Cases of thallium intoxication in Syria: A diagnostic and a therapeutic challenge

Abstract

In mid-March 2015, a mother and her teenage daughter and son from Syria presented to a Syrian American Medical Society (SAMS) refugee clinic in the Beqaa Valley in Lebanon with the chief complaints of hair loss together with weakness and numbness of their lower extremities. They reported that on March 1, a military foe of their relative had given him several boxes of Middle Eastern cookies which were consumed by over 20 members of their families and neighbors. Soon after the consumption, most members of the households developed symptoms including abdominal pain, nausea, vomiting, and constipation. Later, many of the affected individuals, including the three who presented to the clinic, had pain and weakness in the extremities, skin lesions, and hair loss. Two subjects died inside Syria of kidney failure. In this report, we describe the diagnostic challenges faced until the arrival to the diagnosis of thallium intoxication and the therapeutic obstacles to getting adequate therapy. We also report the results of a survey sent to all subjects in the affected households and discuss the context of lawlessness that led to this intoxication and perhaps other cases.

Keywords: Poisoning; Syria; thallium.

Figure 1

A photograph of the boy's head showing patchy hair loss, taken 4 weeks after the ingestion

Figure 2

A photograph of the boy's finger nails showing Mees’ lines, taken 7 weeks after the ingestion

Figure 3

A graph showing the correlation between the number of date cookies eaten and symptoms score

Figure 4

A sample of the sweets brought by patients in Syria, the date cookie is the larger piece

Figure 5

The most common symptoms in the affected subjects

Figure 6

Microalbuminuria to creatinine ratios in the patients who presented to Lebanon, normal is <20 mg/g