Management of Lead Encephalopathy with DMSA After Exposure to Lead-Contaminated Moonshine

Background

Lead encephalopathy is a severe manifestation of lead poisoning that can present with altered mental status and seizures and has been associated with illicit moonshine consumption. Lead encephalopathy has traditionally been treated using dimercaprol (British anti-Lewisite, BAL) and calcium disodium ethylenediaminetetraacetic acid (CaNa₂EDTA).

Case Report

We describe a patient with lead encephalopathy related to lead-contaminated moonshine consumption, who was treated using dimercaptosuccinic acid (DMSA) due to a national shortage of CaNa₂EDTA. A 66-year-old woman presented to a hospital with headache, irritability, and altered mental status. On hospital day 16, she was found to have a whole blood lead concentration of 148.2 μg/dL and a 24-h urine lead concentration of 232 μg/day. Due to a national shortage of CaNa₂EDTA, the patient was given one dose of BAL and then started on DMSA via nasogastric tube. She dramatically improved over 4 days and was subsequently transitioned to oral DMSA and outpatient treatment. One day prior to discharge, her whole blood lead concentration was 47.2 μg/dL and her mental status was normal. DMSA was used in lieu of CaNa₂EDTA to treat the patient with lead encephalopathy. The patient subsequently experienced clinical improvement and declining whole blood level concentrations.

Conclusion

Further prospective studies are needed to compare the efficacy of DMSA versus CaNa₂EDTA in patients with lead encephalopathy.     

Effect of treatment with mercury chloride and lead acetate during the second stage of rapid postnatal brain growth on δ-aminolevulinic acid dehydratase (ALA-D) activity in brain, liver, kidney and blood of suckling rats

The sensitivity of developing rodents to toxic metals differs considerably from that of adults. In the present study, we investigated the in vivo and in vitro effects of inorganic mercury and lead on δ-aminolevulinic acid dehydratase (ALA-D) from brain, liver, kidney and blood of young rats. Eight day-old rats were injected with one or five doses of lead acetate (0, 3.5, or 7.0 mg/kg) or HgCl₂ (0, 2.5, or 5.0 mg/kg). In vitro, the IC₅₀ for mercury inhibition of cerebral, renal and hepatic ALA-D was in the 124 to 160 μM range, while values for lead acetate was in the 7 to 12 μM range. The IC₅₀ of blood enzyme for lead (0.8 μM) and mercury (6.5 μM) was significantly lower than that observed for the other tissues. A single dose of lead did not affect the enzyme activity, but a single dose of HgCl₂ (5 mg/kg) caused a significant inhibition of ALA-D from kidney (40%, P < 0.01) and liver (25%, P < 0.05). Five doses of lead acetate (3.5 or 7 mg/kg) caused an inhibition of about 25 and 40%, respectively (P < 0.01), of hepatic ALA-D, and an increase of 1.4-fold (P < 0.05) and 2.6-fold (P < 0.01) of blood enzyme, respectively. Treatment with five doses of HgCl₂ (5 mg/kg) caused an inhibition of about 25, 60, 50, and 80% of ALA-D from brain, blood, liver and kidney, respectively (all P < 0.05). Five doses of 2.5 mg/kg HgCl₂ caused an inhibition of ALA-D from liver (40%, P < 0.01) and kidney (45%, P < 0.01). These results demonstrate that ALA-D from young rat tissues show different sensitivities to mercury and lead. The enzyme was more affected by mercury than by lead in vivo, while in vitro lead was more potent that mercury as an ALA-D inhibitor.     

