Inflammatory low back pain with radiculopathy revealing epidural disintegration of a bullet complicated by lead poisoning.

Inflammatory low back pain with radiculopathy is suggestive of cancer, infection or inflammatory diseases. We report a unique case of a 42-year-old patient with an acute inflammatory low back pain with bilateral radiculopathy associated with weight loss and abdominal pain, revealing the disintegration of a lead bullet along the epidural space and the S1 nerve root complicated by lead poisoning. Because of the high blood lead level of intoxication (>10 times over the usual lead levels) and the failure of repeated lead chelator cycles, a surgical treatment to remove bullet fragments was performed. It resulted in a significant decrease of pain and lead intoxication.

Individual and Neighborhood Characteristics Associated With Confirmatory and Follow-up Blood Lead Testing Among Children With Elevated Blood Lead Levels.

OBJECTIVES: The aim of this study was to assess the proportions and likelihood of children who receive confirmatory and follow-up blood lead testing within the recommended time frames after an initial capillary elevated blood lead level (EBLL) and confirmed EBLL, respectively, by individual and neighborhood-level sociodemographic characteristics. DESIGN: We linked and used blood testing and sociodemographic characteristics data from a Pennsylvania birth cohort including children born between 2017 and 2018. Generalized linear mixed models were constructed to examine the associations between sociodemographic factors and having recommended confirmatory and follow-up testing. SETTING: A population-based, retrospective cohort study. PARTICIPANTS: In this birth cohort, children who underwent at least 1 BLL test were followed up to 24 months of age. Children with a first unconfirmed (n = 6259) and confirmed BLL (n = 4213) ≥ 5 µg/dL were included in the analysis. MAIN OUTCOME MEASURE: Children had confirmatory and follow-up testing within the recommended time frames. RESULTS: Of the children with unconfirmed and confirmed EBLLs, 3555 (56.8%) and 1298 (30.8%) received confirmatory and follow-up testing, respectively. The proportions of the 2 outcome measures were lower among children experiencing certain sociodemographic disadvantages. In the univariate analyses, lower initial BLLs, older age, non-Hispanic Blacks, lower maternal educational levels, maternal Medicaid, The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment, maternal smoking, and higher quartiles of neighborhood poverty and old housing were associated with lower odds of having confirmatory and follow-up testing. However, in multivariate models, children with lower initial BLLs, older age, maternal smoking, and non-Hispanic Blacks were significantly less likely to have confirmatory and follow-up testing. CONCLUSIONS: There were deficiencies in having recommended confirmatory and follow-up blood lead testing among children, especially those with sociodemographic disadvantages. Public health agencies and stakeholders should finetune policies to improve follow-up testing in conjunction with primary and secondary preventions for early detection and reduction of lead exposure among targeted children at risk of lead poisoning.

Exposición ambiental a plomo y biomarcadores de estrés oxidativo en niños sanos de La Plata, Argentina / Environmental exposure to lead and oxidative stress biomarkers among healthy children in La Plata, Argentina

Introducción. La exposición ambiental a plomo (Pb) aún constituye un problema de salud pública, particularmente para los niños. El estrés oxidativo podría representar un mecanismo primario asociado a su toxicidad. El objetivo del presente estudio fue determinar los niveles de Pb en sangre (Pb-S) en niños de 1 a 6 años de La Plata y alrededores con exposición ambiental, y su relación con biomarcadores de estrés oxidativo. Población y métodos. Estudio analítico de corte transversal. Se evaluaron niños clínicamente sanos de 1 a 6 años. Se determinaron los niveles de Pb-S, las actividades de enzimas antioxidantes y el grado de peroxidación lipídica. Se utilizó el paquete estadístico R versión 3.5.1. Resultados. Participaron 131 niños, mediana de edad 2,33 años. La media geométrica de los niveles de Pb-S fue 1,90 µg/dL; el 32 % presentó plombemias cuantificables y el 3 %, niveles ≥5 µg/dL (referencia internacional). Al comparar los biomarcadores de estrés oxidativo según los niveles de Pb-S, solo se observó diferencia significativa entre las medianas de las sustancias reactivas al ácido tiobarbitúrico (TBARS): 12,0 versus 10,0 nmol MDA/mL plasma; p = 0,02. Asimismo, la correlación entre las plombemias y las TBARS fue positiva (r = 0,24; p = 0,012). Conclusiones. La mayoría de los niños mostraron niveles de Pb-S menores a los límites recomendados por agencias internacionales, que si bien, no producen alteraciones en la actividad de enzimas antioxidantes, sí inducen peroxidación lipídica. Estos resultados reflejan la utilidad de este biomarcador como una herramienta diagnóstica temprana para evaluar los efectos subtóxicos del Pb.

