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Acute radiation syndrome in a non-destructive testing worker: a case report
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Case Report Acute radiation syndrome in a non-destructive testing worker: a case report
Ji-Sung Ahn, Jai-Dong Moon, Wonyang Kang, Hyeong-Min Lim, Seunghyeon Cho, Dae-Young Lim, Won-Ju Park
Annals of Occupational and Environmental Medicine 2018;30:59.
DOI: https://doi.org/10.1186/s40557-018-0270-8
Published online: September 25, 2018

Department of Occupational and Environmental Medicine, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-gun, Gwangju, Jeollanam-do 58128 Republic of Korea

• Received: June 25, 2018   • Accepted: September 17, 2018

© The Author(s). 2018

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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  • Background
    In Korea, there were repeated radiation exposure accidents among non-destructive testing workers. Most of the cases involved local injury, such as radiation burns or hematopoietic cancer. Herein, we report a case of acute radiation syndrome caused by short periods of high exposure to ionizing radiation.
  • Case presentation
    In January 2017, Korea Information System on Occupational Exposure (KISOE) found that a 31-year-old man who had worked in a non-destructive testing company had been overexposed to radiation. The patient complained of symptoms of anorexia, general weakness, prostration, and mild dizziness for several days. He was anemic. The venous injection areas had bruises and bleeding tendency. Blood and bone marrow testing showed pancytopenia and the patient was diagnosed with acute radiation syndrome (white blood cells: 1400/cubic mm, hemoglobin: 7.1 g/dL, platelets: 14000/cubic mm). He was immediately prohibited from working and blood transfusion was commenced. The patient’s radiation exposure dose was over 1.4 Gy (95% confidence limits: 1.1–1.6) in lymphocyte depletion kinetics. It was revealed that the patient had been performing non-destructive tests without radiation shielding when working in high places of the large pipe surface.
  • Conclusions
    Exposure prevention is clearly possible in radiation-exposed workers. Strict legal amendments to safety procedures are essential to prevent repeated radiation exposure accidents.
  • Keywords:

    Keywords

    Acute radiation syndrome; Non-destructive testing; Pancytopenia; Radiation
In Korea, ionizing radiation is used in power plants, industries, medical and research fields. With the exception of nuclear power plants, it is most commonly used in the industrial sector, especially in non-destructive testing. Non-destructive inspection workers are continuously increasing to 5726 persons in 2009 and 7645 persons in 2015 [1]. Non-destructive testing is the use of radiation to identify defects in machinery, equipment, and piping. Using radiation, defects in welds on buildings and ships and joints in piping can be identified. Although this is a convenient method, there is always a risk of exposure to large amounts of radiation. In Korea, there have been repeated radiation overexposure accidents in non-destructive testing workers (Table 1). Most of the cases were local injuries such as radiation burns or hematopoietic cancer due to chronic or subchronic cumulative radiation exposure [2–14].
Fig. 1
Changes in the laboratory results of the patient with acute radiation syndrome
40557_2018_270_Fig1_HTML.jpg
Table 1
Case reports on accident exposure in Korean non-destructive testing workers
Yeara Sex Disease Age at diagnosis (years) Working duration (years) Reference
2017 Male Acute radiation syndrome: pancytopenia, anemia 31 5 This study
2015 – Radiodermatitis: ulcer at fingers – – KINS [1]
2013 Male Azoospermia 39 8 Park J, et al. [6]
2010 Male Myelodysplastic syndrome 35 9 Oh MS, et al. [4]
2009 Male Myelodysplastic syndrome 26 1 Oh MS, et al. [4]
2004 – Radiodermatitis: necrosis at hand – – KINS [11]
2003 – Radiodermatitis: sclerosis at dorsum manus 25 – KINS [11]
~ 2000 Male Radiodermatitis: sclerosis at fingers 40 10 Park SW, et al. [10]
~ 2000 Male Radiodermatitis: necrosis at palm 32 – Park SW, et al. [10]
1999 – Radiodermatitis: ulcer at fingers and palm – – KINS [11]
1986~
1996		 Male Radiodermatitis: ulcer at fingers 22 – Kim KJ, et al. [5]
Male Radiodermatitis: ulcer at fingers 28 – Kim KJ, et al. [5]
Male Radiodermatitis: edema, erythema at fingers 25 – Kim KJ, et al. [5]
Male Radiodermatitis: erosion at palm 19 – Kim KJ, et al. [5]
Male Radiodermatitis: ulcer, sclerosis at fingers 20 – Kim KJ, et al. [5]
Male Radiodermatitis: ulcer, sclerosis at palm 21 – Kim KJ, et al. [5]
~ 1990 Male Radiodermatitis: desquamation, sclerosis at fingers 22 – Ro YS [9]
1989 – Amputation at fingers – – KINS [11]
~ 1989 Male Radiodermatitis: desquamation, sclerosis at fingers 22 – Kim KJ, et al. [8]
Male Radiodermatitis: hardening at fingers 28 – Kim KJ, et al. [8]
Male Radiodermatitis: hardening at fingers 25 – Kim KJ, et al. [8]
Male Radiodermatitis: edema at palm 19 – Kim KJ, et al. [8]
1984 Male Radiodermatitis: soft tissue injury at palm 29 1 Yoon SC, et al. [7]
1983 Male Radiodermatitis: elliptical ulcer at lower abdomen 29 2 Yoon SC, et al. [7]
1983 Male Radiodermatitis: edema, amputation at finger 19 0.1 Yoon SC, et al. [7]
aYear of diagnosis
Acute radiation syndrome is a consequence of brief but heavy exposure (> 1 Gy) of all or part of the body to ionizing radiation. The radiation disrupts chemical bonds, which causes molecular excitation and free radical formation. Highly reactive free radicals react with other essential molecular structures such as nucleic acids and enzymes, which in turn disrupts cellular function. In particular, spermatogonia, lymphocytes, blast cells, other hematopoietic cells, small intestine, stomach, colon, epithelium and skin cells are radiation sensitive [15]. In Korea, cases of acute radiation syndrome caused by occupational exposure are very rare. And there were no cases reported previously. Herein we report a case of acute radiation syndrome caused by relatively short periods of high exposure to ionizing radiation and discuss the problems of the current system.
Patient
Thirty-one-year-old male.
Chief complaint
Anorexia, general weakness, prostration, and mild dizziness for several days.
Past medical history and family disease
No specific findings.
Social history
Current smoker (15 pack-years) and social drinker.
History of present illness
The patient had worked for 5 years in Yeosu National Industrial Complex as a non-destructive testing worker and had no job before. He performed radiographic testing using gamma radiation. In January 2017, the Korea Information System on Occupational Exposure (KISOE) found that his personal thermoluminescent dosimeter (TLD) badge indicated that he had exceeded the exposure limit. The patient’s TLD badge indicated that in December 2016, the patient’s radiation exposure dose for the month was 120 mSv. The patient’s radiation exposure dose was 1191 mSv according to the chromosome aberration test by South Korea’s Nuclear Safety and Security Commission (NSCC) [16]. The patient visited our hospital via the emergency room, and underwent a complete blood count test and bone marrow biopsy. It was revealed that the patient performed non-destructive tests without radiation shielding when working in high places of the large pipe surface.
Physical examination
When the patient came to our hospital, he was clearly conscious with a blood pressure of 140/80 mmHg, temperature of 37.5 °C, pulse rate of 104 beats/min, and respiration rate of 20 breaths/min. He was anemic. The venous injection areas had bruises and bleeding tendency. There were no abnormal findings in the cornea and lens of the eye. We tried to perform semen analysis but failed due to the patient’s condition. Subsequently, semen analysis could not be performed because of refusal by the patient.
Laboratory results
