Management of thallium poisoning in patients with delayed hospital admission

Thallium-induced DNA damage, genetic, and epigenetic alterations

Thallium (Tl) is a toxic heavy metal responsible for noxious effects in living organisms. As a pollutant, Tl can be found in the environment at high concentrations, especially in industrial areas. Systemic toxicity induced by this toxic metal can affect cell metabolism, including redox alterations, mitochondrial dysfunction, and activation of apoptotic signaling pathways. Recent focus on Tl toxicity has been devoted to the characterization of its effects at the nuclear level, with emphasis on DNA, which, in turn, may be responsible for cytogenetic damage, mutations, and epigenetic changes. In this work, we review and discuss past and recent evidence on the toxic effects of Tl at the systemic level and its effects on DNA. We also address Tl's role in cancer and its control.

Plasma Thallium Concentration, Kidney Function, Nephrotoxicity and Graft Failure in Kidney Transplant Recipients

The nephrotoxic effects of heavy metals have gained increasing scientific attention in the past years. Recent studies suggest that heavy metals, including cadmium, lead, and arsenic, are detrimental to kidney transplant recipients (KTR) even at circulating concentrations within the normal range, posing an increased risk for graft failure. Thallium is another highly toxic heavy metal, yet the potential consequences of the circulating thallium concentrations in KTR are unclear. We measured plasma thallium concentrations in 672 stable KTR enrolled in the prospective TransplantLines Food and Nutrition Biobank and Cohort Study using inductively coupled plasma mass spectrometry. In cross-sectional analyses, plasma thallium concentrations were positively associated with kidney function measures and hemoglobin. We observed no associations of thallium concentration with proteinuria or markers of tubular damage. In prospective analyses, we observed no association of plasma thallium with graft failure and mortality during a median follow-up of 5.4 [interquartile range: 4.8 to 6.1] years. In conclusion, in contrast with other heavy metals such as lead, cadmium, and arsenic, there is no evidence of tubular damage or thallium nephrotoxicity for the range of circulating thallium concentrations observed in this study. This is further evidenced by the absence of associations of plasma thallium with graft failure and mortality in KTR.

Repeated poisoning of the life partner by thallium - a case of questionable Munchausen by adult proxy syndrome with ensuing attempted murder

After the use of thallium as rat poison was banned, the knowledge about the severe and treacherous course of poisonings with this toxic metal has widely been lost. In the present case, the male victim sustained two insidious poisoning attacks in 2017 and 2020 by the perpetrator, his female life partner. In the first poisoning episode, he suffered from increasing heavy pain of the abdomen, stinging pain of both legs, persistent obstipation, hyperesthesia, and, after about 2 weeks, tuft-wise loss of hair as typical symptoms of the thallium poisoning. Within 7 weeks, he was successively examined in six hospitals with a wide variety of diagnostic methods, but a conclusive explanation of the complaints was not found. The possibility of a metal intoxication was then suggested by the perpetrator who privately arranged the analysis of a blood sample with the result of 175 µg/l thallium. Although a criminal poisoning was assumed, the perpetrator was not identified. After the victim left the perpetrator, she subtly executed a second poisoning attack with thallium sulfate (blood level 1230 µg/l after 1 day, urine level 4760 µg/l after 10 days, and hair concentrations 3.26-0.49 from proximal to distal in 9 segments). The perpetrator was sentenced to 10.5 years imprisonment for grievous bodily harm and attempted murder. Because of the behavior of the perpetrator, a Munchausen by proxy syndrome was discussed as a motivation of the first poisoning but was excluded by the psychiatric expert because of a missing antisocial personality disorder.

Method Validation for Determination of Thallium by Inductively Coupled Plasma Mass Spectrometry and Monitoring of Various Foods in South Korea

Thallium (Tl) is a rare element and one of the most harmful metals. This study validated an analytical method for determining Tl in foods by inductively coupled plasma mass spectrometry (ICP-MS) based on food matrices and calories. For six representative foods, the method's correlation coefficient (R2) was above 0.999, and the method limit of detection (MLOD) was 0.0070-0.0498 μg kg-1, with accuracy ranging from 82.06% to 119.81% and precision within 10%. We investigated 304 various foods in the South Korean market, including agricultural, fishery, livestock, and processed foods. Tl above the MLOD level was detected in 148 samples and was less than 10 μg kg-1 in 98% of the samples. Comparing the Tl concentrations among food groups revealed that fisheries and animal products had higher Tl contents than cereals and vegetables. Tl exposure via food intake did not exceed the health guidance level.

