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Biology and clinical features of radiation injury in adults

Author
Nicholas Dainiak, MD, FACP
Section Editor
Laurence A Boxer, MD
Deputy Editor
Jennifer S Tirnauer, MD

INTRODUCTION

The occurrence of industrial and medical radiation accidents and the threat of terrorist events involving radioactive material mandate the development and implementation of an appropriate medical response. Medical professionals who would logically be involved in such events include, among others, radiation safety officers, radiation oncologists, nuclear medicine physicians, emergency department physicians, hematologists, medical oncologists, infectious disease specialists, and gastroenterologists. All will be asked to play a significant role in evaluating and treating victims of an accidental or deliberate exposure to radiation. Due to their experience in managing patients with cytopenias and/or marrow aplasia, hematologists and medical oncologists will most likely be asked to take primary responsibility or a consultative role for the medical treatment of individuals exposed to a moderate or high dose of radiation.

However, all physicians, and especially medical triage personnel, must have an understanding of how radiation alters the function of cells, tissues, and organ systems, how radiation levels are quantified, and how victims receiving a significant radiation dose can be recognized and treated. In addition, all medical facilities should have a radiation emergency contingency plan with which their employees are familiar. Emergency personnel and hospital personnel must also be aware of local, state, and national resources that may be employed in the case of a radiological event [1].

General aspects of radiation biology and the clinical features of radiation injury in the adult will be discussed here. Clinical features of radiation exposure in children are presented separately. (See "Clinical features of radiation exposure in children".)

Triage and treatment of individuals involved in radiation accidents are also discussed separately. (See "Treatment of radiation injury in the adult" and "Management of radiation exposure in children following a nuclear disaster".)

Separate topic reviews address the risks of radiation injury from imaging procedures and decision making regarding these risks. (See "Radiation-related risks of imaging studies" and "Radiation dose and risk of malignancy from cardiovascular imaging".)

                               

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Literature review current through: Nov 2016. | This topic last updated: Tue Apr 12 00:00:00 GMT+00:00 2016.
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References
Top
  1. Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med 2004; 140:1037.
  2. Sarkany RP. Ultraviolet radiation and the skin. In: Encyclopedia of Environmental Heath, Nriagu JO (Ed), Elsevier, New York 2011. p.469.
  3. Hall EJ. Radiobiology for the Radiologist, 5th ed, Lippincott, Williams & Wilkins, Philadelphia 2000.
  4. National Research Council, Committee on the Biological effects of Ionizing Radiation. Health Effects of Exposure to Low Levels of Ionizing Radiation, BEIR V. Washington, DC: National Academy Press 1990.
  5. Chinsoo Cho L, Glatstein E. Radiation Injury. In: Harrison's Principles of Internal Medicine, Fauci AS, Braunwald E, Isselbacher KL, et al. (Eds), McGraw-Hill, New York 1998. p.2559.
  6. Mettler FA Jr, Royal HD, Drum DE. Radiation accidents. In: Textbook of pediatric emergency medicine, 4th ed, Fleisher GR, Ludwig S (Eds), Lippincott, Philadelphia 2000. p.965.
  7. Mettler FA Jr, Bhargavan M, Faulkner K, et al. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources--1950-2007. Radiology 2009; 253:520.
  8. Fazel R, Krumholz HM, Wang Y, et al. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 2009; 361:849.
  9. McKetty MH. Study of radiation doses to personnel in a cardiac catheterization laboratory. Health Phys 1996; 70:563.
  10. Brix G, Lechel U, Glatting G, et al. Radiation exposure of patients undergoing whole-body dual-modality 18F-FDG PET/CT examinations. J Nucl Med 2005; 46:608.
  11. Christodouleas JP, Forrest RD, Ainsley CG, et al. Short-term and long-term health risks of nuclear-power-plant accidents. N Engl J Med 2011; 364:2334.
  12. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357:2277.
