Thallium poisoning: Clinical observations through two outbreaks in Basrah

Abstract

Objectives: Thallium is one of the most suitable agents for criminal poisoning of human as it is tasteless and odorless. The aim of this study was to report clinical features of thallium poisoning in two outbreaks. Materials and methods: This case descriptive study was conducted in Basrah Teaching Hospital from January 2009 to February 2010, where a total of 32 patients with thallium poisoning were enrolled. At the first outbreak, poisoning occurred due to ingestion of cake, while the second outbreak was due to acci-dental ingestion of rat poisons. A detailed history was taken and complete clinical examination was per-formed. Thallium in urine was measured using the colorimetric method and was found as positive in all patients. Results: Thirty two patients were evaluated. The first outbreak included 17 patients (mean age 24 years), and the second outbreak included 15 patients (mean age15 years). Among both outbreaks the derma-tological findings were mainly hair loss in diffuse and patchy pattern affected the scalp and limbs. Also dusky ecchymotic red dermatitis like rash was observed on the face, especially perioral region and dor-sum of hands and legs. Neurologic manifestations, mainly of peripheral neuropathy, were seen in 50% patients of the second group. Patients erroneously had received zinc-sulphate before correct diagnosis. Thirty patients were improved and two died. Conclusion: Outbreak of thallium poisoning may be result of accidental ingestion or criminal purposes. It gives characteristic cutaneous, neurological and psychological features that can lead to the definite diag-nosis.

Keywords

• Thallium poisoning, clinical findings, diagnosis, outbreak, Basrah

Talyum zehirlenmesi: Basra\'daki iki salgın nedeniyle klinik gözlemler

Öz

Amaç: Talyum tatsız ve kokusuz olduğu için, kötü amaçlı zehirlemeler için en uygun maddelerden birisi-dir. Bu çalışamını amacı iki ayrı salgında ortaya çıkan talyum zehirlenmesi vakalarının klinik özelliklerini sunmaktır. Gereç ve yöntem: Bu tanımlayıcı vaka çalışmasına Ocak 2009- Şubat 2010 tarihleri arasında Basra Eği-tim Hastanesinde izlenen toplam 32 talyum zehirlenmeli hasta dahil edilmiştir. İlk salgında kek yeme so-nucu, ikinci salgında fare zehiri yeme sonucu zehirlenmeler oluştu. Tüm hastalardan ayrıntılı öykü alındı ve tam bir fizik muayene yapıldı. İdrarda talyum kolorimetrik yöntemle arandı ve tüm hastalarda pozitif bu-lundu. Bulgular: Toplam 32 hasta incelendi. İlk salgında yaş ortalaması 24 yıl olan 17 hasta, ikinci salgında yaş ortalaması 15 yıl olan 15 hasta izlendi. Her iki salgında da ana dermatolojik bulgu, saçlı deri ve ekstremiteleri tutan yamalı veya diffüz tarzda saç ve kıl kaybı idi. İlave olarak yüzde özellikle ağız etrafın-da ve el ve ayak sırtlarında kirli kırmızı ekimotik dermatit benzeri lezyonlar gözlendi. İlk salgında nörolojik bulgular oluşmadı fakat ikinci salgında hastaların %50\'sinde başlıca periferik nöropati şeklinde nörolojik bulgular gözlendi. Hastaların çoğu yanlış olarak çinko eksikliği tanısıyla oral çinko-sulfat tedavisi almıştı. Hastalardan 30\'u iyileşti, ikisi öldü. Sonuç: Talyum zehirlenmesi kazara alım veya suç amaçlı oluşabilir. Talyum zehirlenmesi karakteristik cilt, nörolojik ve psikolojik belirtilere yol açarak kesin tanı koydurur.

Anahtar Kelimeler

• Talyum zehirlenmesi, klinik bulgular, tanı, salgın, Basra

Kaynakça

1. John Peter AL, Viraraghavan T. Thallium: a review of pub- lic health and environmental concerns. Environment Inter- national 2005:31:493-501.
2. Desenclos JC, Wilder MH, Coppenger GW, Sherin K, Tiller R, Vanhook RM. Thallium poisoning: an outbreak in Flor- ida 1988. South Med J 1992;85:1203-1206.
3. Meggs WJ, Hoffman RS, Shin RD, Weisman RS, Gold- frank LR. Thallium poisoning from maliciously contami- nated food. J Toxicol Clin Toxicol 1994;32:723-730.
4. Galvan-Arzate S, Santamaria A. Thallium toxicity. Toxicol Lett 1998;99:1-13.
5. Baldwin DR, Marshall WJ. Heavy metal poisoning and its laboratory investigation. Annals of Clinical Biochemistry 1999;36:267-300.
6. Insley BM, Grufferman S, Ayliffe HE. Thallium poisoning in cocaine abusers. Am J Emerg Med 1986;4:545-548.
7. Moore D, House I, Dixon A. Thallium poisoning: diagnosis may be elusive but alopecia is the clue. BMJ 1993;306:1527-1529.
8. Rusyniak DE, Furbee RB, Kirk MA. Thallium and arsenic poisoning in a small Midwestern town. Ann Emerg Med 2002;39:307-311.

9. BBC News/Middle East/Poison cake kills Iraqi children (Iraqi http://news.bbc.co.uk/2/hi/middle_east/7237086.stm. Force Club).
10. Kuo HC, Huang CC, Tsai YT, Chu CC, Hsieh ST, Chu NS. Acute painful neuropathy in thallium poisoning. Neu- rology 2005;65:302-304.
11. Feldman J, Levisohn DR. Acute alopecia: clue to thallium toxicity. Pediatr Dermatol 1993;10:29-31.
12. Prick JJG. Thallium poisoning: Vinken DJ, Bruyn GW, eds. Handbook of clinical neurology: intoxications of the nervous system. North-Holland Pub Co., Amsterdam 1979;36:239–278.
13. Ching-I Lu, Chin-Chang H, Ya-Ching C, et al. Short-term Thallium Intoxication. Arch Dermatol 2007;143:93-98.
14. Sharquie KE. No man is an island, Thallium poisoning with skin manifestations. Virtual Grand Round in Derma- tology reality.html?showComment=1209569400000.