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

Table 1 Clinical symptoms of five patients with acute thallium poisoning

Patient No.	Age	Initial symptoms	Accompanying symptoms
			Hepatic damage	Alopecia	Coagulopathy	Central nervous symptoms
1	40	Dysesthesia of distal limbs with hyperalgesia, weakness of lower limbs	+	+ (10th day)	+ (11th day-16th day)	+ (13th day)
2	33	Dysesthesia of lower limbs with hyperalgesia, lumbodynia	+	+ (9th day)	-	-
3	49	Hypalgesia of two hands, abdominalgia	+	+ (8th day)	+ (11th day-13th day)	+ (15th day)
4	44	Dysesthesia and paresthesia of lower limbs, abdominalgia,	+	+ (8th day)	-	-
5	37	Dysesthesia, weakness, abdominalgia	+	+ (3rd day)	-	+ (12th day)

The initial symptoms are the chief complaints of the patients at admission. The accompanying symptoms that we observed during hospitalization are recorded in the table. “+”: Symptoms were positive; “-“: Symptoms were negative. Date in parentheses was the occurrence time when the symptoms appeared after exposure.

Table 2 Laboratory findings and electromyography results of five patients with acute thallium poisoning

Patient No.	Abnormal laboratory findings			EMG
	ALT (u/L)	CK-MB (u/L)	APTT (s)	Motor nerve	Sensory nerve
1	117.8	28	163.1 (12th day)	La-Me (m)	La-Me (m)
2	65.8	Normal	Normal	Normal	Normal
3	71.1	22.3	125.2 (12th day)	Normal	La-S (m)
4	92.1	37	Normal	Normal	Normal
5	55.3	Normal	Normal	Normal	Bi-Me (m)

The values of abnormal lab findings at admission are listed in the table. The peak of activated partial thromboplastin time and the time of detection (after exposure) were recorded. Electromyography was performed before or at admission. Bi: Bilateral; La: Lateral; S: Sural nerve; Me: Median nerve; m: Mild-decreased conduction velocity (CV) or amplitude < 20%; M: Moderate-decreased CV or amplitude range from 20% to 50%; ALT: Alanine aminotransferase, ref: 0-50 u/L; CK-MB: Creatine kinase-MB, ref: 0-16 u/L; APTT: Activated partial thromboplastin time, ref: 23-35 s; Normal: Values within normal limits; EMG: Electromyography.

Table 3 Interval from exposure to diagnosis and treatments of five patients with acute thallium poisoning

Patient No.	Interval from exposure to diagnosis (d)	Time of receiving treatments after exposure				Duration of PB treatment (d)	Urine thallium concentration (µg/L)		Blood thallium concentration (µg/L)
		Sodium thiosulfate	DMPS	HP	PB		Before treatment	After treatment	Before treatment	After treatment
1	9	3rd day	12th day	15th day	15th day	14	7200	160	280	0
2	8	3rd day	10th day	10th day	11th day	15	5100	130	210	0
3	11	10th day	11th day	15th day	15th day	15	250	0	150	0
4	12	11th day	11th day	15th day	15th day	14	370	0	40	0
5	12	11th day	11th day	15th day	15th day	16	580	0	46	0

The urine and blood samples were successively sent to Hospital 307 of Chinese People’s Liberation Army to confirm the diagnosis of acute thallium poisoning. The day when the patients underwent detoxification treatments after exposure is listed in the table. The Prussian blue (PB) treatment was implemented in Hospital 307 of Chinese People’s Liberation Army and lasted for 14 to 16 d. The urine and blood thallium concentration before and after PB treatment was recorded. Sodium thiosulfate: 0.64 g, intravenous injection per day; DMPS: Dimercaptopropane sulfonate 0.25 g, intramuscular injection twice daily; HP: Hemoperfusion; PB: Prussian blue 3.3 g in mannitol 50 mL, orally four times daily.