  13. Rohner DJ, Bennett S, Samaratunga C, et al. Cumulative total effective whole-body radiation dose in critically ill patients. Chest 2013; 144:1481.
  14. Dainiak N. Radiation dose and stochastic risk from exposure to medical imaging. Chest 2013; 144:1431.
  15. Rapiscan Systems. Rapiscan Secure 1000 Single Pose. www.rapiscansystems.com/rapiscan-secure-1000-single-pose.html (Accessed on October 16, 2012).
  16. Doses in our daily lives. United States Nuclear Regulatory Commission. www.nrc.gov/about-nrc/radiation/around-us-daily-lives.html (Accessed on October 16, 2012).
  17. Gale RP. Fukushima not a repeat of Chernobyl: A doctor's analysis of nuclear accidents. Cancer Lett 2011; 37:13:April 1.
  18. Neriishi K, Nakashima E, Akahoshi M, et al. Radiation dose and cataract surgery incidence in atomic bomb survivors, 1986-2005. Radiology 2012; 265:167.
  19. Schull WJ. Effects of atomic radiation: A half-century of studies from Hiroshima and Nagasaki, J Wiley, New York 1996.
  20. Rotblat J. Acute mortality in nuclear war. In: The Medical Implications of Nuclear War, Soloman F, Marston RQ (Eds), Institute of Medicine, National Academy of Sciences, Washington, DC 1986.
  21. Mole RH. The LD50 for uniform low LET irradiation of man. Br J Radiol 1984; 57:355.
  22. Reeves GI. Radiation injuries. Crit Care Clin 1999; 15:457.
  23. Lushbaugh CC. Reflections on some recent progress in human radiobiology. In: Advances in Radiation Biology, Augenstein LC, Mason R, Zelle M (Eds), Academic Press, New York 1969. p.277.
  24. Vriesendorp HM, Van Bekkum DW. Susceptibility to total-body irradiation. In: Response to Total-Body Irradiation in Different Spe, Broerse JJ, MacVittie T (Eds), Martinus Nijhoff, Amsterdam 1984.
  25. Anno GH, Young RW, Bloom RM, Mercier JR. Dose response relationships for acute ionizing-radiation lethality. Health Phys 2003; 84:565.
  26. Saenger EL. Radiation accidents. Ann Emerg Med 1986; 15:1061.
  27. Dainiak N, Berger P, Albanese J. Relevance and feasibility of multi-parameter assessment for management of mass casualties from a radiological event. Exp Hematol 2007; 35:17.
  28. Blakely WF, Ossetrova NI, Manglapus GL, et al. Amylase and blood cell-count hematological radiation-injury biomarkers in a rhesus monkey radiation model—use of multiparameter and integrated biological dosimetry. Radiat Meas 2007; 42:1164.
  29. Riecke A, Ruf CG, Meineke V. Assessment of radiation damage-the need for a multiparametric and integrative approach with the help of both clinical and biological dosimetry. Health Phys 2010; 98:160.
  30. Nese J, Skudlarska B, Smith D, Dainiak N. Impact of mass casualties resulting from radiation exposure on healthcare systems. In: Encyclopedia of Environmental Health, Nriagu JO (Ed), Elsevier, New York 2011. p.165.
  31. Knebel AR, Coleman CN, Cliffer KD, et al. Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep 2011; 5 Suppl 1:S20.
  32. Bouville A, Anspaugh L, Beebe GQ. What is desirable and feasible in dose reconstruction for application in epidemiological studies?. In: The Radiological Consequences of the Chernobyl Accident, Karaglou A, Desmetg G, Kelly GN, et al. (Eds), Office for Official Public of the European Communities, Luxembourg 1996. p.995.
  33. Brooks AL. Biomarkers of exposure, sensitivity and disease. Int J Radiat Biol 1999; 75:1481.
  34. Management of Persons Accidentally Contaminated with Radionuclides. NCRP Report No.65, Bethesda, MD: National Council on Radiation Protection and Measurements 1979.
