Hypothyroidism, Perchlorate/toxicity

Environmental Medicine Update

Perchlorate Toxicity- The Curious Case of a 10-Year-Old Boy

Marianne Marchese, ND

Introduction

Perchlorate is a chemical used in fireworks, road flares, explosives, gun powder, adhesives, batteries, and rocket fuel. In the past it was in fertilizer used for tobacco and was used as a medication to treat an over-reactive thyroid gland. It also forms naturally in the environment in some area of the country like western Texas. Perchlorates can also form naturally in the atmosphere, leading to trace levels of perchlorate in precipitation. It can be found in both ground and surface water and the soil. Perchlorates are colorless salts that have no odor. There are five perchlorate salts that are manufactured in large amounts: magnesium perchlorate, potassium perchlorate, ammonium perchlorate, sodium perchlorate, and lithium perchlorate.^1,2 Most people are exposed to perchlorate through food, drinking water, bleach, before and after watching a firework show or lighting off fireworks at home, living near factories that make fireworks and explosive devices, using certain cleaning products and pool chemicals, and through chewing tobacco.^1,2

Food and water are the main sources of exposure, and it can be found in breast milk. In 2005-2006, the FDA’s Total Diet Study revealed that 74% of the 208 foods analyzed had at least one detected perchlorate.¹ Cow milk products, eggs, fruit and dark green vegetables account for most of the food exposure.² Drinking water and water used in agriculture is another common source of exposure. In an analysis of drinking water samples from 3,262 residences of National Health and Nutrition Survey (NHANES) subjects, perchlorates were identified in 83% of samples.² The current California regulatory standard for perchlorate in water is 6 ppb or ug/L. This standard is based on evidence from a human intervention trial linking perchlorate to decreases in iodide uptake into the thyroid gland and hypothyroidism.

In August 2019 the EPA proposed to establish a maximum contaminant level (MCL) and a health-based maximum contaminant level at 56 ppb. The proposed safe level published by the EPA under the Obama administration was 15 ppb, much lower than the current EPA MCL recommended amount.³ Since there is no federal acceptable level of perchlorate in the drinking water, it is up to the states to monitor and set maximum contaminant levels. Only a few states have done so, and the levels vary considerably. California and Massachusetts have set the perchlorate MCL at 6 ug/L and 2 ug/L respectively based on research linking that level of exposure to thyroid disease. The following states have set a public health goal: Arizona at 14, New York at 5, Maryland at 1, New Mexico at 1, New Hampshire at 1. Three states have set an enforceable action levels: New York 18, Nevada 18, Texas 4. This means if the action level is exceeded, the water treatment company is obliged to take appropriate action to reduce the concentration below action level.⁴

Perchlorate is rapidly eliminated from the body through the urine with half-times of approximately 8-12 hours in humans. So, one might conclude it can’t be detected in the body with such a short half-life. However, recent studies have shown widespread exposure to low levels of perchlorate by the general population, detected via urine test. In almost 2700 participants of the NHANES national survey, the geometric mean in urine was 2.63 ug/L and 3.04 ug/L creatine corrected. Urine is the best method of testing, but it might be detectable for only a few days after exposure because it leaves the body so rapidly. This makes testing difficult to capture the exposure.

The health effects of perchlorate are mainly on the thyroid gland where it inhibits iodine uptake leading to hypothyroidism. It may also affect brain development and cause birth defects and developmental delays.^­5,6 It is especially a concern for pregnant women unknowingly exposed through the drinking water as perchlorate is passed in utero affecting fetal health. ^5,6 The Agency for Toxic Substances and Disease Registry cite thyroid as the main organ affected by perchlorate exposure as well as hematological, renal, and hepatic effects in humans from oral exposure.⁷

Given the widespread exposure to perchlorate through drinking water and food sources, the prevalence of hypothyroidism, and recent urine studies showing large scale exposure to perchlorate, doctors and other health care providers may want to start screening patients for exposure. It is important to educate patients on avoidance and know how to mitigate the health effects of perchlorate. The following case example highlights perchlorate testing and treatment options.