Table 4 Symptoms of five patients with acute thallium poisoning during 24-mo follow-up

Patient No.	1 mo	3 mo	12 mo	24 mo
1	Bradypsychia, blepharoptosis, paresthesia of lower limbs, alopecia	Cognitive impairment, alopecia, nystagmus, hypalgesia of limbs	Blind, dysphagia	Blind, disability
2	Dysesthesia of fingers, alopecia	Hypalgesia of limbs, alopecia, bradypsychia	N/A	N/A
3	Dysesthesia of limbs, alopecia	Alopecia, palpitation	Fatiguability	N/A
4	Dysesthesia of lower limbs, alopecia	Alopecia	N/A	N/A
5	Dysesthesia of limbs alopecia, abdominalgia dysphasia	Weakness of lower limbs, alopecia, bradypsychia	N/A	N/A

The clinical follow-up was performed at 1, 3, 12, and 24 mo after discharge. The main symptoms which may be associated with acute thallium poisoning are recorded in the table. N/A: No symptoms or complaints at all.

Table 5 Examination results of five patients with acute thallium poisoning at 12-mo follow-up

Patient No.	EMG		MMSE	HAMA score	HAMD score	mRS
	Motor nerve	Sensory nerve
1	Bi-T (S)	Bi-T (M), Bi-S (M), Bi-Me (M)	5	-	-	4
2	Normal	Bi-S (m)	29	5	3	0
3	Normal	Bi-T (m), Bi-S (m),	22	11	11	0
4	Normal	Normal	26	9	4	0
5	Bi-U (m)	Bi-S (m), Bi-Me (m)	27	4	3	0

The patients received electromyography, Mini-Mental State Examination, Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and Modified Rankin Scale assessments 12 mo after discharge. -: Unable to complete this test; Bi: Bilateral; La: Lateral; T: Tibial nerve; S: Sural nerve; Me: Median nerve; U: Ulnar nerve; m: Mild-decreased conduction velocity (CV) or amplitude < 20%; M: Moderate-decreased CV or amplitude range from 20% to 50%; S: Severe-decreased CV or amplitude > 50%; MMSE: Mini-Mental State Examination (ref: illiteracy > 17; primary school > 20; above middle school > 24); HAMA: Hamilton Anxiety Rating Scale (ref: normal < 7; probable anxiety 7-14; mild anxiety 14-21; moderate anxiety 21-29; severe anxiety > 29); HAMD: Hamilton Depression Rating Scale (ref: normal < 8; probable depression 8-20; depression 20-35; severe depression > 35); mRS: Modified Rankin Scale assessment (ref: 0, no symptoms at all; 4, Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance); EMG: Electromyography.

Table 6 Intervals from exposure to diagnosis and outcomes from published studies on patients with thallium poisoning

Ref.	Number of cases	Mean interval from exposure to diagnosis (d)	Follow-up (mo)	Outcomes
				Death	Survive with severe sequelae	Survive with mild sequelae
Misra et al[27], 2003	1	18	6	0	0	1
Tian et al[28], 2005	1	20	During hospitalization	0	0	1
Lu et al[29], 2007	2	21	12	0	0	2
Zhao et al[8], 2008	3	21.7	1-3	0	0	3
Pelclová et al[30], 2009	2	112.5	18-22	0	2	0
Sun et al[14], 2012	14	14.6	6-8	1	0	13
Huang et al[9], 2014	1	2	During hospitalization	0	0	1
Zhang et al[31], 2014	9	12.1	6	0	0	9
Li et al[11], 2014	13	23.8	12-144	2	0	11
Li et al[12], 2015	2	153	During hospitalization	2	0	0
Almassri et al[32], 2018	3	45	20	0	0	3
Ash and He[33], 2018	1	150	37	0	1	0
Lin et al[10], 2019	34	13	21-96 (31 cases)	0	2	29
Total	86	23.6	1-144	5	5	73

The intervals from exposure of thallium to diagnosis were converted into days. One week = 7 d; One month = 30 d. The recent exposure was chosen for this study in the patients with multiple intoxications. Cases were grouped according to the outcomes described in the original papers: Death, severe sequelae (need assistance with daily activities), and mild sequelae (independent for daily activities).