Influence of chelation therapy on acute lead intoxication in rats

The intraperitoneal administration of Pb acetate (5 × 20 mg Pb/kg per day) evokes a moderate and transient hypochromic anemia, a long-lasting enhanced urinary excretion of -aminolevulinic acid whereas the urinary excretion of alkaline phosphatase is not affected and that of lactic debyhrogenase only marginally. It is concluded that neither the hematologic response nor the slight nephrotoxicity are responsible for the lethal action of Pb. Chelate treatment started 3 days after the last Pb dose and was continued over 7 weeks. The daily intraperitoneal dose was 25, 50, and 100 mol/kg, respectively. The efficacy in promoting the urinary excretion of Pb decreased in the following order: Ca diethylenetriaminepentaacetate > 2,3-dimercaptopropane-1-sulfonate > Zn diethylenetriaminepentaacetate > D-penicillamine. This effect was mainly due to the mobilization of skeletal Pb. The chelating agents also lowered the excretion of -aminolevulinic acid but failed to exert a beneficial influence on the anemia and the lethal action of Pb. These negative results raise questions about the usefulness of chelation therapy in cases of acute Pb poisoning.     

Activity of glutathione-S-transferase in rat liver and kidneys after administration of lead or cadmium

The influence of an acute dose of lead nitrate or cadmium chloride on the activity of glutathione-S-trans-ferase (GST) was investigated in rats. CdCl₂ (10 mol/kg) did not influence the enzyme activity in either organ. In contrast Pb(NO₃)₂ (100 mol/kg) caused a significant increase of GST activity in both organs. SDS polyacrylamide gel electrophoresis (SDS-PAGE) showed that in liver the activity enhancement is due mainly to the induction of the isoenzyme GST 7-7, while in the kidneys the activity of all the isoenzymes is increased.     

Effect of lead on electrophoretic mobility of rat erythrocytes

Lead often affects the erythrocyte membrane. The relationship between the changes in erythrocyte membrane and the anemia caused by lead is still unclear. Initially, the effect of lead injected intraperitoneally on the electrophoretic mobility of rat erythrocytes was investigated in order to study the relationship between them. As indices of lead exposure, hemoglobin (Hb) levels, hematocrits (Ht), δ-aminolevulinic acid dehydratase (ALA-D) activities and blood lead (blood Pb) levels in the injected rats were also examined. Exposure to lead significantly decreased the mobility of rat erythrocytes. The changes in mobility seemed to be less sensitive than those in ALA-D activity, however, the decreases in mobility were simultaneous with or prior to those in Hb level and Ht. The decreases in mobility were evident to some extent below a blood Pb level of 100 μg/100 ml and generally present at a level of 100 μg/100 ml and over. In the rats exposed to lead a significant negative correlation was found between the mobilities and the logarithms of blood Pb level.     

MOBILIZATION OF LEAD BY CALCIUM VERSENATE AND DIMERCAPTOSUCCINATE IN THE RAT

1. Calcium disodium ethylenediaminetetraacetate (CaNa₂ EDTA) and meso-2,3-dimercaptosuccinic acid (DMSA) individually and in permutation-combination in various doses (0.1,0.2 and 0.4 mmol/kg bodyweight) were investigated for their efficacy to mobilize lead from vital tissues into urine and faeces and to restore the lead-sensitive biochemical parameters in lead pre-exposed rats with a view to develop the most acceptable treatment regimen for lead poisoning with a minimal loss of endogenous essential elements. 2. The combined therapy was more effective than a single chelator treatment. 3. The combination of 0.2 mmol/kg CaNa₂EDTA + 0.4 mmol/kg DMSA caused a lower depletion of zinc, calcium and iron but possessed almost equal capability to that of 0.4 mmol/kg CaNa₂EDTA + 0.4 mmol/kg DMSA to produce urinary as well as faecal excretion of lead, to reduce the tissue burden of lead, including that of the brain, and to reverse lead-induced biochemical alterations. 4. The combination of 0.2 mmol/kg CaNa₂EDTA + 0.4 mmol/kg DMSA has shown a definite improvement over previously reported combinations in terms of removal of lead from tissues, particularly the brain, restoration of urinary delta-aminolevulinic acid levels and a decrease in the loss of body zinc and is, therefore, recommended for the treatment of lead intoxication.     

