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.

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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.

Stumped...

Abstract: 60 yo man with unusual cutaneous ulcers and erosions
Presented by Dr. Hamish Dunwoodie, Moncton, New Brunswick
HPI: The patient is a disabled physician's assistant who injured his scalp on a low basement ceiling beam around a year ago. When he was first seen he had a thick escar over the area. This was debrided and cultured. It grew Staph aureus with the usual sensitivities and he was treated with wet compresses, dicloxacillin and bactroban ointment. Since his initial visit 4 months back it has not gotten smaller and now the central portion reaches the calvarium. Over the past six weeks, he has developed similar lesions on shoulders and upper back. By history these began at sites of ECG leads.

Pertinent medical history is positive for insulin-dependent diabetes, hypertension and coronary artery disease. His medications include insulin, warfarin, enalapril, furosemide, ASA, oxycodone.

O/E: 3 cm ulcer mid parietal area of scalp. Erosions on both shoulders, surface somewhat escharotic. Some with irregular borders.

Photos:


4 months later








Lab: Occasional skin cultures positive for S. aureus (not MRSA), CBC shows mild normochromic normocytic anemia. (Hct 32.6.Hgb 11.2).

Pathology: "Ulceration with scar. No evidence of malignancy." Repeat biopsy April 18, 2008 from new lesion on shoulder send to Canadian National Pathology Lab.

Diagnosis: Non-healing erosions etiology unclear. One always considers factitial disease in health care professionals with atypical skin lesions and this man also has free access to needles as a diabetic. In a year, the scalp lesion has shown no tendency to improve.

Further Treatment: He was treated with topical corticosteroids in case this was erosive pustular dermatitis of the scalp (no response) and imiquimod in case erosion might have been hypergranulation tissue. (no response) We ordered Duoderm dressings, but they were too expensive for the patient.

Questions: Where would you go from here? Diagnostic and therapeutic suggestions.

A Leg to Stand On

Abstract: 85 yo man with cellulitis and lymphedema s/p bypass surgery

HPI: In 2000, this retired professor had CABG surgery with saphenous vein harvesting of the left leg, In 2002, while visiting Vienna, he was hospitalized for cellulitis of the left leg and treated with i.v. antibiotics. In the subsequent years, he has had progressive lymphedema of the left leg with the development of elephiantiasis nostra verrucosa. In the past 6 months he has had four documented episodes of cellulitis which have necessitated antibiotics. Recently, he has developed a generalized dermatitis. His medications include: atenolol, amiodarone, digoxin, diovan, thyrpid, Coumadin, Lovastatin, ASA. He has a possible allergy to penicillin (has not taken it in 40 years). He is otherwise quite healthy and intellectually alert.

O/E: Chronic lymphedema left leg with erythema, scale and some honey-colored crust. The leg in involved from just below the knee to the foot. The left leg is only minimally warmer than the right leg. In addition, he has a wide-spread dermatitis consisting of erythematous scaly patches on legs, arms and abdomen -- sparing the face.

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Lab: His internist did a skin culture and CBC b efore sending him here (results not back) . He was on Bactrim at the time of the culture.

Diagnosis: Recurrent Cellulitis s/p saphenous veif harvesting wit the development of chronic lymphedema and early elephiantiasis nostras. This was reported in 1982 (see Reference). The wide-spread dermatitis may be an "id" reaction.

Questions:
1) What has been learned about this entity since 1982?
2) Should he be rechallenged with penicillin and kept on long-term antibiotic prophylaxis.
3) What role does "hypersensitivity" to bacterial exotoxins play in the dermatitis.
4) Does anyone have magic for cases such as this?
5) Allergic contact dermatitis will be ruled out by patch testing.

Comment: My plan at the moment is to "clean up" any residual infection, consider prophylactic antibiotics and work on the dermatitis. I will refer him to a lymphedema center, if possible, for evaluation. Aggressive management of his leg swelling will help. He was told not to bathe the leg and I think this sets him up for infection. Your thoughts will be greatly appreciated. This man's life revolves around his leg. He is a keen student, a political scientist and in his later years he must focus exclusively on a leg. Let's give him "a leg to stand on!"

