220 - From Poisoning to Progress: A Rare Case of Thallium-Induced Critical Illness Polyneuropathy in Acute Inpatient Rehabilitation

Critical illness polyneuropathy secondary to thallium poisoning

Case Description:

A 14-year-old previously healthy Colombian female presented to acute inpatient rehabilitation (AIR) after gastrotomy and tracheostomy placement, for critical illness polyneuropathy secondary to multi-organ failure from thallium poisoning. She was initially hospitalized in Colombia after one day of progressively worsening paresthesias and nausea following ingestion of chocolate-covered fruit found to contain thallium. Her 2.5-month hospitalization was complicated by multiple organ dysfunction syndrome (MODS), including neurotoxic, cardiotoxic, nephrotoxic, and hematotoxic syndromes. Treatment included multimodal mitochondrial support and Prussian Blue chelation therapies with international toxicology teleconsultation. At the time of AIR transfer to the United States, she had severe weakness with trace upper extremity movement, dysphagia, dysarthria, hyperkinetic movements, and neuropathic pain. She was dependent for activities of daily living and mobility.

Discussions:

In collaboration with the patient’s Colombian team, at 5 months post-poisoning she completed Prussian Blue therapy and continues on mitochondrial support with thallium serum < 0.2 mcg/L and urine < 1.0 mcg/L (previously 0.4 mcg/L and 2.8 mcg/L at 4 months). Neuropathic agents and alpha lipoic acid were titrated. Repetitive peripheral magnetic stimulation was administered to bilateral quadriceps and tibialis anterior using a figure-8 coil, delivering 600 theta-burst pulses at 30% stimulator intensity with improved neuropathic pain reported. Respiratory status and dysphagia improved, allowing tracheostomy decannulation and diet upgrades. She continues to demonstrate steady functional gains and is max assist for eating and upper body dressing; moderate assist for power wheelchair use; and dependent for 70 feet of ambulation with body weight support using a platform walker and ankle foot orthosis.

Conclusions:

This case is among the first to detail functional recovery after thallium toxicity. It highlights the importance of early, multidisciplinary rehabilitation, awareness of toxic neuropathies among physiatrists, and international collaboration to optimize outcomes in medically complex patients.