Decay Part 2
Want to know what poison makes bones crumble and glow-in-the-dark? What living thing thrives inside Chernobyl?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patient survive this podcast? It’s up to you and the choices you make. Our episode today is Decay Part 2.
Want to know what poison makes bones crumble and glow-in-the-dark? What living thing thrives inside Chernobyl?
Welcome back. Spoiler alert: This is part 2 so if you missed part 1, I recommend listening to that episode first.
Our patient, a 46-year-old ex-pat Russian dissident is critically ill in the ICU. Her kidneys and liver are failing. Worse, she has bone marrow failure, meaning no white blood cells to fight off infection. In addition low platelets means she’s at risk for serious bleeding complications. You and several other specialists suspect radiation poisoning, but a Geiger counter revealed no radiation. Hate to admit it, but at the moment, we’re stumped.
You and the oncologist gown up to go into the isolation room to talk to her together. Through the door, you hear her on the phone. You can’t hear the whole conversation, but you catch the words expose, Russia, organized crime and corruption.
After entering the room, you both interview her again and examine her, unfortunately gaining no new information. You ask if she thinks someone poisoned her. She says yes, saying she received a threatening phone call this am. You all agree, at this point, to call law enforcement. Maybe they can help.
In the meantime, you review radiation poisoning, looking for clues and trying to figure out what the heck to do next. This brings us to a very famous, very tragic, but fascinating historical case.
Let’s go back in time to 1922, New Jersey. You are working as a primary care doctor. Your patient is a 24-year-old woman. She is complaining of severe leg pain, it’s been going on for months and now so severe she can’t walk. Her only past medical history is ongoing dental infections. Despite antibiotics the infection is so severe, it’s gotten into her jawbone. You diagnose the leg pain as rheumatism and recommend aspirin.
She continues to worsen despite medical and dental care. Brace yourself for the graphic description of her disease progression. Her dentist reports her mouth is essentially one large abscess, from her lower jaw, upper mouth and extending even to the bones of her ears. A few months later, while he’s examining her, her jaw crumbles into his hands. Her lower jaw falls off, literally. Shortly after, the infection eats into her jugular vein, her mouth floods with blood as she hemorrhages and dies. An absolutely horrific way to die. The hospital records syphilis as her cause of death.
Question 1. This disease is caused by syphilis.
A. True
B. False
Answer: B. False. This is definitely not syphilis.
Another young woman arrives at your clinic, during a thunderstorm. She too is having severe pain and dental problems. She has a suppurating wound on her leg that won’t heal. With a crack of lightning and huge crash of thunder, the lights in the clinic flicker and go out. The storm has cut the electricity. You blink to clear your eyes several times, wondering if you’ve suddenly developed psychosis and are hallucinating. The patient’s bones are glowing in the dark. Her dress and fingers are glowing in the dark too, but where she’s pulled up her to dress to allow you to examine the leg, she’s glowing green, from the inside out.
As you stand, speechless, she says several of the women at the factory where she works are also sick. She says she’s here to see you because her friend, the woman who lost her jaw recommended you. You ask what they do. She says they paint the numbers on watch dials.
That’s question number 2. Time to pick your poison. What toxin has your patient been exposed to?
A. Phosphorous
B. Luminol
C. Quinine
D. Radium
Answer: Radium. She and her friend work in a factory owned by the Radium Dial Company. Radium is radioactive. It occurs naturally from the decay of uranium, or is manufactured in a nuclear plant. It’s green color glows in the dark. Women in US and Canadian dial factories in the early 1900s used radium paint to paint the numbers on watch dials. They licked the tips of their brushes to make a pointed tip for the fine brushwork. The women were explicitly told the paint was safe. This despite the fact the men in the factory handled the toxin with lead aprons, only touching the radium with tongs. The women were called ghost girls because they glowed after a shift. Some unfortunately painted their teeth and dresses with radium paint before going out.
Radium is obviously, not safe. What does it do? The body treats it like calcium. It’s taken up into the bones causing bone marrow suppression, cell death and tumors. The women often began with dental pain and loose teeth. Thanks to immune system suppression, these teeth, extractions and surgeries never healed, turning into suppurating abscesses. Radium literally ate away the bones, called osteonecrosis of the jaw. Other bones were affected and horrific tumors developed as well.
Their symptoms were blamed on many things, including x rays they received for evaluation and syphilis as noted above. Worse, the Radium Dial Company manufactured false research during investigations. This effectively deflected blame from the radium dial corporations.
Also at the time, there was a radium craze with radium water being touted as a health tonic, a cure for cancer. Radium could be found in cosmetics, food, and toothpaste. For more on this check out Adam Blumenberg’s great episode on the Toxic History podcast titled Radithor Radioactive Water. At the time, Radium was the most valuable substance on earth costing $120,000 per gram, $2 million per gram at today's money.