Erythrocyte enzymes in experimental lead poisoning

Intravenous administration of 6 mg per kg lead acetate to rabbits resulted in plumbism with elevated erythrocyte lead levels and marked depression of activity of erythrocyte -aminolevulmic acid dehydratase. By comparison other erythrocyte enzymes were insensitive to the effects of lead. Activities of anaerobic glycolysis and of the hexose monophosphate shunt were unaffected by lead administration as were erythrocyte methemoglobin reductase, acid phosphatase, glucose-6-phosphate dehydrogenase, malic dehydrogenase and acetylcholinesterase. The insensitivity of these erythrocyte enzymes to inhibition by lead excludes their usefulness for detection or diagnosis of plumbism.     

Lead in blood and tissues of mice after administration of low lead doses

Lead levels in whole blood could be determined reliably up to a lower limit of 2 g/100 ml blood, using a modified micromethod of the graphite tube furnace technique. Lead contents of various tissues were also determined by using the automated graphite tube furnace after wet ashing of the organs with nitric acid in autoclaves.Animal experiments with mice showed no measurable increase in blood lead level after a single, 10- or 30-days oral administration of lead in doses of 10–1000 g lead acetate/kg body weight/day. However, these doses led to a rise in tissue lead content. There was a clear dependence of tissue lead content on type of organ examined, lead dose and duration of lead exposure.According to our experiments, the threshold dose which leads to a long-term increase in tissue lead content is assumed to be about 100 g lead acetate/kg body weight/day, orally administered.We are thankful to Prof. Dr. H. Rüssel, Hannover and Dr. M. Fleischer, Saarbrücken for helping in comparison studies.We would also like to thank Mr. H. Dick and Miss. Ch. Hecker for the technical and laboratory assistance.     

Effect of Zinc or S-Adenosyl-l-methionine on Long Term Administration of Low Doses of Lead to Rats

Two alternatives for the treatment of lead intoxication, administration of zinc or a thiol donor, S-adenosyl-L-methionine (SAM), were analysed. Rats were exposed to lead (Pb)-acetate (60 mg/1) in drinking water during 90 days; one group also received SO₄Zn in water (40 mg/l), while another received both Pb and SAM (5 mg/24 hr intraperitoneally. Erythrocytic δ-aminolaevulinic dehydratase (ALA-D) activity was significantly reduced (P<0.001) both in rats receiving Pb alone and in rats receiving Pb and each of the other two treatments. The high erythrocytic uroporphyrinogen synthetase (URO-S) activity noticed in Pb administered rats, was significantly (P< 0.001) reduced in animals treated either with zinc or with SAM. Hepatic ALA-D activity tended to decrease while renal enzyme activity was not modified by the low level Pb exposure used in this work. Interestingly, SAM treated rats in both tissues exhibited significantly (P<0.01) higher activities of the enzyme. It is argued that SAM treatment causes a surplus of thiols that allows the full expression of ALA-D catalytic activity.     

Influence of dietary factors on the gastrointestinal absorption of lead

Gastrointestinal absorption of lead was investigated in mice after oral administration of lead acetate labeled with ²¹⁰Pb. When doses of 0.2, 2 and 20 mg of Pb/kg were given, the magnitude of the dose did not appear to affect significantly the percent absorbed. The presence of food in the gastrointestinal tract reduced lead absorption when a tracer dose was administered but did not affect absorption after 2 mg of Pb/kg po. The chelators nitrilotriacetic acid and sodium citrate increased absorption of lead, as did orange juice, a source of citric acid. Milk and the chelating agents, ethylenediaminetetraacetic acid and diethylenetriaminepentaacetic acid, did not affect significantly lead absorption.     