Introduction. Environmental exposure to lead is still a major public health problem, especially in children. Oxidative stress may be a primary mechanism associated with toxicity. Theobjective of this study was to measure blood lead levels (BLLs) in children aged 1 to 6 years expos to lead in La Plata and suburban areas and their relation to oxidative stress biomarkers. Population and methods. Cross-sectional,analytical study. Clinically healthy children aged1 to 6 years were analyzed. BLLs, antioxidant enzyme activity, and extent of lipid peroxidation were measured. The statistical softwarepackage R, version 3.5.1, was used. Results. A total of 131 children participated; their median age was 2.33 years. The geometric mean of BLLs was 1.90 µg/dL; 32% showed a measurable BLL and 3%, BLLs ≥ 5 µg/dL (international reference). The comparison ofoxidative stress biomarkers based on BLshowed a significant difference in median thiobarbituric acid reactive substances (TBARS):12.0 versus 10.0 nmol MDA/mL of plasma;p = 0.02. In addition, the correlation between BLLs and TBARS was positive (r = 0.24; p = 0.012 Conclusions. Most children had a BLL below the limit recommended by international agencies; although such BLLs do not affantioxidant enzyme activity, they can induce lipid peroxidation. These results demonstrate theusefulness of this biomarker as an early diagnosistool to assess subtoxic lead effects.

Abdominal pain caused by lead toxicity due to over the counter herbal medicines: A case series.

In the last three decades, the use of herbal medications has been increasing for the treatment of various chronic disorders. Studies in the past have shown that many of these medicines could contain high levels of heavy metals, including lead. Therefore, we planned this study to evaluate the possibility of lead toxicity as the underlying cause in patients consuming these unnamed herbal medicines among patients presenting with significant abdominal pain. (Unexplained abdominal pain means pain in abdomen in which no etiology could be ascertained after all possible routine and specialized investigations including computerized axial tomography [CT] of the abdomen and upper gastrointestinal [UGI] endoscopy/colonoscopy). This is an observational case series of prospectively maintained data of all patients having unexplained abdominal pain and found to have an elevated blood lead level from 2011 to 2019. Lead toxicity was diagnosed when its blood lead level was >25 µg/dL. Total sixty-six patients with unexplained abdominal pain from 2011 to 2019 were recruited. Out of the sixty-six patients, seventeen had elevated blood lead levels. All seventeen patients had a history of ingestion of herbal medicines for more than 6 months. Among the seventeen patients, eight were taking it for infertility and sexual dysfunction, six for diabetes, two for arthritis and one for hypertension. Basophilic stippling was seen in one patient. Fourteen patients had low hemoglobin with a median value of 9.7 g/dL. Mean serum blood lead level was 87.1 µg/dL. None of them required anti-chelating agent. Lead toxicity owing to herbal medicine is not uncommon cause of unexplained abdominal pain. Most of these patients do not require a chelating agent for treatment. There is a need to bring these herbal medicines under strict regulations for displaying its constituents and their concentrations.

Basophilic stippling in red blood cells in the bone marrow: indication for lead poisoning diagnosis.

A 40-year-old man presented at our hospital with anaemia that had been undiagnosed for 2 years. Blood tests, endoscopy, and contrast-enhanced computed tomography were performed, but a definitive diagnosis could not be made. A subsequent bone marrow biopsy revealed basophilic stippling in transformed red blood cells, which led to a differential diagnosis of lead poisoning. Additional tests revealed elevated levels of lead in the blood. Basophilic stippling is generally found on a peripheral blood smear in lead poisoning patients; however, in this case, basophilic stippling was found only on the bone marrow smear and not in the blood smear. Even if basophilic stippling is not found in the peripheral blood, lead poisoning cannot be excluded.

Lead screening in children presenting to three hospitals in Lebanon.

BACKGROUND: Lead damages most body organs and its effects are most profound in children. In a study in Beirut in 2003, before banning the leaded gasoline, 79% of the participants showed blood lead levels (BLLs) higher than 5 µg/dL. The prevalence of lead exposure in Lebanon after the ban on leaded gasoline has not been studied. This study assessed the BLL in Lebanese children aged 1-6 years. METHODS: This cross-sectional study was conducted in three hospitals in Beirut. The children's BLLs were tested, and their caregiver completed a questionnaire to identify subgroups at risk of exposure. Participants were provided with a WHO brochure highlighting the risks of lead. RESULTS: Ninety children with a mean age of 3.5±1.5 years were enrolled in the study and had a mean BLL of 1.1±0.7 µg/dL, with all values being below 5.0 µg/dL, showing a marked decrease in BLL compared with the mean BLL before the ban on leaded gasoline in 2002. Having a father or a mother with a college degree (p=0.01 and p=0.035, respectively) and having a monthly household income greater than $1000 (p=0.021) were associated with significantly lower BLL. Having more rooms at home and residing close to construction sites were associated with a significantly lower BLL (p=0.001 and p=0.026, respectively). Residing in a house aged >40 years and receiving traditional remedies were associated with a significantly higher BLL (p=0.009 and p<0.0001, respectively). CONCLUSION: BLLs have declined among Lebanese children and this could be attributed to multiple factors including the ban of leaded gasoline. It would be beneficial to conduct a larger study with a nationally representative sample to better characterise the BLL.

