Saturday, April 26, 2008

No Man is an Island

Thallium poisoning with skin manifestations

Presented by Professor Khalifa Sharquie
Baghdad, Iraq

History: A few weeks ago, an outbreak of thallium poisoning occurred in Baghdad and all of the patients had positive tests for thallium. We had the opportunity to see cases with skin manifestations. All patients gave a history of eating cakes and presented to hospital with nausea, vomiting followed by mental and peripheral neurological complaints. The case I am presenting was that of a 30 yo adult male referred to me two weeks after poisoning. He had severe hair loss, both diffuse and patchy, affecting mainly scalp and body hair. Also he had a non-pruritic rash affecting the face, limbs and groins.

O/E: The striking findings were severe anagen hair loss, diffuse and in patches. The hairs were easily plucked and microscopically were typical anagen phase. The next important finding was dermatitis-like picture that covered the face especially around the mouth and the limbs mainly on the dorsae of both hands. The groins had intertrigo simulating tinea cruris. The rash was dusky red and ecchymotic in appearance.

Photographs:





This picture was strange enough to make one think about the following Differential Diagnosis:
Acquired zinc deficiency
Pellagra
Erythema multiforme
But only suspicion can lead you into right diagnosis. Accordingly, before the definite diagnosis was established, we gave oral zinc sulfate 100mg 3 times a day for some patients. Surprisingly they recovered and resolved.

Reason Presented: Thallium is nice rat poison since it is colorless, tasteless and odourless. It can be used as massive lethal chemical weapon and is practiced this way in Iraq as a way to kill people. It is my opinion that thallium should be prohibited and considered as a chemical weapon like nitrogen mustard. It is better to let rats run free than to kill human beings.

Reference:
A good article on this subject appeared in the Archives of Dermatology in January, 2007. Short-term thallium intoxication: dermatological findings correlated with thallium concentration.
Arch Dermatol. 2007 Jan;143(1):93-8
.

Lu CI, Huang CC, Chang YC, Tsai YT, Kuo HC, Chuang YH, Shih TS.
Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan.
One can view this free online: Arch Dermatol article

Comment: John Donne wrote: "All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated....No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

Our Western civilization began in the Fertile Crescent. Iraq was at the epicenter. The strory told here diminishes all of us. Professor Sharquie bravely bears witness as he helps and serves his people.

4 comments:

  1. samer A dhaherApril 27, 2008

    I would like to express my great thanks to prof. sharquie for this valuable observation..about 2 months ago an outbreak of greatly suspected thallium poisoning was observed in Basra, southern Iraq.. they were all boys came to the hospital complaining of sudden onset of fever, joint pain & anagen hair loss.. all patients reported eating cooked rice in Ashoora feasts..I then asked the local health authority & toxicology center to trace for thallium in these cases..On follow up of many of these cases complete recovery was achieved after treatment with zn sulphate orally.. It remained to be answered what had been reported in basra was related in some way or another to the current cases..as prof. sharquie comment some try to use thallium to kill Iraqi people.. samer A dhaher..Basra .Iraq

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  2. Thank you for sharing your experiences with us. This is an important observation so that we are aware of this condition. I noticed most of the thallium poisoning cases in Iraq are from food contamination. There was apparently another case of thallium poisoning in February 2008 where members of Iraqi air force club and some of their children were poisoned by cake laced with thallium. Two of the children died. (Ref: Poison cake kills Iraqi children, news.bbc.co.uk, February 9, 2008.) The successful treatment with oral zinc for the skin manifestation is remarkable. Wonder if the patients were treated also with oral activated charcoal and Prussian Blue too?

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  3. DR.KHALIL AL HAMDIMay 06, 2008

    Thanks a lot for prof. sharquie who brought our attention to this valuable observation.Two days ago i saw a newly married women who lost her nice hair with two of her sisters after ingesting cake also.All patients showed purpuric rash that affected mostly the face ,buttock &limbs look like that of zink diffency associated with arthraligia and anagen hair loss.I think that these cases are also due to thallium poisioning silimar to cases of prof. sharquie so i gave them zinc sulphate & i hope that this poor lady &her sisters will be better.

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  4. Abbas Naji AlshammariMay 09, 2008

    Nice presentation and good lesson. what is the role of zinc in thallium toxication? does high serum thallium result in acute zinc deficiency?. If so please evaluate serum level of both elements otherwise it has a healing and regenerating effect upon damaged targets which seemed wonderful.

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