Acute Elevation of Blood Lead Levels Within Hours of Ingestion of Large Quantities of Lead Shot

Background: Ingestion of elemental lead foreign bodies is felt to have a low risk of clinically significant lead absorption unless gastrointestinal pathology and/or prolonged transit time are present. We present a case of ingestion of a large quantity of small diameter lead shot accompanied by rapid elevation of blood lead levels. Case Report: A 5½-year-old previously healthy girl was found eating the pellets from an ankle weight. She vomited and complained of abdominal pain. In the emergency department, she had no complaints and normal vital signs. An abdominal X-ray showed thousands of small, round, metallic density objects in the stomach. Her white blood cell count was 14,700/mm³, and the hemoglobin, mean corpuscular volume, free erythrocyte protoporphyrin, zinc protoporphyrin, biochemistry panel 21, and urinalysis were normal. She had no prior lead level for comparison. Whole-bowel irrigation was begun and she passed over 11 stools with pellets as well as other foreign bodies (erasers, bead, etc.) in the first 24 hours. Pellets were still seen on X-ray the following day so she received a high-fiber diet and bisacodyl tablets 10 mg/d. On hospital day 2, her admission blood lead (drawn 13 hours after ingestion) was reported as 57 μg/dL (2.7 μm/L) and chelation was begun with oral 2,3-dimercaptosuccinic acid 10 mg/kg 3x/d for 5 days, then 2x/d for 14 days. Her peak measured lead level was 79 μg/dL approximately 36 hours after ingestion. She excreted 2273 μg lead in the urine during her first 24 hours of chelation. Her blood lead dropped to 14.3 μg/dL by the end of chelation. She did not develop any apparent signs of lead poisoning. Conclusion: Acute elevations of blood lead concentrations may occur rapidly after ingestion of multiple small elemental lead objects.     

Case of elevated blood lead in a South Asian family that has used Sindoor for food coloring

After a routine blood testing, a local pediatrician discovered that a 13-month-old boy had an elevated blood lead level (BLL) of 57 microg/dL. Since the baby was mostly breast-fed, the pediatrician did a blood test on the mother, and the result showed a BLL of 85 microg/dL. As the mother denied any history of pica behavior, the pediatrician suspected a source of lead to which the entire family might have been exposed and tested the father's BLL. The results showed a BLL of 95 microg/dL, and the pediatrician informed the poison center. The subsequent epidemiological investigation revealed that the parents had used a product called Sindoor for food coloring. Laboratory analyses showed that the product contains more than 57.8% of acid-extractable lead by weight. Given the extremely high content of Pb in this product, Sindoor poses a serious risk of lead poisoning if it is used for food coloring.     

Whole bowel irrigation in an acute oral lead intoxication

An 89-year-old man acutely ingested approximately three ounces of a ceramic glaze preparation with a 30% lead oxide content. A blood lead level of 18 micrograms/mL was reported from a sample drawn within 1 hour of ingestion and just prior to gastric lavage. Following lavage, an abdominal radiograph demonstrated lead throughout the small intestine. Whole bowel irrigation was then undertaken and subsequent x-rays demonstrated clearing of all lead in the small bowel. At 16 and 24 hours post-ingestion, blood lead levels rose to 39 micrograms/dL and 42 micrograms/dL, respectively, and the patient then underwent a 5-day course of chelation therapy. This is the first reported case of the use of whole bowel irrigation in an acute lead ingestion. The use of decontamination techniques in acute lead ingestions is reviewed.     

Multiple lead appendoliths following ingestion of lead shot: Time course and removal by laporoscopic appendectomy

Systemic lead poisoning may occur from ingested lead foreign bodies. Rarely, these may cause a retained appendolith. The risks of lead toxicity from these appendoliths, the time course of retention in the appendix, the rapidity of inhibition of heme synthesis, and the best approach to removal remain controversial. Fourteen days post-ingestion of a “handful” of lead shot, a 15-year-old male was admitted for elevated lead level; an x-ray showed aggregation of many pellets in the teen's appendix. A laparoscopic appendectomy was performed; examination of the removed appendix revealed greater than 50 retained pellets. An abdominal film obtained post-procedure showed removal of all but three of the pellets. Results from admission blood work found a blood lead level of 41 mcg/dL and free erythrocyte porphyrin (FEP) level of 114 μmol/mol heme (reference normal <70). After a short recovery the patient was discharged on succimer chelation therapy and on follow up, his lead level was <5 mcg/dL.     