Follow-up: The patient was treated with compression stockings, cephalexin 250 mg qid for two weeks (based on sensitivities), desoximetasone 0.25% cream and lymphatic massage. There was no evidence of tinea pedis. He has improved markedly.
Photos taken June 10, 2008





Reference:

Recurrent cellulitis after saphenous venectomy for coronary bypass surgery.
Baddour LM, Bisno AL.
Ann Intern Med. 1982 Oct;97(4):493-6.

We describe a previously unreported complication of coronary artery bypass
grafting, recurrent cellulitis. Five patients had 20 episodes of acute
cellulitis, each occurring in the lower extremity in which saphenous venectomy
had been done. The cases were striking because the patients presented with high
fever and considerable systemic toxicity. The appearance of the lesions, presence
in one case of obvious associated lymphangitis, and prompt response in three
instances to therapy with penicillin alone all suggest group A streptococcal
infection. In one case, a beta-hemolytic, bacitracin-susceptible Streptococcus
strain was isolated from the lesion. The pathogenesis of this syndrome remains
obscure but, based on our understanding of postsurgical erysipelas, this
cellulitis likely results from the interplay of several factors, including local
compromise of lymphatic drainage, direct bacterial invasion, and acquired
hypersensitivity to streptococcal exotoxins.

Recurrent Cheilitis in a 37 yo Woman

Abstract: 37 yo woman with 18 year recurrent cheilitis

HPI: This 37 yo woman has had recurrent cheilitis for 18 – 20 years. She works as a medical assistant. At one time, she was thought to be latex sensitive because blowing up balloons makes her feel sick, but a RAST test was negative. The episodes last five to six days. The day before the present episode she had eaten a “Mediterranean Dip” which included cucumber, garlic, feta, tomato, and horseradish. She noted nothing till the next morning when there was mild erythema of upper lip. She may have a history of mild atopic dermatitis. She can recall no meds she took before this or other episodes.

O/E: Erythema and mild crusting of lips and adjacent glabrous skin. Remainder of exam normal. Occasionally she’ll have mild erythema around outer canthi.

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Lab/Path: N/A

Diagnosis: ? Allergic Cheilitis. Role of Foods? Doubt Fixed Drug Eruption. To me this looks like an allergic contact cheilitis.

Questions: What would be the best way to work this up? This woman has 3 - 4 episodes per year, so it is unlikely that her cheilitis is related to something whe uses daily, and she does not recall anything she applies only intermittently.

Reference:
Allergic contact cheilitis in the United Kingdom: a retrospective study.
Strauss RM, Orton DI.
Am J Contact Dermat. 2003 Jun;14(2):75-7.

Abstract: Environmental and Contact Dermatitis Unit, Amersham Hospital, Whielden Street,
Amersham, Buckinghamshire, HP7 0JD, United Kingdom. strauss@strauss.karoo.co.uk

BACKGROUND: To date, only a few cohorts of patients with allergic cheilitis have
been described, most of them from Australia and Asia. OBJECTIVE: To establish the
prevalence of cheilitis in a UK specialist contact dermatitis clinic and to
identify the most common allergens. METHOD: We analyzed our patch-test database
in a tertiary referral center in the United Kingdom, retrospectively. All
patients presenting with cheilitis over a 19-year period (1982 to 2001) were
included. RESULTS: Data were available from a total of 146 patients. A positive
allergic patch-test reaction was thought to be relevant in 15% of the patients (n
= 22) and to be of possible relevance in 6.8% (n = 10). Of the 22 patients with
relevant allergic results, 95% (n = 21) were women. The most common allergens
included fragrance mix (mainly cinnamaldehyde, oak moss, and isoeugenol) in 41%
of patients, shellac in 18%, colophony in 18%, and Myroxylon pereirae in 14%. For
half of the patients, the allergen was believed to stem from lipsticks or lip
products. Eighteen percent of patients with allergic cheilitis reacted to only
their own products. CONCLUSIONS: Patients should be tested to extended
lipstick/cosmetic vehicle series in addition to standard series. As a significant
percentage of patients react to their own products only, a thorough clinical
history and testing to patients' own products are important.