  35. Bender MA, Gooch PC. Somatic chromosome aberrations induced by human whole-body irradiation: the "Recuplex" criticality accident. Radiat Res 1966; 29:568.
  36. Bender MA. Cytogenetics research in radiation biology. Stem Cells 1995; 13 Suppl 1:172.
  37. Kolanko CJ, Pyle MD, Nath J, et al. In situ detection of a PCR-synthesized human pancentromeric DNA hybridization probe by color pigment immunostaining: application for dicentric assay automation. Biotech Histochem 2000; 75:91.
  38. Pantelias GE, Maillie HD. Direct analysis of radiation-induced chromosome fragments and rings in unstimulated human peripheral blood lymphocytes by means of the premature chromosome condensation technique. Mutat Res 1985; 149:67.
  39. International Atomic Engery Agency. Cytogenetic Dosimetry: Applications in Preparedness for and Response to Radiation Emergencies. IAEA, Vienna 2011. http://www-pub.iaea.org/MTCD/Publications/PDF/EPR-Biodosimetry%202011_web.pdf (Accessed on December 12, 2013).
  40. Lloyd DC, Edwards AA, Moquet JE, Guerrero-Carbajal YC. The role of cytogenetics in early triage of radiation casualties. Appl Radiat Isot 2000; 52:1107.
  41. Fliedner TM, Friesecke I, Beyrer K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome, The British Institute of Radiology, Oxford 2001.
  42. Goans RE, Holloway EC, Berger ME, Ricks RC. Early dose assessment in criticality accidents. Health Phys 2001; 81:446.
  43. Goans RE, Holloway EC, Berger ME, Ricks RC. Early dose assessment following severe radiation accidents. Health Phys 1997; 72:513.
  44. Wald N. Diagnosis and therapy of radiation injuries. Bull N Y Acad Med 1983; 59:1129.
  45. Hartmann A, Bojar H, Zamboglou N, et al. [The significance of clinical prodromes for dosage estimation after whole-body radiation exposure]. Strahlenther Onkol 1994; 170:538.
  46. Gottlöber P, Krähn G, Peter RU. [Cutaneous radiation syndrome: clinical features, diagnosis and therapy]. Hautarzt 2000; 51:567.
  47. Goans RE. Clincal care of the radiation-accident patient: patient presentation, assessment and initial diagnosis. In: The Medical Basis for Radiation-accident preparedness: The clinical care of victims, Ricks RC, Berger ME, O'Hara FM (Eds), Parthenon Publishing Group, Boca Raton, FL 2002.
  48. Demidenko E, Williams BB, Swartz HM. Radiation dose prediction using data on time to emesis in the case of nuclear terrorism. Radiat Res 2009; 171:310.
  49. Dainiak N, Gent RN, Carr Z, et al. Medical management of acute radiation syndrome: an international consensus and evidence based recommendations. Manuscript submitted for publication.
  50. Prasanna PG, Escalada ND, Blakely WF. Induction of premature chromosome condensation by a phosphatase inhibitor and a protein kinase in unstimulated human peripheral blood lymphocytes: a simple and rapid technique to study chromosome aberrations using specific whole-chromosome DNA hybridization probes for biological dosimetry. Mutat Res 2000; 466:131.
  51. Fenech M. The lymphocyte cytokinesis-block micronucleus cytome assay and its application in radiation biodosimetry. Health Phys 2010; 98:234.
  52. Garty G, Chen Y, Salerno A, et al. The RABIT: a rapid automated biodosimetry tool for radiological triage. Health Phys 2010; 98:209.
  53. Dainiak N, Schreyer SK, Albanese J. The search for mRNA biomarkers: global quantification of transcriptional and translational responses to ionising radiation. BJR Suppl 2005; 27:114.
  54. Amundson SA, Bittner M, Meltzer P, et al. Induction of gene expression as a monitor of exposure to ionizing radiation. Radiat Res 2001; 156:657.
  55. Schreyer SK, Karkanitsa LV, Albanese J, et al. Analysis of radiation-associated changes in gene expression using microarray technology. Br J Radiol 2002; Suppl 26:129.