Multiple lead appendoliths following ingestion of lead shot: time course and removal by laporoscopic appendectomy

Systemic lead poisoning may occur from ingested lead foreign bodies. Rarely, these may cause a retained appendolith. The risks of lead toxicity from these appendoliths, the time course of retention in the appendix, the rapidity of inhibition of heme synthesis, and the best approach to removal remain controversial. Fourteen days post-ingestion of a "handful" of lead shot, a 15-year-old male was admitted for elevated lead level; an x-ray showed aggregation of many pellets in the teen's appendix. A laparoscopic appendectomy was performed; examination of the removed appendix revealed greater than 50 retained pellets. An abdominal film obtained post-procedure showed removal of all but three of the pellets. Results from admission blood work found a blood lead level of 41 mcg/dL and free erythrocyte porphyrin (FEP) level of 114 μmol/mol heme (reference normal <70). After a short recovery the patient was discharged on succimer chelation therapy and on follow up, his lead level was <5 mcg/dL.     

Adverse effects of reduced-dose d-penicillamine in children with mild-to-moderate lead poisoning

BACKGROUND: Oral chelation therapy with d-penicillamine (d-PCN) has been proven to be effective in the treatment of mild-to-moderate lead poisoning. However, d-PCN is associated with a relatively high incidence of adverse effects when given in the standard dose of 25-30 mg/kg/d. Lower doses of d-PCN may reduce the rate of adverse effects without a significant reduction in the drug's efficacy. OBJECTIVE: To examine the incidence of rash, white blood cell and platelet count depression, and abnormal urinalysis with d-PCN when given in a dose of 15 mg/kg/d to children with blood lead concentrations <40 microg/dL. METHODS: Retrospective analysis of a clinical treatment course of children who received d-PCN during 1996 in the Lead and Toxicology Clinic of Children's Hospital, Boston. All children were treated under a reduced-dose d-PCN chelation protocol. RESULTS: During the study period, 55 children (mean age 37.4 mo) received 66 courses of d-PCN. Mean blood lead concentration before chelation was 24 microg/dL (range 15-37), with a corresponding erythrocyte protoporphyrin concentration of 42 microg/dL. After 77 days of treatment with d-PCN, blood lead concentration was reduced to mean 16 microg/dL (mean fall 35%; p = 0.005) and erythrocyte protoporphyrin was reduced to 28 microg/dL (p = 0.009). During chelation therapy, the white blood cell count fell below 5,000/mm3 in seven cases (9.7%); there were no episodes of platelet counts falling below 150,000/mm3. No cases of abnormal urinalysis were reported; three episodes of rash (4.5%) were recorded. The only patients prematurely terminated from therapy were those who developed rash; in all three cases, drug eruption was an isolated occurrence, which resolved within 48 hours of diphenhydramine therapy. All adverse effects were transient and resolved during or immediately after chelation therapy. CONCLUSIONS: Reduced-dose d-PCN appears to maintain efficacy at reducing blood lead concentrations. Reduced-dose d-PCN also appears to be associated with a rate of adverse effects lower than previously reported; observed adverse effects appear to be benign and transient.     

Asymptomatic congenital lead poisoning – case report

Context. Congenital lead poisoning is uncommon and there is no consensus on the management of the newborn. Case Details. A female infant was born to a lead-burdened woman identified by screening just prior to delivery. Maternal blood lead level (BLL) was 58 μg/dL. The infant's BLL on the second day of life was 72 μg/dL with a free erythrocyte protoporphyrin level of 175 μg/dL. The child was managed by an exchange transfusion followed by chelation. The BLL 6 h after exchange transfusion was 11.4 μg/dL. Follow-up 2 years later showed a BLL of 9 μg/dL and normal development. Discussion. We present the details of a case of congenital lead poisoning treated aggressively which appears to have resulted in a favorable outcome.     