The acute systemic toxicity of thallium in rats produces oxidative stress: attenuation by metallothionein and Prussian blue

Thallium (TI) is one of the most toxic heavy metals. Human exposure to Tl occurs through contaminated drinking water and from there to food, a threat to health. Recently, environmental contamination by Tl has been reported in several countries, urging the need for studies to determine the impact of endogenous and exogenous mechanisms preventing thallium toxicity. The cytoprotective effect of metallothionein (MT), a protein with high capacity to chelate metals, at two doses (100 and 600 µg/rat), was tested. Prussian blue (PB) (50 mg/kg) was administered alone or in combination with MT. A dose of Tl (16mg/kg) was injected i.p. to Wistar rats. Antidotes were administered twice daily, starting 24h after Tl injection, for 4 days. Tl concentrations diminished in most organs (p < 0.05) by effect of PB, alone or in combination with MT, whereas MT alone decreased Tl concentrations in testis, spleen, lung and liver. Likewise, brain thallium also diminished (p < 0.05) by effect of PB and MT alone or in combination in most of the regions analyzed (p < 0.05). The greatest diminution of Tl was achieved when the antidotes were combined. Plasma markers of renal damage increased after Tl administration, while PB and MT, either alone or in combination, prevented the raise of those markers. Only MT increased the levels of reduced glutathione (GSH) in the kidney. Finally, increased Nrf2 was observed in liver and kidney, after treatment with MT alone or in combination with PB. Results showed that MT alone or in combination with PB is cytoprotective after thallium exposure.

Early diagnosis, treatment, and outcomes of five patients with acute thallium poisoning

BACKGROUND

Thallium poisoning is rare and difficult to recognize. Early diagnosis and treatment of thallium-poisoned patients are essential to prevent morbidity and mortality.

AIM

To evaluate the efficacy of treatments and outcomes of five patients with early diagnosis of acute thallium poisoning.

METHODS

Five patients who consumed a thallium-contaminated meal were hospitalized in succession, and underwent clinical examinations such as blood tests and electromyography tests. Urine and blood tests confirmed the diagnosis of thallotoxicosis, revealing the occurrence of food poisoning. All patients underwent detoxification treatment, including hemoperfusion (HP) and treatment with Prussian blue (PB). A 24-mo follow-up was performed to evaluate the long-term outcomes on the patients after discharge.

RESULTS

Initially, the patients presented with symptoms of acute thallium poisoning including hyperalgesia of the limbs and abdominalgia, which may differ from common peripheral neuropathy. Accompanying symptoms such as hepatic damage and alopecia were observed in all the patients, which further confirmed the diagnosis of poisoning. Treatment with chelating agents was ineffective, while HP and treatment with PB drastically decreased the thallium concentration in the urine and blood. With early diagnosis and intervention, four patients had a good prognosis and no permanent sequelae. One patient developed blindness and disability during the 24-mo follow-up period.

CONCLUSION

Identification of incident cluster and characteristic symptoms is extremely important for early diagnosis of acute thallium poisoning. HP plus PB is essential to improve the prognosis of thallium-poisoned patients.

Long-term misdiagnosis and neurologic outcomes of thallium poisoning: A case report and literature review

INTRODUCTION

Thallium poisoning is a rare occurrence. Therefore, thallium poisoning is easily misdiagnosed and is often accompanied by a series of serious sequelae and can even result in death in severe cases. Here, we report long-term follow-up of a case of a patient who was poisoned with thallium on two separate occasions.

METHODS

A 43-year-old man was initially misdiagnosed as gastroenteritis, diabetic peripheral neuropathy, and Guillain-Barré Syndrome (GBS) within 21 months. The correct diagnosis was confirmed by blood and urine thallium assays. After Prussian blue treatment, thallium was undetectable in the blood by day 60. Following this investigation, a criminal suspect confessed to two instances of adulterating thallium sulfate in the patient's beverage. A 6-year follow-up was performed after discharge, and a comprehensive literature was review.

RESULTS

We found that the original gastrointestinal symptoms, skin lesions, and hair loss were reversed and had recovered, except for residual neurologic damage, even with long-term rehabilitation.

DISCUSSION

Thallium intoxication may have been initially identified if neurologic symptoms had occurred concurrently with gastrointestinal and cutaneous symptoms. Neurologic damage represented the main sequelae of thallium poisoning in our present case report.

Determination of thallium(iii) ions by oxidative hydrolysis of rhodamine–hydroxamate

A colorimetric and turn-on type fluorescence Tl³⁺ signaling probe for the early screening of elevated urinary thallium levels in acute poisoning cases using a readily available smartphone was developed.

Clinical characteristics and treatment of thallium poisoning in patients with delayed admission in China

Thallium is highly toxic and its effects are cumulative. The clinical symptoms of thallium poisoning are non-specific, thereby delaying admission and treatment. This study aimed to summarize the clinical features and treatment experience of patients with delayed admission who experience thallium poisoning.We conducted a retrospective descriptive analysis of patients in our hospital from 2008 to 2018 who had thallium poisoning and experienced a delay in hospital admission. The time from symptom onset to admission was assessed. The patients were divided into 3 groups and descriptive analyses of their clinical characteristics, including basic patient information, symptoms, laboratory test results, examination findings, treatment methods, outcomes, and follow-up information, were conducted.A total of 34 patients with thallium poisoning were included: 8 were admitted to the hospital early or with mild delay, 9 had a moderate delay, and 17 had a severely delayed admission. The time from illness onset to admission was 13 (interquartile range, 7.5-26) days. Some patients with delayed admission had significant symptoms associated with central nervous system damage, and changes in magnetic resonance images and electroencephalograms were also noted. After admission, all patients received Prussian blue treatment, and some patients with relatively high blood concentration received blood purification treatments. Following treatment, the blood and urine thallium concentrations of all patients decreased significantly, and their symptoms were alleviated.Our results show that delayed patient admission in cases of thallium poisoning is associated with greater risk of central nervous system damage. Use of Prussian blue combined with blood purification treatments might improve patients' conditions.