Lipid abnormalities in rats given small doses of lead

Previous human and experimental studies have demonstrated that lead exposure may modify the metabolism of lipids. Several studies have indicated that exposure to lead produces an increase in lipid peroxidation and inhibits blood superoxide dismutase activity. Recently, lipid peroxides have been shown to impair tissue membranes and to be a risk factor for vascular diseases. The aim of the present investigation was to evaluate the impact of subclinical lead poisoning on rat lipids in the context of atherosclerosis. The degree of poisoning was analogous to that in populations exposed to lead in a contaminated environment. Experiments were performed on male Buffalo rats with body weights of 150–200 g. The experimental animals received lead acetate intragastrically in doses of 35 mg lead/kg body wt. (Pb/kg) once weekly or 70 mg Pb/kg twice weekly for 7 weeks. Control rats were fed in the same manner with sodium acetate equimolar to the acetate in the lead acetate solution. One day after the feeding was over, venous blood samples, under ether anesthesia, were collected. The animals were killed by exsanguination and the liver was excised for determination of the metal (lead, copper, and zinc) content. A segment of the abdominal aorta was excised for histological examination. In venous blood the following were estimated: triglycerides, total cholesterol, high-density lipoprotein (HDL)-cholesterol fraction, serum lipid peroxides, and blood superoxide dismutase activity. Metal content (lead, copper, and zinc) in blood and liver was determined by means of atomic absorption spectrophotometry. In rats poisoned with small doses of lead, decreases in the plasma cholesterol level and the HDL-cholesterol fraction were observed. In parallel with the decrease in the cholesterol concentration, lead increases the serum triglyceride level, this increase being dependent upon lead levels in blood. In our studies a significant influence of lead on serum lipid peroxide level or blood superoxide dismutase activity was not found. In the histological examination, atrophy of the elastic fibers in the aorta was observed. The possible significance of the inhibitory effect of lead on lipoprotein lipase activity is discussed.     

The effects of CaNa(2)EDTA on brain lead mobilization in rodents determined using a stable lead isotope tracer.

Studies have demonstrated the efficacy of CaNa(2)EDTA for reducing lead (Pb) levels in blood and soft tissues, including brain. However, a concern remains that a single dose of CaNa(2)EDTA may cause a significant increase in brain Pb levels due to a redistribution of endogenous Pb. Here we utilized a rodent model of Pb exposure in combination with a sensitive stable Pb isotope tracer methodology to assess the effects of CaNa(2)EDTA chelation treatment on the redistribution of Pb in brain, blood, kidney, and bone tissues. Thirty-two adult female albino rats (n = 6-7 animals/group) were exposed to 100 microg Pb/mL in drinking water for 4 weeks. Stable (204)Pb tracer was administered via i.p. injection over 2 days prior to chelation. CaNa(2)EDTA was administered i.p. at a dose of 150 mg/kg/day for 1 to 5 days. Statistical differences were evaluated with univariate ANOVA. Under the Pb exposure and chelation treatment regimens utilized here, there was no evidence of a measurable redistribution of endogenous Pb (as total Pb or labile (204)Pb tracer) into the brain after a single CaNa(2)EDTA dose. Further, CaNa(2)EDTA was not efficacious in measurably reducing brain or bone Pb levels, although brain levels of labile (204)Pb tracer were significantly reduced after 5 days of chelation. CaNa(2)EDTA treatment was effective in significantly reducing both blood and kidney Pb levels. Overall, these data substantiate the efficacy of CaNa(2)EDTA for reducing soft tissue Pb levels, but not total brain Pb, and they do not support concern for a transient increase in brain Pb levels with treatment.     

The effect of ethylenediaminetetraacetic acid (EDTA) and EDTA plus salicylate on acute cadmium toxicity and distribution

The lethality of various dosages of intravenously administered cadmium (as CdCl₂) was tested in female Swiss Webster mice weighing 30–45 g which were given CaNa₂-ethylenediaminetetraacetic acid (EDTA) (0.5 mmol/kg ip) or CaNa₂EDTA plus sodium salicylate (SA, 2 mmol/kg ip) immediately after the Cd injection. In mice given saline instead of a chelator the LD50 for Cd was about 3.5 mg Cd/kg. Mice given either EDTA or EDTA + SA were protected from the lethal effects of Cd up to 5 mg Cd/kg. No difference in survival was found between animals treated with either EDTA + SA or EDTA alone at any dosage of Cd. The tissue concentrations of a sublethal dosage (1 mg Cd/kg) of radiolabeled Cd (¹⁰⁹Cd) injected intraveneously were measured in blood, plasma, heart, lung, pancreas, spleen, small intestine, kidney, stomach, bone, brain, liver, and muscle of mice also treated with various dosages of EDTA with or without a fixed dosage of salicylate (2 mmol/kg). EDTA, in dosages as low as 0.3 mmol/kg, significantly decreased the concentration of Cd found in most tissues. The addition of sodium salicylate to the chelator therapy did not significantly alter tissue Cd concentrations when compared to that found in mice given EDTA alone.     