Spoiler alert, it wasn’t a health tonic.
It took the first woman 2 years to find a lawyer to take her case. The company stalled, intentionally, literally waiting for the women to die. But these extremely brave women, so weak at the time of the lawsuit, some couldn’t lift their arms to take the oath, persisted. Eventually the so-called radium girls settled, with several on their deathbeds, they had little other choice.
By 1927 more than 50 of the factory workers died from radium poisoning. One of the victims didn't work at the factory. Her exposure? She slept in the same bed as her sister worked there.
The case became an important landmark in United States legal history, establishing the rights of workers to sue for damages for labor safety and leading to improvements in industrial standards. Their legacy is so important, they are credited with keeping workers safe in the 1950s at the start of the atomic age. Their history was studied to set up safety standards that worked and continue to work.
There are so many layers to this story, poverty, sexism, corporate greed, the legal system and occupational regulation. I wish we had time for it all, but if you want to know more, I recommend the book Radium Girls by Kate Moore.
Anyway, the women are buried in lead coffins. Their bones are still glowing because radium continues to decay and has a half-life of 1600 years.
This brings us to types of ionizing radiation. The risk of radiation is from the decay of radioactive particles and ionizing radiation is radiation with sufficient energy to disrupt either an atom or a molecule. There are several types, the ones that matter most from a medical standpoint are alpha particles, beta particles, gamma rays and x-rays. The physics, full disclosure, is not my favorite topic, but a quick review might give us more insight into our patient in the ICU and the missing radiation.
X-rays and gamma rays are very similar when it comes to patients, they penetrate through the body and can penetrate several feet of insulating concrete. Beta particles have less penetrating ability than gamma radiation, but can still pass a few centimeters deep into humans.
Question #3. What stops alpha particles?
A. Paper
B. Clothes
C. Lead
D. Skin
E. All of the above
Answer is D. All of the above. Alpha particles are easily stopped. They can be stopped by your skin, or even by a piece of paper or clothing. Beta particles are medium level, they can sometimes penetrate the skin but are stopped by plastic and often by clothes. Gamma rays and x rays are very similar. The main difference is how they are produced. Gamma rays come from inside the nucleus, x-rays are produced from outside. They are hard to stop, requiring lead or thick concrete. Think about an x-ray, we sometimes shield the body with a lead apron and the xray tech is behind a barrier or steps away from the beam.
We all know about the risk of radiation with x-rays. Why do we care about alpha particles in medicine if they can’t penetrate the skin? They can still cause harm if they are incorporated into the body via ingestion or inhalation. Interestingly, alpha particles can’t be measured with a Geiger counter. If someone has ingested them, they don’t penetrate back out of the skin from inside, so it can’t be measured by the machine and requires special testing.
Uh oh. This brings us right back to our patient. Concern for radiation poisoning without finding radiation? It sounds like we need some expert help. You reconvene with onc and medicine to review a sentinel case in medical literature. Afterwards, you’re all in agreement. We need expert help. You talk to law enforcement. In the US, radiation experts are in the Oak Ridge Tennessee National Laboratory. Eventually, a multidisciplinary committee is formed, with you, her other physicians, law enforcement, and the radiation scientists. You send the blood and urine they request via special courier.
Your patient’s case has blown up into a national incident with allegations of poisoning, terrorist attacks and assination attempts on US soil along with hysteria about contamination. After passing a gauntlet of reporters and news cameras on your way into work, the ED is surprisingly quiet for a change. The patient in the meantime is deteriorating in the ICU. She’s developed sepsis. Despite aggressive antibiotic treatment, she’s progressed to septic shock.
While we await the advanced testing, let’s talk about radiation exposure. Of course, fear is always present with nuclear disasters like Chernobyl and Fukushima. One radioactive isotope that might be released, is interestingly iodine. This is the reason people in the fallout zone are told to take iodine, with the idea that your thyroid will uptake the regular iodine, rather than the radioactive isotope, hopefully preventing thyroid cancer.
These disasters are no secret when they happen. It’s more challenging when radiation exposure occurs outside a known context. This occurred in Brazil. several men looking for salvage in an old hospital found a device with a glue glowing powder inside. The powder was beautiful and mesmerizing and was shared among several family members including a six-year-old child. Four people died, including the child and 50 were hospitalized. This was a teletherapy machine, used for medical radiation to treat cancer and the glowing blue powder was radioactive cesium 137. Most radioisotopes don’t have an antidote. Cesium does. It’s Prussian blue, the pigment used in paintings like van Gogh’s Starry Night. Remember what else Prussian blue is the antidote for? That’s question 4.
A. Aspirin
B. Mercury
C. Thallium
D. anticholinergic toxicity
Answer: C. Prussian Blue is also the antidote for thallium, see the Poisoner’s poison episode for more.