In a pre-placement medical examination conducted 6 months before the accident, all blood parameters were in the normal range: white blood cell count: 4920 cells/mm3, absolute neutrophil count: 2410 cells/mm3, absolute lymphocyte count: 1880 cells/mm3, hemoglobin: 14.7 g/dL, and platelet: 217 ×  103/mm3. A blood test performed in the hospital after the symptoms appeared showed severe pancytopenia: white blood cell count: 1360 cells/mm3, absolute neutrophil count: 500 cells/mm3, absolute lymphocyte count: 680 cells/mm3, hemoglobin: 7.1 g/dL, and platelet: 14 × 103/mm3. The laboratory results showed a slight recovery after 26 days from the date of prohibition of work: white blood cell count: 2200 cells/mm3, absolute neutrophil count: 760 cells/mm3, absolute lymphocyte count: 1080 cells/mm3. After a 13-month follow-up on the blood test, pancytopenia improved over time; however, it did not recover to the level before the accident (Table 2, Fig. 1).
Table 2
Changes in the laboratory results of the patient with acute radiation exposure
Variables Normal ranges Preplacement medical exama Days after prohibition of work
0 1 26 82 119 174 256 405
WBC (count/mm3) 4000-10,800 4920 1360 1400 2200 2100 2800 3500 4100 3800
ANC (count/mm3) 1500-8000 2410 500 590 760 830 1380 1660 1950 1470
ALC (count/mm3) 1500-4000 1880 680 650 1080 1030 1030 1280 1570 1780
AMC (count/mm3) 200–1000 560 179 150 310 210 360 520 550 520
Hemoglobin (g/dl) 12–18 14.7 7.5 7.1 10.3 7.3 10.8 13.2 14.0 14.1
RBC (× 103/mm3) 420–610 458 201 293 191 284 370 407 419
Hematocrit (%) 37–52 44.4 19.4 28.9 20.7 31.3 38.8 41.4 42.8
Platelet (× 103/mm3) 130–450 217 14 27 38 51 130 101 115
Reticulocyte (%) 0.5–1.5 1.05 1.72 1.69 1.9 1.54
Abbreviations: WBC white blood cell, ANC absolute neutrophil count, ALC absolute lymphocyte count, AMC absolute monocyte count, RBC red blood cell
aThe preplacement medical examination was conducted 6 months prior to the accident
Assessment of radiation dose
The patient’s radiation exposure dose was assessed using lymphocyte depletion kinetics. The patient’s lowest absolute lymphocyte count was 0.65 × 109 cells/L, and the radiation exposure dose based on this count was 1.4 Gy (95% confidence limits: 1.1–1.6) [17, 18]. The patient’s radiation exposure dose was 1191 mSv in the chromosome aberration test by South Korea’s NSCC [16].
On April 26, 1986, an explosion accident occurred in the Chernobyl nuclear power plant. On the day of the accident, about 600 employees worked in the site, and 134 of them had acute radiation syndrome due to the radiation exposure of 0.8 to 16 Gy. Within the first 3 months of the accident, 28 men died from radiation exposure [19]. In 1987, medical cesium-137 was stolen in Goiania, Brazil. Twenty villagers showed acute radiation syndrome, and 4 of them died [20, 21]. After these catastrophic accidents, the risk of radiation was spread widely; consequently, acute radiation syndrome cases have become rare due to strict controls. In the Fukushima nuclear power plant accident in March 2011, there was no report of acute radiation syndrome patients.
In Korea, radiation accidents repeatedly occurred to non-destructive testing workers, and tighter regulations and harsher punishment policies have been introduced. However, their fundamentally poor working conditions have not improved greatly as they still perform non-destructive testing overnight. To reduce radiation exposure doses in non-destructive testing workers, what needs to be done is: (i) use suitable shielding equipment, (ii) keep a safe distance from the source of radiation, (iii) reduce exposure time, and (iv) use safety equipment such as the personal dosimeter. In addition, replacing the penetration test that uses radiation with the ultrasound test could be a fundamental solution. While many applicable laws and rules are enforced for safety management, radiation exposure accidents have continued to occur in Korea. Furthermore, there could be many radiation over-exposure accidents that have not been reported. Along with further legislation, it is required to provide training and improve perception of changes among employers and employees.
A pre-placement medical examination is a process that conducts a medical check-up on the workers who are scheduled to do a job that exposes themselves to hazards before they are assigned to the job and identifies whether there is any health problem. A pre-placement medical examination was performed on this study’s subject 6 months before the accident pursuant to the Occupational Safety and Health Act. As a result, it was demonstrated from a blood test that all parameters were in the normal range and the subject was healthy before the accident. Accordingly, it served as definitive evidence proving that the subject’s pancytopenia was an acute health effect from the radiation exposure accident. This is a case where a pre-placement medical examination, which is mandatory, was effective for the healthcare of a worker. Had a pre-placement medical examination not been provided, it would have been difficult to identify whether the patient’s pancytopenia was a personal or occupational disease.
In Korea, workers exposed to health hazards receive a special health examination periodically, which is performed by occupational and environmental medicine specialists pursuant to the Occupational Safety and Health Act. However, a special health examination by occupational and environmental medicine specialists is not necessarily provided to radiation-exposed workers if a general health examination was provided already as per the Nuclear Safety Act or the Regulation on the Safety Management of Diagnostic Radiation Equipment. Occupational and environmental medicine specialists are medical doctors specializing in the prevention and early diagnosis of occupational diseases. A strict special health examination by occupational and environmental medicine specialists is required periodically for radiation-exposed workers just as for other workers exposed to health hazards.
Exposure prevention is clearly possible in radiation-exposed workers. Strict legal amendments are essential to prevent repeated radiation exposure accidents. Health care of radiation-exposed workers should be strictly managed by occupational medicine specialists.