Failure of dialysis therapy in potassium dichromate poisoning

A fatal case of oral ingestion of potassium dichromate is presented. Following an initial presentation of abdominal pain and vomiting, the patient had a rapid progression to coma with the development of methemoglobinemia, coagulopathy, gastrointestinal hemorrhage, and respiratory distress syndrome. A blood concentration of chromium on admission was 5,800 mcg/dL, 80% of which was found to be in the intracellular fraction. Supportive treatment was also initiated as a four-hour period of hemodialysis followed by a one-hour period of charcoal hemoperfusion. Neither of these treatment modalities was found to significantly remove chromium from whole blood and neither seemed to affect the progression or outcome of this intoxication. We conclude that the ingestion of potassium dichromate is highly toxic and may rapidly lead to death. Hemodialysis and charcoal hemoperfusion appear to have little role in the management of chromium intoxication.     

哈尔滨市140302例就诊患儿血铅检测结果分析

目的了解哈尔滨地区儿童血铅含量的现状,预防铅中毒。方法对2009年1月至2010年11月140 302例就诊患儿血铅含量测定结果分析,应用北京博晖钨舟型原子吸收光谱仪及专用稀释液进行测定。结果患儿血铅大于10μg/dL为血铅超标,分析患儿的血铅含量与患者年龄,应用统计学软件分析说明铅中毒与年龄有相关性(P<0.05),并且血铅与性别相关性密切(P<0.05)。结论儿童的铅中毒与儿童年龄性别有关,对儿童生长发育危害极大,有效的预防,及时的治疗至关重要。     

Combined exchange transfusion and chelation therapy for neonatal lead poisoning

OBJECTIVE: To describe the results of combined exchange transfusion and chelation therapy in a neonate with an elevated blood lead level (BLL). CASE SUMMARY: A 34-year-old Latina woman with a long history of pica (eating glazed pottery) gave birth to a healthy-appearing girl at 40 weeks of gestation. The mother's preconception BLL was 117 microg/dL and remained elevated throughout pregnancy. At parturition, the mother's BLL was 87 microg/dL and the infant's cord BLL was 100 microg/dL. The infant underwent single-volume exchange transfusion within 12 hours of birth. BLL was 28 microg/dL following the exchange, and a 5-day course of chelation with dimercaprol and CaNa2 ethylenediamine tetraacetic acid was initiated at 36 hours of life. The infant's BLL was 37 microg/dL at the end of inpatient chelation. DISCUSSION: Long-term neurologic disability from in utero lead exposure is well described, but the optimal treatment of elevated neonatal BLLs in healthy-appearing infants at the time of birth is not established. This strategy of combined chelation and exchange transfusion therapy was well tolerated and resulted in decreased lead levels, but the long-term neurologic efficacy of our combination strategy remains to be seen. CONCLUSIONS: Combined exchange transfusion and chelation therapy resulted in rapidly decreased lead levels in a neonate with chronic in utero lead exposure.     

Combined methylprednisolone and dexamethasone therapy for paraquat poisoning

OBJECTIVE: To report a severe case of paraquat poisoning successfully treated with repeated-pulse therapy of methylprednisolone. DESIGN: Case study. SETTING: University Hospital, Lin-Kou Medical Center, Taipei, Taiwan, Republic of China. PATIENTS: A 60-yr-old man with paraquat poisoning with severe acute renal failure (serum creatinine level of 11.8 mg/dL and serum paraquat level of 3.66 microg/mL at 10 hrs after ingestion) and severe hypoxemia (Pao2, 66.6 mm Hg). INTERVENTION: Repeated 3-day pulse therapy with methylprednisolone, one course of 2-day cyclophosphamide, and a high dose of dexamethasone for 33 days. MEASUREMENTS AND MAIN OUTCOME: Arterial blood gas analysis was obtained regularly. A chest radiography was obtained every week. The arterial blood oxygen concentrations dramatically elevated from 66 mm Hg to 97 mm Hg, and the chest radiographs markedly improved after repeated-pulse therapy with anti-inflammatory agents and cyclophosphamide. CONCLUSIONS: We successfully treated a severe paraquat poisoned patient with repeated methylprednisolone pulse therapy and prolonged dexamethasone treatment. This case demonstrates that the severe inflammation, not the fibrosis, of the lungs plays a major role in the lethal hypoxemia of patients with paraquat poisoning during the subacute period and confirms our previous hypotheses. Clearly, the use of anti-inflammatory therapy to treat paraquat-poisoned patients needs further evaluation; however, anti-inflammatory therapy may be an effective treatment after failure of standard therapies.     

