105 J Pak Med Assoc Abstract Chronic Arsenic Toxicity may have varied clinical presentations ranging from non-cancerous manifestations to malignancy of skin and different internal organs. Dermal lesions such as hyper pigmentation and hyperkeratosis, predominantly over palms and soles are diagnostic of Chronic Arsenicosis. We report two cases from a family living in Sukkur who presented with classical skin lesions described in Chronic Arsenicosis. The urine, nail and hair samples of these patients contained markedly elevated levels of arsenic. Also the water samples from their household and the neighbouring households were found to have alarming levels of inorganic Arsenic. Introduction Chronic Arsenic Poisoning can result from chronic exposure to high levels of Arsenic (As) in the air, food or water. However most cases result from consuming water with toxic levels of Arsenic. Arsenic toxicity impacts on the entire body but some clinical features are pathognomic e.g skin hyper pigmentation and classical hyperkeratosis of palms and soles. Clinical features of Chronic Arsenicosis are highly variable and depend on the levels and duration of As exposure as well as the degree of host susceptibility. We describe two cases in a family from Sukkur comprising of nine family members in whom Arsenic toxicity was confirmed by the presence of markedly elevated Arsenic content in their hair and nail samples. Case 1: An 18 year old carpenter, resident of Sukkur, was admitted with progressive weakness and numbness of all four limbs for 3 months. There was no urinary or faecal incontinence, headache, visual problems, memory loss or fits. This was associated with brownish, non-itchy, painless, scaly lesions over palms and soles (Fig-1). Patient had significant weight loss and was bed bound for 2 months. There were no other respiratory or gastrointestinal symptoms. The patient's mother had died a few months back and was not reported to have a similar illness. His father who was also admitted at the same time suffered from a similar illness with similar skin lesions and pattern of weakness. Two of his five sisters, of ages 8 and 12 respectively, had also developed similar skin lesions in the previous 2 to 3 months. Two brothers were reported to be normal. This family lived in a single room house where they had made "traditional wooden beds". They worked with wood and paints but did not use any wood preservatives. On examination, the patient was wasted and anaemic and had grayish-brown scaly lesions over his palms and soles with hyper pigmentation on the skin of the neck and abdomen His trunk had rain drop hypo pigmented skin lesions anteriorly. He had reduced bulk, power and tone in all limbs with absent reflexes. There was glove and stocking pattern loss of all sensations up to elbows and mid thigh. Higher mental function and cranial nerves were intact. Rest of the examination was unremarkable. The investigations revealed haemoglobin of 10 g%, MCV 89.7 fl, ESR 55 mm/hr, normal WBC, platelets and urea, creatinine and electrolytes. LFTs showed total biluribin 0.9 mg/dl, GGT 89 mg/dl, SGPT 103 mg/dl, alkaline phosphatase 937 mg/dl, total proteins 7.6 mg/dl, albumin 3.9 mg/dl, PT/INR normal. Chest X-ray was normal, Ultrasound showed altered texture of liver parenchyma with mild hepatomegaly. Liver biopsy showed mild hepatitis with patchy parenchymal inflammation. Nerve conduction studies showed demyelinating sensory motor neuropathy in the limbs. Pulmonary function test showed mixed restrictive and obstructive pattern. Case Report Chronic Arsenic Poisoning Tasnim Ahsan, 1 Kaneez Zehra, 2 Alia Munshi, 3 Samiah Ahsan 4 Medical Unit II, Jinnah Postgraduate Medical Centre, 1,2 Centre of Environmental Studies, Pesir, 3 Pathology Lab, OMI, 4 Karachi. Brownish, scaly lesion on the sole.