  56. Albanese J, Martens K, Karanitsa LV, et al. Multivariate analysis of low-dose radiation-associated changes in cytokine gene expression profiles using microarray technology. Exp Hematol 2007; 35:47.
  57. Meadows SK, Dressman HK, Muramoto GG, et al. Gene expression signatures of radiation response are specific, durable and accurate in mice and humans. PLoS One 2008; 3:e1912.
  58. Paul S, Amundson SA. Development of gene expression signatures for practical radiation biodosimetry. Int J Radiat Oncol Biol Phys 2008; 71:1236.
  59. Paul S, Smilenov LB, Amundson SA. Widespread decreased expression of immune function genes in human peripheral blood following radiation exposure. Radiat Res 2013; 180:575.
  60. Marchetti F, Coleman MA, Jones IM, Wyrobek AJ. Candidate protein biodosimeters of human exposure to ionizing radiation. Int J Radiat Biol 2006; 82:605.
  61. Johnson CH, Patterson AD, Krausz KW, et al. Radiation metabolomics. 5. Identification of urinary biomarkers of ionizing radiation exposure in nonhuman primates by mass spectrometry-based metabolomics. Radiat Res 2012; 178:328.
  62. Swartz HM, Burke G, Coey M, et al. In Vivo EPR For Dosimetry. Radiat Meas 2007; 42:1075.
  63. Dewitt R, Klein DM, Yukihara EG, et al. Optically stimulated luminescence (OSL) of tooth enamel and its potential use in post-radiation exposure triage. Health Phys 2010; 98:432.
  64. Sullivan JM, Prasanna PG, Grace MB, et al. Assessment of biodosimetry methods for a mass-casualty radiological incident: medical response and management considerations. Health Phys 2013; 105:540.
  65. Bentzen SM. Preventing or reducing late side effects of radiation therapy: radiobiology meets molecular pathology. Nat Rev Cancer 2006; 6:702.
  66. Barnett GC, West CM, Dunning AM, et al. Normal tissue reactions to radiotherapy: towards tailoring treatment dose by genotype. Nat Rev Cancer 2009; 9:134.
  67. Dainiak N. Hematologic consequences of exposure to ionizing radiation. Exp Hematol 2002; 30:513.
  68. McCulloch EA, Till JE. The sensitivity of cells from normal mouse bone marrow to gamma radiation in vitro and in vivo. Radiat Res 1962; 16:822.
  69. van Bekkum DW. Radiation sensitivity of the hemopoietic stem cell. Radiat Res 1991; 128:S4.
  70. Inoue T, Hirabayashi Y, Mitsui H, et al. Survival of spleen colony-forming units (CFU-S) of irradiated bone marrow cells in mice: evidence for the existence of a radioresistant subfraction. Exp Hematol 1995; 23:1296.
  71. Fliedner TM, Tibken B, Hofer EP, Paul W. Stem cell responses after radiation exposure: A key to the evaluation and prediction of its effects. Health Phys 1996; 70:787.
  72. Amundson SA, Bittner M, Meltzer P, et al. Physiological function as regulation of large transcriptional programs: the cellular response to genotoxic stress. Comp Biochem Physiol B Biochem Mol Biol 2001; 129:703.
  73. Amundson SA, Do KT, Shahab S, et al. Identification of potential mRNA biomarkers in peripheral blood lymphocytes for human exposure to ionizing radiation. Radiat Res 2000; 154:342.
  74. Goldberg Z, Schwietert CW, Lehnert B, et al. Effects of low-dose ionizing radiation on gene expression in human skin biopsies. Int J Radiat Oncol Biol Phys 2004; 58:567.
  75. Amundson SA, Fornace AJ Jr. Gene expression profiles for monitoring radiation exposure. Radiat Prot Dosimetry 2001; 97:11.
  76. Sreekumar A, Nyati MK, Varambally S, et al. Profiling of cancer cells using protein microarrays: discovery of novel radiation-regulated proteins. Cancer Res 2001; 61:7585.
