Abstract
Background
Thallium is a highly toxic compound and is occasionally involved in intentional overdoses or criminal poisonings. Accidental poisonings also occur, but are increasingly rare owing to restricted use and availability of thallium. We report a fatal suicidal ingestion of thallium sulfate rodenticide in which multi-dose activated charcoal (MDAC) and Prussian Blue (PB) were both used without changing the outcome.
Case report
A 36 year old man ingested an unknown amount of thallium sulfate grains from an old rodenticide bottle. He presented to an emergency department (ED) 45 minutes later with abdominal pain and vomiting. On examination he was agitated with a blood pressure of 141/60 mmHg and a heart rate of 146 beats per minute (bpm). He received MDAC during his initial ED management and was started on PB 18 hours post arrival; he was intubated on the following day for airway protection. The patient continued to be tachycardic and hypertensive and subsequently developed renal failure. On hospital day three, the patient developed hypotension that did not respond to fluids. The patient required vasopressors and was transferred to a tertiary care center to undergo continuous renal replacement therapy (CRRT). The patient died shortly after his transfer. His last blood thallium concentration was 5369 mcg/L, a spot urine thallium >2000 mcg/L, and a 24- hour urine thallium was >2000 mcg/L.
Conclusion
Though extremely rare, thallium intoxication can be lethal despite early administration of MDAC and use of Prussian blue therapy. Rapid initiation of hemodialysis can be considered in cases of severe thallium poisoning, to remove additional thallium, to correct acid-base disturbance, or to improve renal function.
References
Lamy, Claude-Auguste (1862) "De l'èxistence d'un nouveau métal, le thallium". Comptes Rendus LIV:1255–1339
Chamberlain PH, Stavinoha WB, Davis H et al (1958) Thallium poisoning. Pediatrics 22:1170–1182
Munch, J.C.: Human thallitoxicosis (1934) J.A.M.A., 102:1929-1934
Moore D, House I, Dixon A (1993) Thallium poisoning. Diagnosis may be elusive but alopecia is the clue. BMJ 306(6891):1527–1529, PubMed CrossRef ChemPort
National Poison Data System: Annual reports 1983–2008. Alexandria (VA): American Association of Poison Control Centers; [2010 Oct 1]. Retrieved May 11, 2011,www.aapcc.org. fromhttp://www.aapcc.org/dnn/NPDSPoisonData/NPDSAnnualReports.aspx
Hoffman Robert S, Mercurio-Zappala Maria (2006) "Chapter 96. Thallium" (Chapter). Lewis S. Nelson, Neal A. Lewin, Mary Ann Howland, Robert S. Hoffman, Lewis R. Goldfrank, Neal E. Flomenbaum: Goldfrank's toxicologic emergencies, eighth edition. United States of America: McGraw-Hill Companies, pp. 1364-1372
Melnick RL, Monti LG, Motzkin SM (1976) Uncoupling of mitochondrial oxidative phosphorylation by thallium. Biochem Biophys Res Commun 69:68–73
Misra UK, Kalita J, Yadav RK, Ranjan P (2003) Thallium poisoning: emphasis on early diagnosis and response to haemodialysis. Postgrad Med J 79:103–105
De Groot G, van Heijst AN (1988) Toxicokinetic aspects of thallium poisoning. Methods of treatment by toxin elimination. Sci Total Environ 71:411–418
Prick JJG, Sillevis Smitt WG, Muller L (1955) Thallium poisoning. Elsevier Publ. Co, Amsterdam, pp 1–155
Rios C, Monroy-Noyola A (1992) d-Penicillamine and Prussian blue as antidotes against thallium intoxication in rats. Toxicology 74:69–76
Hoffman RS (2003) Thallium toxicity and the role of Prussian blue in therapy. Toxicol Rev 22:29–40
Mulkey JP, Oehme FW (1993) A review of thallium toxicity. Vet Hum Toxicol 35:445–453
Wainwright AP, Kox WJ, House IM et al (1988) Clinical features and therapy of acute thallium poisoning. Q J Med 69:939–944
Malbrain ML, Lambrecht GL, Zandijk E, Demedts PA, Neels HM, Lambert W, De Leenheer AP, Lins RL, Daelemans R (1997) Treatment of severe thallium intoxication. J Toxicol Clin Toxicol 35(1):97–100
Aoyama H, Yoshida M, Yamamura Y (1986) Acute poisoning by intentional ingestion of thallous malonate. Hum Toxicol 5:389–392
Stevens W, van Peteghem C, Heyndrickx A, Barbier F (1974) Eleven cases of thallium intoxication treated with Prussian blue. Int J Clin Pharmacol Ther Toxicol 10:1–22
Pedersen RS, Olesen AS, Freund LG et al (1978) Thallium intoxication treated with long-term hemodialysis, forced diuresis and Prussian blue. Acta Med Scan 204:429–432
Piazolo P, Franz HE, Buch W, Wald D, Wilk G (1971) Behand-lung der Thalliumvergiftung mit der Htimodialyse. Dtsch Med Wochenschr 96:1217
Loewe H, Ellmans P, Winter R, Wiessman B, Koch R, Schiller M (1972) Thallium Elimination'durch Htimodialyse in Vergleich zur grossen Diurese bei einer schweren Thalliumintoxication. Med Welt 23:1411
Barckow J, Inss H (1976) Thalliumvergiftgung. Med Klin 71:1377
Fawzi Al H, Ghaleb D, Anas S, Raed Abu G (2011) Acute thallium poisoning: series of ten cases. J Med Toxicol 7(4):306–311
Dart RC, Borron SW, Caravati EM, Cobaugh DJ, Curry SC (2009) Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med 54(3):386–394
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Riyaz, R., Pandalai, S.L., Schwartz, M. et al. A Fatal Case of Thallium Toxicity: Challenges in Management. J. Med. Toxicol. 9, 75–78 (2013). https://doi.org/10.1007/s13181-012-0251-1
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DOI: https://doi.org/10.1007/s13181-012-0251-1