Locomotor damage and brain oxidative stress induced by lead exposure are attenuated by gallic acid treatment

We investigated the antioxidant potential of gallic acid (GA), a natural compound found in vegetal sources, on the motor and oxidative damages induced by lead. Rats exposed to lead (50 mg/kg, i.p., once a day, 5 days) were treated with GA (13.5 mg/kg, p.o.) or EDTA (110 mg/kg, i.p.) daily, for 3 days. Lead exposure decreased the locomotor and exploratory activities, reduced blood ALA-D activity, and increased brain catalase (CAT) activity without altering other antioxidant defenses. Brain oxidative stress (OS) estimated by lipid peroxidation (TBARS) and protein carbonyl were increased by lead. GA reversed the motor behavior parameters, the ALA-D activity, as well as the markers of OS changed by lead exposure. CAT activity remained high, possibly as a compensatory mechanism to eliminate hydroperoxides during lead poisoning. EDTA, a conventional chelating agent, was not beneficial on the lead-induced motor behavior and oxidative damages. Both GA (less) and EDTA (more) reduced the lead accumulation in brain tissue. Negative correlations were observed between the behavioral parameters and lipid peroxidation and the lead levels in brain tissue. In conclusion, GA may be an adjuvant in lead exposure, mainly by its antioxidant properties against the motor and oxidative damages resulting from such poisoning.     

Absence of an effect of lead acetate on sperm morphology,sister chromatid exchanges or on micronuclei formation in rabbits

The influence of lead on sperm morphology, sister chromatid exchanges or on micronuclei formation was studied on male rabbits after exposure to doses of 0, 0.25, and 0.50 mg lead acetate/kg body weight subcutaneously injected three times a week during 14 weeks, each on a group of five rabbits. At the end of exposure phase the lead in blood concentrations of the three groups of rabbits were 0.32, 2.57, and 2.97 mol/l respectively. The results did not show any evidence of treatment related effects on sperm count or on morphologic abnormalities of the sperms, neither on the histopathology of the testis. Statistical analysis of the number of sister chromatid exchanges per metaphase in lymphocytes indicated no differences between the groups. Also no dose dependent effect was observed on the relative number of micronuclei in bone marrow erythrocytes. The different susceptibility to lead in different organ systems of the rabbits was discussed.     

Different effects on hemesynthesis in male and female rabbits treated with lead acetate

The feasibility of an animal model was investigated to study the mechanisms underlying the difference in response to inorganic lead exposure between males and females, as shown in the different increase of zincprotoporphyrin (ZPP) in blood concentrations. Groups of rabbits of both sexes received s.c. injections of 0.25 (L) or 0.50 (H) mg lead acetate/kg b.w. or a control solution three times a week during 14 weeks. A steep increase of blood lead (PbB) was found in the first 4 weeks of exposure; in subsequent weeks PbB leveled off. In the L-group PbB increased to 775–1387 /1 rbc and in the H-group to 892–1522 g/l rbc. In female rabbits ZPP increased earlier than in males; the relative increase of ZPP was stronger in female rabbits, particularly in the H-group. No effect on Hb, Ht and body weight was observed. The response to lead in female and male rabbits is very similar to that observed in humans.     

Ultrastructural changes in the kidneys of rabbits treated with lead acetate

Electron microscopical studies were carried out on the kidneys of rabbits given s.c. injections of 0 (control), 0.25 or 0.50 mg lead acetate/kg b.w. 3 times a week during 14 weeks. At the end of the experimental period the animals had lead blood levels of 60, 500 and 600 g/1 whole blood respectively. Treatment-related renal changes were found in the proximal tubules; they consisted of a dose-related increase in the amount of lysosomes in epithelial cells of the convoluted part, and of severely damaged cells and loss of brush border in the straight part. There was also an increase in lysosomal tubular inclusions, which are considered characteristic of lysosomes of the proximal tubular cells of the rabbit kidney. The significance of these findings for assessing the risk of occupational exposure to lead is briefly discussed.     

