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铊中毒的病程、预后和致死

Posted by woodinwind on January 2, 2002

http://www.inchem.org/documents/pims/chemical/pim525.htm

9.3 Course, prognosis, cause of death

Ingestion of the poison may sometimes give rise to
vomiting, but typically only nausea is experienced. This is
followed by a latent period of 3-4 days followed by
constipation that fails to respond to purgatives. About 1 to
2 weeks after ingestion, hyperaesthesia develops. Often the
first complaint of the patient is the sensation of walking on
felt, followed by neuralgiform pain in the legs. These
disturbances in sensory nerves are soon followed by motor
disturbances. The patient can no longer stand. The
neuralgiform pains increase gradually until the patient
cannot bear even the weight of the sheets on his legs.
Excessive thirst and sleeplessness are prominent symptoms.
Further striking mental changes occur which often are
interpreted as hysteria. A characteristic early sign, often
present in the first week of poisoning, is dark pigmentation
round the roots of the hair.

Tachycardia develops during the second week, usually
associated with a moderate increase in blood pressure and a
progressive polyneuritis becomes apparent. Sometimes the
arms are affected together with some of the cranial nerves.
Complete arreflexia of the lower limbs may ensue, and the
initial hyperaesthesia may gradually be replaced by
hypoaesthesia.

At the end of the second week, or even earlier in severe
poisoning, the typical symptom of hair loss appears. At first
the hair can merely be more easy plucked; later, it begins to
fall spontaneously in tufts, and by the third week there is
usually complete alopecia. Axillary and pubic hair may also
disappear. Most textbooks state that only the lateral parts
of the eyebrows will fall out, but this statement may have
been copied from previous publications without
substantiation.

If the patient recovers, hair will grow normally in the
course of time. The skin becomes dry and scaly because of
destruction of sweat and sebaceous glands. In the third or
fourth week, lunular stripes across the nails (bands of Mees)
may sometimes be seen as a sign of impaired growth for a
certain period.

Some months after poisoning, pronounced caries may become
apparent and severe atrophy of the muscles develops.

In a follow-up study of 48 children who survived the initial
stage of poisoning (caused by accidental ingestion of
pesticides containing thallium sulphate), they were
specifically examined for sequelae between 6 months and 7
years after the intoxication. Neurological abnormalities
were verified in 26 children. Mental abnormalities, namely
retardation and psychosis, were the most common finding.
Several children were so retarded that they had to be placed
in institutions. Abnormal reflexes, ataxia and tremor were
the next most common finding (Reed et al, 1963).

Prognosis

In massive poisoning the prognosis is poor. Severe poisoning
treated with intensive care, haemoperfusion (in the first 48
h after ingestion), forced diuresis and colloidal Prussian
Blue, the outcome may be more favourable.

Causes of death

Death may be caused by pulmonary or cardiac failure.

Paralysis of the vagal nerve was observed in two patients
which could have been the direct cause of death on the 11th
day after suicidal ingestion of 600 – 700 mg thallium
sulphate (Moeschlin, 1980).

A 26-year-old man who ingested 10 g of thallous malonate died
of cardiac failure 48 h after ingestion. A higher
concentration of thallium was found in the heart that in
other organs, suggesting that the heart is the main target in
the early stage of acute poisoning (Aoyama et al, 1986).

Death by ventilatory insufficiency is possible in patients
with ascending polyneuritis if they are not artificially
ventilated in time.

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