Case Definition: Barium

Clinical description

Ingestion of certain forms of barium (e.g., barium carbonate or barium fluoride) in toxic amounts can lead to gastrointestinal signs and symptoms (e.g., vomiting, abdominal pain, and watery diarrhea). Within 1--4 hours of ingestion, profound hypokalemia and generalized muscle weakness can develop which may progress to paralysis of the limbs and respiratory muscles. Severe hypokalemia induced by barium toxicity can cause ventricular dysrhythmias (1-7).

Barium sulfate is not absorbed when taken by mouth and therefore is commonly used as a contrast agent for radiographic procedures.

Laboratory criteria for diagnosis

• Biologic: An elevated urinary barium concentration. A urinary barium concentration greater than the 95th percentile for the general population is an unusual level of exposure for a person with no known occupational exposure to barium (CDC).

- OR-

• Environmental: Detection of barium compounds in environmental samples. (8-11)

Case classification

• Suspected: A case in which a potentially exposed person is being evaluated by health-care workers or public health officials for poisoning by a particular chemical agent, but no specific credible threat exists.
• Probable: A clinically compatible case in which a high index of suspicion (credible threat or patient history regarding location and time) exists for barium exposure, or an epidemiologic link exists between this case and a laboratory-confirmed case.
• Confirmed: A clinically compatible case in which laboratory tests have confirmed exposure.

The case can be confirmed if laboratory testing was not performed because either a predominant amount of clinical and nonspecific laboratory evidence of a particular chemical was present or the etiology of the agent is known with 100% certainty.

Additional resources

1. Sigue G, Gamble L, Pelitere M, et al. From profound hypokalemia to life-threatening hyperkalemia: a case of barium sulfide poisoning. Arch Intern Med 2000;160:548-51.
2. Shankle R, Keane JR. Acute paralysis from inhaled barium carbonate. Arch Neurol 1988;45:579-80.
3. Johnson CH, VanTassell VJ. Acute barium poisoning with respiratory failure and rhabdomyolysis. Ann Emerg Med 1991;20:1138-42.
4. CDC. Barium toxicity after exposure to contaminated contrast solution---Goias State, Brazil, 2003. MMWR 2003;52:1047-8.
5. Dawson A. Barium. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, eds. Goldfrank's Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill;1364-73.
6. Agency for Toxic Substances and Disease Registry. Toxicological Profile for Barium and Barium Compounds[online]. 2007. [cited 2013 March 27]. Available from URL: http://www.atsdr.cdc.gov/ToxProfiles/tp24.pdf
7. Environmental Protection Agency. Barium and compounds[online]. 2005.[cited 2013 March 27]. Available from URL: http://www.epa.gov/iris/subst/0010.htm
8. NIOSH. NIOSH manual of analytical methods [online]. 2003. [cited 2013 Apr 5]. Available from URL: http://www.cdc.gov/niosh/docs/2003-154/.
9. OSHA. Sampling and analytical methods [online]. 2010. [cited 2013 Apr 5]. Available from URL: http://www.osha.gov/dts/sltc/methods/index.html.
10. FDA. Food: Laboratory methods [online]. 2013. [cited 2013 Apr 5]. Available from URL: http://www.fda.gov/Food/FoodScienceResearch/LaboratoryMethods/default.htm.
11. EPA. Selected analytical methods: chemical methods query [online]. 2013. [cited 2013 Apr 5]. Available from URL: http://www.epa.gov/sam/searchchem.htm.