Behavioral and neurochemical changes in rats simultaneously exposed to manganese and lead

Groups of rats were exposed simultaneously to manganese chloride (3 mg Mn²⁺/ml water) through drinking water and lead acetate intraperitoneally at dosages of 5.0, 8.0 and 12.0 mg Pb²⁺/kg daily for a period of 14 days. The magnitude of changes in the behavioral pattern, contents of biogenic amines and accumulation of lead in the brain of rats simultaneously exposed to the two metals was significantly greater than observed in rats after exposure to either of the metals alone. A definite dose-response relationship was, however, noticed only with the changes in the motoractivity, norepinephrine, 5-hydroxytryptamine levels and in the accumulation of lead in rats simultaneously exposed to manganese and lead. The lowering in the contents of norepinephrine after combined treatment was found to be related with the decrease in the motoractivity in the rats. The exact role of depression in the levels of dopamine and 5-hydroxytryptamine in inducing marked impairment in learning ability and increased aggressive behavior in rats after the combined exposure to manganese and lead could not be ascertained. The overall analysis of the data indicated that the simultaneous exposure to manganese and lead, particularly with highest dose of the latter, may produce serious derangements in the behavioral pattern and levels of biogenic amines in the brain of rats.     

Impairment of testicular endocrine function after lead intoxication in the adult rat

To clarify the mechanism of the action of lead on male reproductive function, adult male rats were injected intraperitoneally (i.p.) with lead acetate (8 mg/kg/day of lead), 5 days a week for 35 days. Despite this high dose, germ cells and Sertoli cells did not appear to be major targets of lead. However, lead determination in the reproductive organs showed that the accessory sex glands are such a target. Epididymal function was unchanged. In lead-exposed rats, plasma and testicular testosterone dropped by about 80%, but plasma luteinizing hormone (LH) only dropped by 32%. After luteinizing hormone releasing hormone (LHRH) stimulation of the pituitary, the plasma LH level reached the control one, but plasma testosterone remained significantly reduced by 37%. The sharp decrease in the testosterone: LH ratio in lead-exposed rats, combined with the significant reduction of intertubular tissue volume in the testes, indicate impaired Leydig cell function.     

Study on the impact of lead acetate pollutant on immunotoxicity produced by thiamethoxam pesticide

Objective:

The curtailed knowledge about neonicotinoids that it has low affinity for vertebrate relative to insect nicotinic receptors is a major factor for its widespread use assuming that it is much safer than the previous generation insecticides. But literature regarding effect of thiamethoxam (second generation neonicotinoid)on immune system is not available. Also, there might be chances of interaction of heavy persistent metals in the water table with these pesticides. So, this study was undertaken with the objective to find immunotoxic alterations of lead acetate after exposure with thiamethoxam in animal model.

Materials and Methods:

For this albino mice were randomly divided into 6 groups (numbered I to VI) each containing 6 mice. Animals of groups I and II were administered 87.1 mg/kg b.w.(body weight) and 43.5 mg/kg b.w. respectively of thiamethoxam. Group III animals, lead acetate was administered orally and IV and V mice were administered combination of lead acetate and thiamethoxam at higher and lower dose level for 28 days. The group VI was control group. On 29^th day and humoral and cell mediated immune responses, TLC (Total leukocyte count), DLC (Differential leukocyte count), serum total protein, globulin and albumin, and histopathological studies were conducted.

Result:

The result obtained clearly indicated that on oral administration of thiamethoxam immunotoxicity was induced in mice in dose related manner. Lead acetate when administered for 28 days showed immunotoxic potential. Thiamethoxam and lead acetate when administered together did not lead to any new altered immunotoxic response but additive toxic effects of both were observed.KEY WORDS: Thiamethoxam, Immunotoxicity, interaction, lead acetate, albino mice, oral