Death Due to Acute Salicylate Intoxication Despite Dialysis

Background: Salicylate poisoning is a common problem with appreciable morbidity and mortality. We present a case of a patient with a large aspirin ingestion who expired despite aggressive hemodialysis (HD). Case Report: A 35-year-old man arrived at the Emergency Department 7.5 h after ingesting 400 tablets of 325-mg aspirin. He was afebrile, the respiratory rate (RR) was 30 breaths/min, heart rate (HR) 120 beats/min, blood pressure (BP) 125/76 mm Hg, and oxygen saturation 99% on room air. His salicylate concentration was 89.6 mg/dL. His initial arterial blood gas: pH 7.48, pCO₂ 21 mm Hg, PaO₂ 97 mm Hg, and bicarbonate 15.8 mmol/L. His initial serum chemistry panel was normal. He received activated charcoal and intravenous hydration with sodium bicarbonate. Two hours after arrival, salicylate concentration was 91.6 mg/dL. The patient became agitated and HD was initiated; 22 h after presentation, repeat salicylate concentration was 88.4 mg/dL and his creatinine was 3.9 mg/dL. A second run of HD was performed. After this, his temperature had risen to 39.06°C (102.3°F), BP 122/64 mm Hg, HR 168 beats/min, RR 43 breaths/min, and oxygen saturation 95% (2 L nasal cannula). His confusion increased, and he died 40 h after his ingestion. Conclusion: HD is widely advocated in managing severe salicylate intoxications, however, no consensus exists for the duration and best mode of therapy. Patients with severe salicylate poisonings may require extended durations of HD to effectively mitigate toxicity. Additional study is warranted to determine optimal therapy in severe salicylate intoxications.     

Lactate as a prognostic factor in carbon monoxide poisoning: a case report

Carbon monoxide (CO) poisoning results in various neuropsychological impairments, including delayed encephalopathy (DE) and death. However, factors related to these outcomes are unknown. A group suicide was attempted by 3 young people--a 31-year-old man (patient 1), a 21-year-old woman (patient 2), and a 20-year-old man (patient 3)--by burning charcoal in a closed car. At the emergency department, hypotension and hyperthermia were severe in patient 1, moderate in patient 2, and absent in patient 3, although all the patients were comatose. The initial serum lactate levels were 75.1 mg/dL in patient 1, 41.9 mg/dL in patient 2, and 26.3 mg/dL in patient 3, although the carboxyhemoglobin levels were approximately equal in all the patients. Hyperbaric oxygen therapy (HBOT) was immediately initiated and continued for 10 days in all the cases; however, the outcomes of these patients varied considerably. Patient 1 remained comatose and died on day 31 because of central diabetes insipidus after shock. Patient 2 recovered from coma and was discharged; however, she was rehospitalized for DE on day 45 and recovered completely after another 10-day HBOT. Patient 3 gained consciousness and recovered completely with no sequelae during the 1-year follow-up. From these cases, we can consider that the initial blood lactate may correlate with the patient outcomes and prove to be a useful prognostic factor. Thus, we should particularly consider elevated lactate levels in CO poisoning.     