  77. Gale RP. Immediate medical consequences of nuclear accidents. Lessons from Chernobyl. JAMA 1987; 258:625.
  78. Roberts L. Radiation accident grips Goiânia. Science 1987; 238:1028.
  79. Gerusky TM. Three Mile Island: assessment of radiation exposures and environmental contamination. Ann N Y Acad Sci 1981; 365:54.
  80. Brumfiel G. Fukushima's doses tallied. Nature 2012; 485:423.
  81. Akashi M, Tominaga T, Hachiya M. Medical management of the consequences of the Fukushima nuclear power plant incident. Proceedings of the 5th International REAC/TS Symposium: The Medical Basis for Radiation Accident Preparedness and the Biodosimetry Workshop, Oak Ridge Associated Universities, Oak Ridge 2013. p.19.
  82. Yasumura S, Hosoya M, Yamashita S, et al. Study protocol for the Fukushima Health Management Survey. J Epidemiol 2012; 22:375.
  83. Ricks RC. The radiation-accident patient in the new millennium: past history and future threats. In: The Medical Bases for Radiation-Accident Preparedness: The Clinical Care of Victims, Ricks RC, Berger ME, O'Hara FM (Eds), The Parthenon Publishing Group, Boca Raton, FL 2002. p.1.
  84. Dainiak N, Ricks RC. The evolving role of haematopoietic cell transplantation in radiation injury: potentials and limitations. BJR Suppl 2005; 27:169.
  85. DiCarlo AL, Maher C, Hick JL, et al. Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep 2011; 5 Suppl 1:S32.
  86. Fliedner TM, Feinendergen LE, Hopewell JW. Chronic irradiation: tolerance and failure in complex biological systems. Br J Radiol 2002; suppl 26:1.
  87. Fliedner TM, Meineke V, Dainiak N, et al. Radiation-Induced Multi-Organ Involvement and Failure: A Challenge for Pathogenetic, Diagnostic and Therapeutic Approaches and Research, British Insitute of Radiology, Ulm 2003.
  88. Petrova A, Gnedko T, Maistrova I, et al. Morbidity in a large cohort study of children born to mothers exposed to radiation from Chernobyl. Stem Cells 1997; 15 Suppl 2:141.
  89. The Radiological Consequences of the Chernobyl Accident, Karaoglou A, Desmet G, Kelly GN, Menzel HG (Eds), Luxembourg: Office of the European Communities, 1996.
  90. Flynn D. Advances in the diagnosis and management of acute radiation syndrome, cutaneous radiation syndrome, and acute local radiation injuries. Proceedings of the 5th International REAC/TS Symposium: The Medical Basis for Radiation Accident Preparedness and the Biodosimetry Workshop, Oak Ridge Associated Universities, Oak Ridge 2013. p.109.
  91. Albanese J, Dainiak N. Ionizing radiation alters Fas antigen ligand at the cell surface and on exfoliated plasma membrane-derived vesicles: implications for apoptosis and intercellular signaling. Radiat Res 2000; 153:49.
  92. Goans RE, Iddins CJ, Christensen DM. Ultrasound and thermography for diagnosis of extent and magnitude of acute local radiation injury (LRI). Proceedings of the 5th International REAC/TS Symposium: The Medical Basis for Radiation Accident Preparedness and the Biodosimetry Workshop, Oak Ridge Associated Universities, Oak Ridge 2013. p.133.
  93. Gottlöber P, Steinert M, Weiss M, et al. The outcome of local radiation injuries: 14 years of follow-up after the Chernobyl accident. Radiat Res 2001; 155:409.
  94. Barabanova AV. Acute radiation syndrome with cutaneous syndrome. In: The Medical Basis for Radiation-Accident Preparedness, Ricks RC, Berger ME, O'Hara FM Jr (Eds), The Parthenon Publishing Group, New York 2002. p.217.
