutritional supplement claimed a selenium content of 7.33 µg/mL (92.83 µmol/L). Analysis of this product found the actual selenium level to be 800.50 µg/mL (10 140 µmol/L) (Industrial Analytical Services, Leominster, Massachusetts). Given the patient’s intake of 30 mL/d of this supplement, her daily selenium intake was approximately 24 015 µg (304.14 µmol). This is more than 400 times the U.S. recommended daily allowance of 55 µg (0.70 µmol). Analysis of the supplement also found an elevated chromium level of 58.8 µg/mL (1.13 µmol/L) instead of the intended 6.67 µg/mL (0.13 µmol/L). The patient did not have any clinical manifestations of chromium toxicity, such as gastrointestinal hemorrhage, pancreatitis, hemolysis, or renal failure.

Discussion: Although natural sources of selenium, such as meats, grains, plants, and nuts, provide enough selenium to meet daily nutritional requirements (3), the number of persons who supplement their diets with products containing selenium continues to grow. Selenocysteine residues are important to the function of the antioxidant enzymes thioredoxin reductase and glutathione peroxidase (4). Perhaps as a result of research into selenium as an antioxidant adjuvant in treating coronary artery disease and various types of cancer, the nutritional supplement industry markets selenium for a wide array of medical ailments, and selenium is a component of many nutritional supplements.

A consequence of unregulated use of selenium-containing supplements is selenium toxicity. Primary toxicity (selenosis) is diagnosed infrequently and information regarding its long-term health effects is limited. Pathophysiologic mechanisms to explain the clinical manifestations of selenium toxicity have not been fully elucidated. Hair loss has been attributed to the disruption of structural proteins in keratin; it is thought that selenium interpolates into disulfide bridges, causing a structural weakness that leads to hair loss (5). Other manifestations of selenosis, including nausea, vomiting, fatigue, irritability, and paresthesias, are similar to those associated with arsenic and other metal toxicities; however, direct biochemical pathways have yet to be identified.

Conclusion: An error in the formulation of a selenium-containing nutritional supplement led to an outbreak of selenium toxicity in the United States, which manifested as diarrhea, hair loss, and fingernail changes in our patient. Physicians must consider the use of supplements, as with any medication, in the evaluation of their patients.