ALC

Absolute lymphocyte count

AMC

Absolute monocyte count

ANC

Absolute neutrophil count

WBC

White blood cell
Prof. W-JP and MD. J-SA designed this report, prepared the draft of this manuscript. MD. H-ML and MD. WK collected and interpreted the data. MD. SC and MD. D-YL helped the clinical diagnosis. Prof. J-DM critically reviewed this manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Written informed consents were obtained from the patient for publication of this Case report and any accompanying data.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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      Acute radiation syndrome in a non-destructive testing worker: a case report
      Ann Occup Environ Med. 2018;30:59  Published online September 25, 2018
      DOI: https://doi.org/10.1186/s40557-018-0270-8
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    Acute radiation syndrome in a non-destructive testing worker: a case report
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    Fig. 1 Changes in the laboratory results of the patient with acute radiation syndrome

    Fig. 1

    Acute radiation syndrome in a non-destructive testing worker: a case report
    YearaSexDiseaseAge at diagnosis (years)Working duration (years)Reference
    2017MaleAcute radiation syndrome: pancytopenia, anemia315This study
    2015–Radiodermatitis: ulcer at fingers––KINS [1]
    2013MaleAzoospermia398Park J, et al. [6]
    2010MaleMyelodysplastic syndrome359Oh MS, et al. [4]
    2009MaleMyelodysplastic syndrome261Oh MS, et al. [4]
    2004–Radiodermatitis: necrosis at hand––KINS [11]
    2003–Radiodermatitis: sclerosis at dorsum manus25–KINS [11]
    ~ 2000MaleRadiodermatitis: sclerosis at fingers4010Park SW, et al. [10]
    ~ 2000MaleRadiodermatitis: necrosis at palm32–Park SW, et al. [10]
    1999–Radiodermatitis: ulcer at fingers and palm––KINS [11]
    1986~
    1996    		MaleRadiodermatitis: ulcer at fingers22–Kim KJ, et al. [5]
    MaleRadiodermatitis: ulcer at fingers28–Kim KJ, et al. [5]
    MaleRadiodermatitis: edema, erythema at fingers25–Kim KJ, et al. [5]
    MaleRadiodermatitis: erosion at palm19–Kim KJ, et al. [5]
    MaleRadiodermatitis: ulcer, sclerosis at fingers20–Kim KJ, et al. [5]
    MaleRadiodermatitis: ulcer, sclerosis at palm21–Kim KJ, et al. [5]
    ~ 1990MaleRadiodermatitis: desquamation, sclerosis at fingers22–Ro YS [9]
    1989–Amputation at fingers––KINS [11]
    ~ 1989MaleRadiodermatitis: desquamation, sclerosis at fingers22–Kim KJ, et al. [8]
    MaleRadiodermatitis: hardening at fingers28–Kim KJ, et al. [8]
    MaleRadiodermatitis: hardening at fingers25–Kim KJ, et al. [8]
    MaleRadiodermatitis: edema at palm19–Kim KJ, et al. [8]
    1984MaleRadiodermatitis: soft tissue injury at palm291Yoon SC, et al. [7]
    1983MaleRadiodermatitis: elliptical ulcer at lower abdomen292Yoon SC, et al. [7]
    1983MaleRadiodermatitis: edema, amputation at finger190.1Yoon SC, et al. [7]
    VariablesNormal rangesPreplacement medical examaDays after prohibition of work
    012682119174256405
    WBC (count/mm3)4000-10,800492013601400220021002800350041003800
    ANC (count/mm3)1500-800024105005907608301380166019501470
    ALC (count/mm3)1500-40001880680650108010301030128015701780
    AMC (count/mm3)200–1000560179150310210360520550520
    Hemoglobin (g/dl)12–1814.77.57.110.37.310.813.214.014.1
    RBC (× 103/mm3)420–610458201293191284370407419
    Hematocrit (%)37–5244.419.428.920.731.338.841.442.8
    Platelet (× 103/mm3)130–45021714273851130101115
    Reticulocyte (%)0.5–1.51.051.721.691.91.54
    Table 1 Case reports on accident exposure in Korean non-destructive testing workers

    aYear of diagnosis

    Table 2 Changes in the laboratory results of the patient with acute radiation exposure

    Abbreviations: WBC white blood cell, ANC absolute neutrophil count, ALC absolute lymphocyte count, AMC absolute monocyte count, RBC red blood cell

    aThe preplacement medical examination was conducted 6 months prior to the accident

    Table 1

    Table 2

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