Case Example

In April of 2019, a 10-year-old boy developed left side, unilateral areola swelling. His mother, a physician, and his pediatrician did a thorough exam and found no mass or breast bud development, no dermatological changes to the area, no signs of an infection, and no lymph node swelling. The area was tender with palpation compared to the right areola, but otherwise it did not hurt. There was no preceding trauma or injury; however, he is an active boy and could have easily bumped the area. Two years prior he had the exact same symptom, left areola swelling. At that time, he was seven years old; and he went to his pediatrician had a complete exam and blood work-up that included CBC, CMP, TSH, FT4, FT3, iron, ferritin, prolactin, FSH, LH, SHBG, testosterone and estradiol. All the tests were normal for a seven-year-old boy and after three-to-four months the symptom eventually self-resolved without any treatment.

Now at age 10 he once again developed the same areola swelling and as stated above was examined by both his pediatrician and mother who is a physician. He is 80-85% for his height, 60-65% for his weight and physical exam was unremarkable. He eats a primarily organic diet, including some meat and dairy, and is gluten free. He eats organic fruits and vegetables daily, and on school days drinks veggie/fruit/protein smoothie with his breakfast. The drinking and cooking water were filtered with reverse osmosis, which can remove perchlorate, and there is a whole house carbon water filter in place. Basic lab tests were all normal and included CBC, CMP, TSH, FT4, FT3, iodine, estradiol, and ESR. An in-depth environmental medicine history revealed household mold exposure for years (from age 4-7). The mold exposure was a slow leak in a bathroom with visible mold. This was remediated in 2017. On February 24, 2019, prior to the onset of the symptom, the patient had a mycotoxin test done, which was negative.

Since the basic labs and exam were normal and this was the second time this symptom had appeared, toxin profiles and immune profiles were ordered to look for potential environmental sources of hormone modulation. A May 19, 2019, organic acid test was normal, and a toxicant panel test revealed a perchlorate level of 152 ug/g creatine. Based on the NHANES reference ranges listed above for this age group, anything above 15 ug/g creatine is in the 95% percentile. His urine level was extremely elevated. Although it is not known for perchlorate to cause areolar swelling, it was the only test that came back positive. Perchlorate is a known hormone disruptor mostly affecting thyroid function, yet this patient’s thyroid function at this time was normal.

Given the very high level of perchlorate in his urine, we looked for a source of exposure and started treatment to mitigate the effects of perchlorate exposure. The initial treatment consisted of avoiding the unfiltered water at his school and taking three supplements: cholestyramine for past mold exposure, a supplement that provided cofactors to support liver phase one and two metabolic reactions, and an herbal product to cleanse the liver and gall bladder that consisted of milk thistle, beet root, dandelion, burdock and artichoke. The cofactor support product contained vitamin A, vitamin D3, vitamin K1, vitamin B1, vitamin B2, vitamin B3, vitamin B5, vitamin B6, vitamin B12 (as methylcobalamine), vitamin C, vitamin E, biotin, folate (5-methyl-tetrahydrofolate), calcium, chromium, copper, iodine, magnesium, manganese, molybdenum, potassium, selenium, zinc, choline, inositol, boron, vanadium, green tea extract, and turmeric.

In terms of a source of perchlorate exposure, he mostly eats organic, does not use bleach, was not around fireworks and his home water is filtered with reverse osmosis. He was drinking the water at school which was unfiltered. Due to several factors it took four months for the water to be tested. A home and school water test were run through National Testing laboratory September 2019 and both were normal. The water at home was reverse osmosis and perchlorate was normal at less than 0.05 ug/l. The water at school was unfiltered and was 0.91 ug/l. These levels are well below even the strictest minimal acceptable level in Massachusetts of 2 ug/l.

After avoiding the water at school and taking the three supplements, he repeated the urine perchlorate test on October 8, 2019; and the perchlorate level dropped to 4.8 ug/g creatine. This is within the NHANES normal reference range of 50% for his age group. But at what level we see health effects remains an area for further investigation. Some studies indicate anything over the 50% percentile will over time lower iodine and lead to thyroid disease.⁸ Of course, this patient never had thyroid disease, he had left areola swelling, which resolved by August 2019.