Finally, you get some answers back from the very specialized testing. It’s been two weeks, we still don’t know what’s happened to our dying patient. Time to pick your poison. Again! Question # 5.
A. Radium
B. Polonium
C. Cesium
D. Iodine
Answer: B. This is polonium poisoning. All the others above emit beta and gamma rays, so they’d be picked up on a Geiger counter. Iodine causes thyroid problems. Law enforcement finds polonium in one of the two wine glasses in her room. Is there an antidote? No. Back to this in a minute.
You’ve been taking care of a patient poisoned with a radioisotope for two weeks. She’s dying. Are you next? What about your other patients? Your family?
Polonium is the toxin used to assassinate Alexander Litvinenko in 2006. He was poisoned in London. And these very questions arose. Radiation was found all over London, in hotels, bars, restaurants, a stadium, the hospital and his car. It was found all the way to Hamburg and Russia. But no one else became sick.
Why? Polonium is an alpha emitter. So, it was all over the place, but touching it won’t make you sick because it’s entry into your body is stopped by your skin. The assassins put it into his tea. When he drank it, it became incorporated into his body this way. In fact, the two assassins carried it on an airplane, disposed of it in their hotel sink and one even told his child to shake Litvinenko’s hand after poisoning him. Litvinenko’s father said he was killed by a tiny nuclear bomb.
Interesting side note, polonium was found in the body of Yasser Arafat, though evidence is lacking as to whether or not this is related to his cause of death. As far as I can tell, there was too much politics and subterfuge at play to arrive at an actual medical conclusion.
Polonium was discovered by Marie Curie, who named it after her homeland Poland. Why name a dangerous radioactive isotope after your country? Interestingly, she hoped to bring awareness to the fact Poland didn’t exist as a country at that time, it was occupied by the Russians, Germans, and the Austro-Hungarian empire.
Back to our patient. Radiation is found all over the hospital and the ICU. However, the surface contamination is not a risk to you or others, because as we said before, the radiation is stopped by your skin.
How do we treat polonium? The same way we treat any radiation exposure, good supportive care. Many patients who die from acute radiation syndrome are suffering from fluid loss, infection and bleeding. Treatment with antiemetics, IV fluids and anti-diarrheals is the appropriate first step, as we did with our patient in the hotel and ED.
Radiation burns are treated like thermal burns. Infection and sepsis, of course with antibiotics. We have medicine to increase the white blood cell count often used in chemo patients, called GM-CSF stimulants. These would be worth trying. We have limited data on polonium poisoning for obvious reasons. Chelation with various agents has been suggested.
Where do you find polonium? It is used in manufacturing to eliminate static, it's also been investigated as a source of heat in outer space. Need another reason to stop smoking? It’s found in small amounts on tobacco leaves.
Think this difficulty in diagnosis is fictional? It’s not. Litvinenko died 23 days after exposure. Polonium wasn’t diagnosed until six hours before his death. The same issue occurred. The medical team considered radiation as the source of his illness, but the Geiger counter didn’t show radiation. Interestingly, they considered thallium poisoning, due to his hair loss, but he lacked the excruciating pain it causes. The diagnosis required special testing by highly trained scientists.
Our patient, despite our best medical and ICU care, develops overwhelming sepsis, followed by several cardiac arrests and death. Law enforcement investigation proves the hospitalist right. She was killed by polonium. Surveillance footage along with tracking of radiation implicated a man she met with in her hotel room. He claimed to be a whistleblower regarding corruption at the highest levels of the government, but in fact had shadowy ties to the Russian government and intelligence agencies. His hotel room was highly contaminated. He was well appearing in airport surveillance footage escaping back to his home country. This is a fictional case, as are all out cases to protect the innocent, but based on real poisonings that have occurred.
I want to mention a really cool topic I came across during my research, radiotrophic fungi found in Chernobyl. The fungi eat radiation and harness it into energy via radiosynthesis, like photosynthesis, but with radiation. Taking a line from Jurassic park - “Life finds a way.” The fungi are known for extreme recalcitrance and actually grow towards the most radioactive areas. They are black due to high levels of melanin, the compound giving us our skin pigmentation, and the compound that uses the radiation.
An amazing study on the international space station showed a layer 1.7mm thick of the fungi blocked 2% of radiation. Scientists extrapolated a layer 21mm thick could block the radiation on Mars. Imagine living in a house on Mars with a fungus roof.
Question #6 is the last in the podcast and today’s pop culture consult. What movie monster has radioactive breath and -I did not know this before- skin based on keloid scars of atomic bomb survivors?
A. Jaws
B. King Kong
C. Predator
D. Godzilla
Follow the Twitter and Instagram feeds both @pickpoison1 and you’ll see the answer when I post it. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.