Primary prevention of coronary artery disease through a family-oriented cardiac risk factor clinic

Primary prevention of coronary artery disease in children and young adults is important and can be instituted through a family-oriented cardiac risk factor clinic. Such a clinic was initiated at the Medical College of Georgia in March 1988. Children whose total cholesterol level (TC) exceeded 200 mg/dL when screened by their primary care physician were referred with their siblings and parents for fasting lipid profile and further evaluation. Data are available for the initial 21 families, including 30 children and 36 adults. The mean TC level was 258 mg/dL for index cases, 195 mg/dL for siblings, and 233 mg/dL for parents. Follow-up data obtained after therapy at a mean of 6 months are available for 12 families, including 14 children and 14 adults. The mean change in TC was from 265 to 246 mg/dL; 82% of the patients had a decrease in TC. Only one index case was documented as having neither a sibling nor a parent with an elevated cholesterol level. Family-oriented cardiac risk factor clinics are important for the identification and treatment of hypercholesterolemia in asymptomatic young people when primary prevention is possible.     

Biventricular assist device for scombroid poisoning with refractory myocardial dysfunction: a bridge to recovery

We report the usefulness of biventricular mechanical circulatory support in a 36-yr-old woman with refractory myocardial dysfunction resulting from scombroid poisoning. DESIGN: Case report. SETTING: Medical and surgical university care units. PATIENT: A previously healthy 36-yr-old woman with severe myocardial dysfunction unresponsive to epinephrine (1.3 microg/kg/min) and dobutamine (18 microg/kg/min) after the ingestion of cooked fresh tuna. INTERVENTION: Implantation at day 3 of a biventricular assist device consisting of two paracorporeal pneumatic pumps set at 70 beats/min to reach an output of 5.6 L/min during 8 days. MAIN RESULTS: The biventricular mechanical circulatory assist device allowed weaning of the inotropic drugs, maintenance of end-organ function, and support of the patient until myocardial recovery. The patient was successfully explanted 11 days after ingestion. Cardiac function had totally recovered, but a stroke was noted. At 3-yrs follow-up, there was no cardiac or neurologic sequela. CONCLUSIONS: This report describes severe myocardial dysfunction secondary to scombroid poisoning and demonstrates the usefulness of a mechanical circulatory assist device as a bridge to recovery.     

Modeling the effect of succimer (DMSA; dimercaptosuccinic acid) chelation therapy in patients poisoned by lead

Context: Kinetic models could assist clinicians potentially in managing cases of lead poisoning. Several models exist that can simulate lead kinetics but none of them can predict the effect of chelation in lead poisoning. Our aim was to devise a model to predict the effect of succimer (dimercaptosuccinic acid; DMSA) chelation therapy on blood lead concentrations.

Materials and methods: We integrated a two-compartment kinetic succimer model into an existing PBPK lead model and produced a Chelation Lead Therapy (CLT) model. The accuracy of the model’s predictions was assessed by simulating clinical observations in patients poisoned by lead and treated with succimer. The CLT model calculates blood lead concentrations as the sum of the background exposure and the acute or chronic lead poisoning. The latter was due either to ingestion of traditional remedies or occupational exposure to lead-polluted ambient air. The exposure duration was known. The blood lead concentrations predicted by the CLT model were compared to the measured blood lead concentrations.

Results: Pre-chelation blood lead concentrations ranged between 99 and 150?μg/dL. The model was able to simulate accurately the blood lead concentrations during and after succimer treatment. The pattern of urine lead excretion was successfully predicted in some patients, while poorly predicted in others.

Conclusions: Our model is able to predict blood lead concentrations after succimer therapy, at least, in situations where the duration of lead exposure is known.     