Discussion

This was the first patient I had encountered with elevated perchlorate levels; 152 ug/g creatine is well above all labs reference ranges and NHANES percentiles. This case was challenging because the patient did not have a known source of exposure. Food and water are the most common sources of perchlorate exposure. Both his home and school water were tested and within the normal acceptable levels. Since both water tests were done four months after discovering the elevated urine level, it is theorized that he was exposed to perchlorate through the unfiltered water at school in early 2019 but not captured on the testing done months later. It is the only possible source of exposure.

Another interesting part of this case is the patient’s thyroid hormones and iodine levels were normal and his presenting symptom, areola swelling, is not a known common effect of perchlorate. However, in animal studies perchlorate exposure from food and water does cause breast gland dysplasia and other histopathological lesions in the mammary gland.⁹ Other studies do show that absorbed perchlorate, regardless of the route of exposure, will distribute to the breast tissue and mammary epithelium. Perchlorate is also detected in human breast milk showing an affinity for breast tissue deposition.⁹ Therefore it is theorized that the very high level of perchlorate in the urine of this nine-year boy, 152 ug/g creatine, may have created breast areola swelling. After three-to-four months of avoiding the unfiltered drinking water at school and taking the three supplements described above, the urine perchlorate level was normal, 4.8, and the areola swelling resolved.

Summary

Perchlorate is a hormone-disrupting toxicant that is often overlooked by doctors and health care providers. It is a common contaminate in water and food, and people are exposed to it on a daily basis at low levels. Over time, it is known to disrupt thyroid function and is linked to fetal brain development and other health effects. It is important to educate patients and the public on avoidance and know how to mitigate the health effects of perchlorate.

Bio

Dr. Marianne Marchese is the author of the bestselling book, 8 Weeks to Women’s Wellness, about the environmental links to women’s health and detoxification. She maintains private practice in Phoenix, Arizona, and is adjunct faculty at SCNM, teaching both environmental medicine and gynecology. She served on the State of Arizona Naturopathic Physicians Medical Board

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National Association of Environmental Medicine, Arizona Naturopathic Medical Association, and Council on Naturopathic Medical Education. She lectures throughout the US and Canada on women’s health, environmental, and integrative medicine topics. Dr. Marchese recently helped develop three supplements for Priority One Vitamins. www.drmarchese.com

References

1. Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Perchlorates. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Services. www.atsdr.cdc.gov. Accessed Dec 16 2019.

2. Steinmaus CM. Perchlorate in water supplies: sources, exposures, and health effects. Curr Environ Health Rep. 2016 Jun;3(2):136-43.

3. Environmental Working Group. Trump EPA Sets Tap Water Limit for Rocket Fuel Chemical 3X Higher Than Agency Scientists Recommend. https://www.ewg.org/release/trump-epa-sets-tap-water-limit-rocket-fuel-chemical-3x-higher-agency-scientists-recommend. Accessed Dec 17 2019.

4. Water Quality Association. Perchlorate Fact Sheet. Lisle, IL 2013. https://www.wqa.org/Portals/0/Technical/Technical%20Fact%20Sheets/2016_Perchlorate.pdf. Accessed Dec 17 2019.

5. Steinmaus C, Miller MD, Smith AH. Perchlorate in drinking water during pregnancy and neonatal thyroid hormone levels in California. Occup Environ Med. 2010 Dec;52(12):1217-24.

6. Maffini MV, Trasande L, Neltner TG, Perchlorate and Diet: Human Exposures, Risks, and Mitigation Strategies. Curr Environ Health Rep. 2016 Jun;3(2):107-17

7. https://www.atsdr.cdc.gov/ToxProfiles/tp162-c3.pdf

8. Blount BC, at al. Perchlorate and thyroid hormone levels in adolescent and adult men and women living in the United States. Environ Health Perspect. 2006;114(12):1865–1871.

9. Agency for Toxic Substances and Disease Registry (ATSDR). Health Effects of Perchlorates. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Services. www.atsdr.cdc.gov. Accessed Jan 5, 2020.