Successful treatment of a patient with severe thallium poisoning in a coma using Prussian blue and plasma exchange: A case report

RATIONALE

This is the first reported severe thallium poisoning patient successfully treated with Prussian blue (PB) and plasma exchange (PE).

PATIENT CONCERNS

A 42-year-old woman in a coma owing to severe thallium poisoning was admitted to our department after day 44 of poisoning. At admission, blood and urine thallium concentrations were 380.0 and 2580.0 ng/mL, respectively.

DIAGNOSIS

The patient was diagnosed with toxic encephalopathy induced by thallium poisoning; in addition, she was also diagnosed with bilateral pneumonia, respiratory failure, moderate anemia, hypoproteinemia, and electrolyte imbalance based on her chest X-ray, blood gas analysis, Hb level, albumin levels, and serum electrolyte results.

INTERVENTIONS

The patient was intubated and treated with PB (6600 mg/d, 15 days in total) combined with PE (once daily, 5 days in total) as well as other symptomatic supportive care measures.

OUTCOMES

After treatments, her blood and urinary thallium concentrations gradually decreased and on the 13th day after admission, the blood thallium concentration decreased to 0 ng/mL. The oxygenation index gradually improved, meantime, the patient gradually regained consciousness, and on the 50th day of admission, the patient's consciousness reverted to a clear-headed state. The patient recovered mostly after 37 months of follow-up.

LESSONS

Through this case, we learned that the gradual reduction in blood and urine thallium concentration and the patient's improved condition is correlated with PB and PE treatment. For patients with severe thallium poisoning, this treatment method might be effective; but the exact curative effect is unconfirmed, requiring further research to verify.

Changes in thallium distribution in the scalp hair after an intoxication incident

In cases of criminal thallium poisoning, forensic investigation is required to identify the amount and time of thallium exposure. Usually, blood and urine thallium levels are respectively used as biomarkers. Additionally, hair has the unique potential to reveal retrospective information. Although several studies have attempted to clarify how thallium is distributed in hair after thallium poisoning, none have evaluated the time course of changing thallium distribution. We investigated changes in the distribution of thallium in hair at different time points after exposure in five criminal thallotoxicosis patients. Scalp hair samples were collected twice, at 2.6 and 4.2-4.5months after an exposure incident by police. Results of our segmented analysis, a considerable amount of thallium was detected in almost all hair sample segments. The thallium exposure date estimated from both hair sample collections matched the actual exposure date. We found that determination of thallium amounts in hair samples divided into consecutive segments provides valuable information about exposure period even if a considerable time passes after exposure. Moreover, when estimating the amount of thallium exposure from a scalp hair sample, it is necessary to pay sufficient attention to individual differences in its decrease from hair.

Alopecia and Associated Toxic Agents: A Systematic Review

Importance/Objective

There are a number of toxic agents that can cause alopecia. In this review we summarize the known substances that cause alopecia as one of the clinical signs of overdose or toxicity.

Evidence Review

A search was conducted using PubMed, EMBASE, and Cochrane for studies describing hair loss of any type as a result of exposure to or ingestion of a toxic agent. The search yielded 856 articles, with 47 studies included in this review.

Findings

Agents with the strongest evidence of association to alopecia include thallium, mercury, selenium, and colchicine. Agents with described incidents include boric acid, arsenic, vitamin A, botulinum toxin, Podostroma cornu-damae, and the synthetic opioid MT-45.

Conclusions and Relevance

Numerous toxic agents have been implicated in alopecia, and the strength of evidence behind each agent varies. Toxic levels of thallium and colchicine have long been established to cause alopecia, as compared to agents such as botulinum toxin A and synthetic recreational drugs which have less literature describing their links to alopecia and will need further investigation to characterize their relationships to hair loss. Knowledge of typical presentations of hair loss will aid in the development of a differential diagnosis for patients presenting with alopecia.

A Successfully Treated Case of Criminal Thallium Poisoning

Thallium was once commonly used as a household rodent or ant killer, but many countries have banned such use due to unintentional or criminal poisonings of humans. A common initial clinical manifestation of thallium poisoning is gastrointestinal symptoms followed by delayed onset of neurological symptoms and alopecia. These clinical characteristics can provide important diagnostic clues regarding thallium poisoning. Here, we report a 23-year-old woman who was poisoned by a business colleague when she unknowingly drank tea containing the toxic substance several times. The patient was treated with multi-dose activated charcoal with airway protection and Prussian blue.