A Fatal Case of Thallium Toxicity: Challenges in Management

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.

Thallium

“…Use of colorimetric analyses of these specimens can lead to false positives (CDC, 1987). Prussian Blue is the treatment of choice for Tl exposure, in that it acts by binding Tl in the gastrointestinal tract, making it unavailable for reabsorption (Altagracia-Martínez et al, 2012;Sun et al, 2012;Riyaz et al, 2013). Treatment should be initiated when 24 h urinary Tl excretion exceeds 0.5 mg. Additionally, a toxic level of Tl in the urine of >300 μg/L has been suggested (Sullivan, 1992).…”

Metallothionein alone or in combination with Prussian blue attenuates acute thallium systemic toxicity in rats.

“…Rat Tl LD 50 is about 30-32 mg/Kg, while human LD 50 of thallium has been estimated to be 10 mg/kg, lower than As, Hg, Pb and Cu. human poisoning around the world, because the rat poison was not collected from human communities for its destruction [11,12]. Since 2012 to 2017 it has been reported acute Tl poisoning in China, Mexico and Japan with at least 25 patients involved [13][14][15][16].…”

“…Cases of intoxication manifest gastrointestinal signs and symptoms (diarrhea and vomiting), dermatologic alterations (alopecia, eruptions of the face, Mee´s stripes in nails, eczematous lesions, anhidrosis, palmar erythema, stomatitis, and painful glossitis), cardiac (tachycardia and hypotension) and neurological dysfunctions (Disorientation, lethargy, ataxia, convulsion, psychosis, insomnia and coma) [2,14,17]. In severe cases of intoxication, individuals died less than a week after thallium ingestion [12,15,18].…”

Chelation of Thallium (III) in Rats Using Combined Deferasirox and Deferiprone Therapy

“…Their study focused on the protective and antioxidant effects of diallyl sulfide and curcumin against thallium-induced liver injury and oxidative stress in rats ( 8 ). Additionally, recently, Riyaz et al reported an interesting case involving a suicidal patient treated for thallium toxicity using the antidote Prussian Blue ( 9 ).…”