A lost pigtail
Authors: Jean-Marc Cosset, Chris Sharp, Krishna Clough, Khosro Mojir Sheibani
Journal: Journal of the Royal Society of Medicine (1999)

A 33-year-old illiterate worker from a village in rural Iran developed nausea and vomiting, and subsequently marrow depression and radiation skin injuries, in 1996 whilst working as a general factotum at the construction site of a combined cycle fossil fuel power plant. The patient had been collecting insulating materials from a trench below a high pressure boiler at the start of the day when he found a shiny metal capsule attached to a 'pigtail'. Fascinated by this object's appearance, he held it for some time in his hand and over the next 90 minutes placed it for variable periods in two separate pockets of his overalls, taking the object out repeatedly to examine it. During the previous night, an industrial radiography team had examined the welds in the boiler using a Gammamat Projector, which contained an iridium192 source with an activity 5 curies (1 .85 1011 Becquerels). At some time after radiography was complete, the source and its linking pigtail became detached from the cable, which would have drawn it back into its portable safety housing, and fell into the trench. The loss was not discovered until 1 hour after the patient found the source. Around 90 minutes after his discovery, the patient started to experience dizziness, nausea, lethargy and a burning feeling in his chest. Ascribing these symptoms to the object, he returned the source to the trench where it was found 30 minutes later. Plant staff were unaware that the patient had handled the source until 5 hours after his initial discovery, when he reported events to his colleagues and the site manager was informed. The patient was taken to the local hospital, where a blood count showed leucocytosis, but a differential count was not performed and he was discharged home. During the next two days the nausea and vomiting improved but the burning in his chest continued. He was moved to the Imam Hossein Hospital in Teheran and treated under the care of a radiotherapist. The radiotherapist found that the patient had marked erythema of his right chest and upper abdomen. Over the next few days the chest lesion expanded and he developed erythema and blistering on the medial side of his right antecubital fossa, right anterior thigh and left palm. Concurrently, his white cell and platelet counts had started to decline rapidly, the white cells reaching a nadir at 23 days after the exposure (total white count 0.8 x 109/L, neutrophils 0.2 x 109/L, lymphocytes 0.3 x 109/L, platelets 19 x 109/L). Serious consideration was given in Iran to performing a bone marrow transplant early in the admission, but the patient's half-brother was HLA incompatible and he had no other close relatives; non-related donor grafting is not possible in Iran. The patient was managed in an isolation room with supportive therapy consisting of platelet transfusions, prophylactic antibiotics and topical sulphadiazine. With persisting signs of severe marrow depression, therapy with granulocyte colony stimulating factor (G-CSF) was started 22 days after the exposure (subcutaneous Leucomax 400pg twice daily). The Iranian physicians felt that bone marrow transplantation might still be the only way to save the patient's life and arranged for his transfer to the Institut Curie in Paris, where he arrived 25 days after the exposure. The staff at the Institut Curie faced a substantial difficulty in being unable to converse with the patient (he spoke only a little Farsi, his tongue being a regional language); he was very distressed, not only by his first journey away from his village and country, but also by the severe pain from his skin lesions. His chest lesion had lost the entire epidermis (Figure 1), his palm contained a tense 5 cm circumference bulla and he had lesser lesions at the other two sites. Thermography suggested that both the chest and elbow lesions had a viable dermis and hence reepithelialization was possible. Dermal damage was limited on the hand and thigh and compatible with spontaneous healing, although there was concern about functional impairment in the hand. Treatment was continued by use of reverse barrier nursing techniques with intravenous fluids, antibiotics and morphine. Platelet transfusions and G-CSF (300,ig daily) were continued for a further 10 days until the white count improved; the platelet count improved after G-CSF was discontinuedl. Although the chest lesion showed progressive re-epithelialization, the time to full cover was predicted to be 12-18 months, so the decision was taken to graft this lesion and the thigh at 66 days after the exposure. A free graft from the thigh to the chest 'took' without complications. The patient was returned to Iran 84 days after exposure, and was shortly afterwards discharged to his home. He was alive at 26 months and follow-up continues. Subsequent reconstruction of this heterogeneous exposure, based on the evolution of symptoms, marrow depression and cytogenetic investigations suggests that the effective whole body dose was 3.0-3.5 Gy2'3; the LD50/30 H-