When Ukrainian presidential candidate Viktor Yushchenko was diagnosed as suffering from dioxin poisoning, with the second highest blood level ever recorded, he entered medical history as one of the few humans whose exposure to that agent was apparently deliberate. In fact, the medical literature contains only two other cases of intentional dioxin poisoning, cases that were never solved, producing symptoms lasting for years, and that were treated with doses of Pringle's Fat-Free Potato Chips.
But I'm getting ahead of myself.
Dioxin isomers are highly lipophilic, accumulate in fat, and can have elimination half-lives lasting years
Mr. Yushchenko apparently became ill on Sept. 6, 2004, with headache and abdominal pain. The previous night he had dined with the chief and deputy chief of S.B.U., the Ukrainian Secret Service. Whether this was a coincidence is a matter of dispute. Although clinical experience is limited, some experts believe that symptoms of dioxin poisoning do not begin immediately upon exposure but only after a delay of several days to several weeks. (A recent news report suggests that Mr. Yushchenko's symptoms may have begun even before the Sept. 5 dinner.)
By Sept. 10, the symptoms had become so severe that Mr. Yushchenko was flown to Rudolfinerhaus Hospital in Vienna, where he was admitted with severe abdominal pain and inability to walk. He was described as being groggy, and having an unusual grayish tinge to his skin. He also had paralysis of the left side of his face. Laboratory tests revealed pancreatitis, abnormally high liver enzymes, and an elevated white blood count. His entire gastrointestinal tract was studded with ulcers.
No single medical condition seemed to explain his presentation, and tests for some obvious poisons with prominent gastrointestinal effects, such as arsenic, were negative. Eight days after he arrived in Vienna, Mr. Yushchenko left the hospital against medical advice to resume his campaign.
He returned 10 days later with back pain so severe it could be controlled only with morphine administered through an epidural catheter inserted into the thoracic spine. By this time, his facial appearance had undergone a remarkable transformation. His skin, still dusky grey, was now covered with multiple cysts and inflammatory lesions, looking something like the worst case of acne imaginable. By this time, poisoning was strongly suspected. Further tests were needed, but because of the campaign, Mr. Yushchenko could not return to Vienna until late fall. Finally, on Dec. 11, the diagnosis was announced. The striking skin changes were manifestations of chloracne. Viktor Yushchenko had been poisoned with dioxin.
Dioxin is not a single chemical, but rather a group of more than 70 cyclic organic compounds containing chlorine, the most toxic of which is 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). It is possible that the exact mix of dioxin isomers found in Mr. Yushchenko's tissues may allow the poison to be traced back to a specific source. These chemicals are not natural, but are formed as byproducts of certain manufacturing processes such as those used to make pesticides and antiseptics. They are highly lipophilic, accumulate in fat, and can have elimination half-lives lasting years.
Chloracne is a distinct skin condition whose characteristic changes are produced only by exposure to halogenated cyclic hydrocarbons. Features of chloracne include:
- ▪ Prominence of rash on lateral sides of eyes and behind the ears.
- ▪ Relative sparing of nose (not true in Mr. Yushchenko's case).
- ▪ Presence of comedones (blackheads) and small straw-colored cysts that may become inflamed and enlarged as the disease progresses.
- ▪ Conjunctivitis.
- ▪ Lag of two to four weeks from exposure to appearance of skin lesions.
Dioxin poisoning itself frequently causes hepatic inflammation, elevated g-GT, peripheral neuritis, and leukocytosis — all findings present in Mr. Yushchenko. Because dioxins have such long half-lives, once the diagnosis is suspected, it is relatively easy to demonstrate the causative agent in the blood. Mr. Yushchenko's blood dioxin level was the second highest on record — 100,000 pg per gram of blood fat. By comparison, the typical background level in the population is 10 to 45 pg per gram.
There is considerable experience with dioxin exposure as a result of industrial accidents. For example, a 1976 leak at the Icmesa hexachlorophene factory in Seveso, Italy, exposed tens of thousands in the surrounding cities to TCDD. Some, mostly children and adolescents, developed chloracne, but in virtually all the manifestations of TCDD toxicity were mild and self-limited. Cases of intentional, massive exposure are extremely rare.
The two other such cases reported in the medical literature occurred in Vienna. In the spring of 1998, two women working in a textile institute presented with chloracne, which had been preceded by gastrointestinal symptoms. The more seriously affected patient had hundreds of cysts on her face and in areas not usually involved in acne eruptions — the ears, eyelids, limbs, and genital region. Her blood dioxin level was 144,000 pg per gram of blood fat. She was initially treated with topical tretinoin without benefit.
Additional treatment included surgical removal of skin lesions, steroids, antibiotics, and analgesics. Because the nonabsorbable fat substitute olestra increases fecal excretion of TCDD (by binding and trapping it in the gut), both patients were given multiple doses over 38 days in the form of Pringle's Fat-Free chips (10 gm olestra/28 g chips). Although this did increase clearance of TCDD, the clinical effects of this increase were not known, and both patients eventually found the regimen unpalatable. Other ways of removing fat from the body — liposuction, induced lactation — were discussed but not attempted. The source of exposure was never identified.
These cases are described in Environmental Health Perspectives (2001;109:865). The article, along with color pictures of the skin lesions, can be found online at http://ehp.niehs.nih.gov/members/2001/109p865-869geusau/geusau-full.html.
Although Viktor Yushchenko has survived the worst stage of acute dioxin poisoning, he might continue to experience dermatological problems for some time. One of the Vienna victims was still requiring surgical treatment of her skin lesions three years after exposure.