Blood Lead Levels in Emergency Department Patients with Retained Lead Bullets and Shrapnel

OBJECTIVE: To determine whether patients with retained lead shrapnel who present to the ED have elevated whole blood lead levels (BLLs) compared with matched control patients. METHODS: Test subjects were patients with x-ray evidence of retained lead shrapnel who presented to any of three urban EDs, and consented to inclusion in the study. BLLs were obtained from 15 ED patients, and data regarding time since injury and symptoms of plumbism were collected. Control subjects consisted of 15 ED patients, without similar lead exposure, matched for age, sex, race, and place of dwelling as determined by zip code, who also presented to any of the same three EDs. RESULTS: The mean (+/-SD) BLL in the test subjects was 17+/-9.78 microg/dL (range 7-50 microg/dL). Time since impalement ranged from 1 to 45 years. The mean BLL in the control subjects was 7+/-3.77 microg/dL (0-16 microg/dL). This difference was statistically significant (two-tailed t-test p = 0.002). CONCLUSIONS: In this preliminary study, the patients with retained lead shrapnel who presented to the ED had significantly elevated BLLs, compared with the matched control subjects. Chronic plumbism may be considered in patients with retained lead shrapnel, and a history should be taken to assess the presence of symptoms referable to plumbism. These patients may require long-term follow-up to assess the development of elevated blood lead level and lead toxicity.     

Methanol ingestion: prevention of toxic sequelae after massive ingestion

Methanol ingestion, a rare but potentially fatal poisoning, is often difficult to diagnose in the Emergency Department (ED) and historically has been difficult to treat. In this article, we report a methanol ingestion with a blood concentration of 692 mg/dL, which was treated with 4-methylpyrazole (Fomepizole) and dialysis, without sequelae. To our knowledge, such a massive ingestion has never been treated with this modality without development of long-term disability. Another unusual feature of this case is the significantly elevated serum osmolal gap at presentation without elevation in anion gap, demonstrating the effects of co-ingestion of ethanol. Additionally, there was a marked disparity between the patient’s breath alcohol analyzer level and the blood ethanol concentration, illustrating the inability of the breath alcohol analyzer to differentiate between volatile alcohols. Treatment of the methanol-poisoned patient with Fomepizole is discussed.     

Comparative analysis of zinc protoporphyrin and blood lead levels in lead-exposed Andean children

OBJECTIVES: The objective of this study was to investigate the zinc protoporphyrin/heme ratio (ZPP/heme) as a biomarker for chronic lead (Pb) poisoning in children with a history of high Pb exposure. DESIGN AND METHODS: ZPP/heme ratio was measured in blood samples from 78 children (44 females and 34 males) with persistent Pb exposure from Pb glazing of ceramics in a local cottage industry in the Andes Mountains of Ecuador. RESULTS: Mean blood lead (PbB) level was 26.4 microg/dL (SD: 23.2; range: 4.0-107.0), and the mean ZPP/heme ratio was 152.4 micromol/mol (SD: 190.6; range: 36.0-1064.0). A regression analysis of PbB level and ZPP/heme ratio revealed a significant association (r=0.761, p= <0.0001), with the logZPP showing a higher correlation with PbB (r=0.869, p= <0.0001). The ZZP/heme ratio decreased significantly with increasing age (ANOVA, p=0.030). The mean ZPP/heme ratios for females and males were 139.6 and 169.0 micromol/mol, respectively, and were not statistically different (t-test, p=0.504). CONCLUSION: The elevated ZPP/heme ratios, coupled with high PbB levels observed in this cohort of Andean children of Pb-glazing workers, suggest chronic Pb intoxication and probable iron deficiency.     

厦门市婴儿至学龄前儿童血铅检测结果与分析

目的了解厦门市儿童血铅水平分布状况,为预防儿童铅中毒提供依据。方法随机选择厦门妇幼保健院门诊就诊的儿童,年龄0～10岁,采用原子吸收石墨炉法测定全血血铅值。结果 2010～2013年间共有11 271例儿童检测全血血铅水平,血铅均值为51.0μg/L。不同年龄组的男童铅中毒率高于女童,差异有统计学意义(P0.05)。在1～6岁期间,随着年龄增加血铅均值逐渐上升,并在学龄前期达到高峰,之后的学龄期儿童均值不再增高,但血铅中毒率始终呈现逐渐下降的趋势。结论厦门市儿童铅中毒率接近国内其他城市平均水平,但学龄前儿童血铅的均值水平随年龄增长而增加,铅污染对儿童身体健康危害应引起重视。