  95. Guidance for radiation accident management www.orau.gov/reacts/guidance.htm (Accessed on August 10, 2004).
  96. Lushbaugh CC. Human radiation tolerance. In: Bioastronautics Data Book. NASA-S-30006, Parker J Jr (Ed), National Aeronotics and Space Administration, Washington, DC 1973. p.421.
  97. Wald N. Radiation Injury. In: Cecil Textbook of Medicine, Wyngaarden JB, Smith LH Jr (Eds), WB Saunders, Philadelphia 1982. p.2228.
  98. Anno GH, Baum SJ, Withers HR, Young RW. Symptomatology of acute radiation effects in humans after exposure to doses of 0.5-30 Gy. Health Phys 1989; 56:821.
  99. Fliedner TM, Friesecke I, Beyrer K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome, Institute of Radiology, Oxford 2001.
  100. Gangloff H. Hippocampal spike activity following low doses of irradiation. In: Response of the Nervous System to Ionizing Radiation, Haley TJ, Snider RS (Eds), Little Brown, Boston 1964. p.221.
  101. Medical Consequences of Nuclear Warfare. Walker RI, Cerveny RJ (Eds), Office of the Surgeon General, Falls Church, VA 1989. Available at: www.afrri.usuhs.mil (Accessed on August 10, 2004).
  102. Dubois A, Walker RI. Prospects for management of gastrointestinal injury associated with the acute radiation syndrome. Gastroenterology 1988; 95:500.
  103. Chinsoo Cho L, Glatstein E. Radiation Injury. In: Harrison's Principles of Internal Medicine, Fauci AS, Braunwald E Isselbacher KL, et al (Eds), McGraw-Hill, New York 1998. p.2559.
  104. Husebye E, Hauer-Jensen M, Kjørstad K, Skar V. Severe late radiation enteropathy is characterized by impaired motility of proximal small intestine. Dig Dis Sci 1994; 39:2341.
  105. Stodtmeister R, Sandkuhler S, Fliedner TM. Uber die pathogenese akuter knochenmarkatrophie bei ratten nach ganzkorperbestrahlung mit schnellen elektronen. Folia Haematologica 1956; 3:303.
  106. Pichardo JC, Trindade AA, Brindle JM, Bolch WE. Method for estimating skeletal spongiosa volume and active marrow mass in the adult male and adult female. J Nucl Med 2007; 48:1880.
  107. Andrews GA, Auxier JA, Lushbaugh CC. The importance of dosimetry to the medical management of persons accidentally exposed to high levels of radiation. In: Personnel Dosimetry for Radiation Accidents, IAEA, Vienna, Vienna 1965. p.3.
  108. ANDREWS GA, CLOUTIER RJ. ACCIDENTAL ACUTE RADIATION INJURY. THE NEED FOR RECOGNITION. Arch Environ Health 1965; 10:498.
  109. Barlow Y. T lymphocytes and immunosuppression in the burned patient: a review. Burns 1994; 20:487.
  110. Cheadle WG, Pemberton RM, Robinson D, et al. Lymphocyte subset responses to trauma and sepsis. J Trauma 1993; 35:844.
  111. Lebedev MY, Sholkina MN, Utkina TM, et al. Immunophenotype of Peripheral Blood Lymphocytes in Patients with Burns. Russ J Immunol 2001; 6:47.
  112. Vorobiev AI. Acute radiation disease and biological dosimetry in 1993. Stem Cells 1997; 15 Suppl 2:269.
  113. Rezvani M, Hopewell JW, Wilkinson JH, et al. Time- and dose-related changes in the thickness of skin in the pig after irradiation with single doses of thulium-170 beta particles. Radiat Res 2000; 153:104.
  114. Peter RU. Cutaneous radiation syndrome — clinical and therapeutic aspects. Rad Protect Bull 1996; 183:19.
  115. Medical Management of Radiation Accidents, 2nd ed, Gusev I, Guskova AK, Mettler Fa Jr (Eds), CRC Press, Boca Raton, FL 2001.