Resolving Pediatric Preventive Care Gaps Through Hospital Inreach.

OBJECTIVES: Panel management processes have been used to help improve population-level care and outreach to patients outside the health care system. Opportunities to resolve gaps in preventive care are often missed when patients present outside of primary care settings but still within the larger health care system. We hypothesized that we could design a process of "inreach" capable of resolving care gaps traditionally addressed solely in primary care settings. Our aim was to identify and resolve gaps in vaccinations and screening for lead exposure for children within our primary care registry aged 2 to 66 months who were admitted to the hospital. We sought to increase care gaps closed from 12% to 50%. METHODS: We formed a multidisciplinary team composed of primary care and hospital medicine physicians, nursing leadership, and quality improvement experts within the Division of General and Community Pediatrics. The team identified a smart aim, mapped the process, predicted failure modes, and developed a key driver diagram. We identified, tested, and implemented multiple interventions related to role assignment, identification of admitted patients with care gaps, and communication with the inpatient teams. RESULTS: After increasing the reliability of our process to identify and contact the hospital medicine team caring for patients who needed action to 88%, we observed an increase in the preventive care gaps closed from 12% to 41%. CONCLUSIONS: A process to help improve preventive care for children can be successfully implemented by using quality improvement methodologies outside of the traditional domains of primary care.

[Comparison of network report and actual detection of suspected occupational diseases among lead exposed workers in Jiangsu Province from 2016 to 2018].

Objective: To analyze and compare the detection level and actual detection of suspected occupational diseases of lead exposed workers in the network report of occupational disease and occupational health information monitoring system, so as to provide a basis for formulating and improving relevant laws and regulations on occupational disease monitoring in the future. Methods: From January 2016 to December 2018, the network report occupational health examination data of lead exposed workers in Jiangsu Province were selected, the network report detection rate of suspected occupational diseases of lead exposed workers was counted and compared with the actual detection rate judged in the early stage, and the distribution characteristics of the network report detection rate of different years, regions and occupational health examination institutions and the reasons for the difference with the actual detection rate were analyzed. Results: Network report detection rate of suspected occupational disease in Jiangsu Province from 2016 to 2018 (0.042%, 30/71810) was significantly lower than the actual detection rate of 1.12% (805/71810) , and the difference was statistically significant (χ(2)=723.518, P<0.01) . The network report detection rates of suspected occupational chronic lead poisoning showed an increasing trend year by year, and the difference were statistically significant (χ(2)(trend)=7.627, P<0.01) . All the 30 network report cases were male, and 28 cases (93.33%) were from small and medium-sized enterprises. Among the 805 cases of suspected occupational chronic lead poisoning, 689 cases (85.59%) came from small and medium-sized enterprises. The three cities with more cases were Huai'an 222 cases (27.58%) , Suzhou 208 cases (25.84%) and Changzhou 138 cases (17.14%) . Compared with the actual detection, the number of network reports in Yangzhou accounted for 85.29% (29/34) of the actual detection from 2016 to 2018, that in Suqian accounted for 10.00% (1/10) , and that in other prefecture level cities was 0. From 2016 to 2018, 46.22% (33191/71810) of the occupational health examinations of lead exposed workers were undertaken by Centers for Disease Control and prevention at all levels (referred to as "CDC") . The 30 suspected cases of occupational chronic lead poisoning reported network came from CDC, accounting for 4.89% (30/614) of the actual detection, and the rest were 0. Conclusion: There are great differences between the network report and the actual detection rate of suspected occupational chronic lead poisoning among lead exposed workers, mainly due to the differences in the judgment level of suspected occupational diseases in different regions, the nature of institutions and the level of professional technicians.

A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports.

Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.

The Case For Cadmium and Lead Heavy Metal Screening.

Exposure to cadmium and lead is widespread, and is related to environmental contamination, occupational sources, food, tobacco and other consumer products. Lower socioeconomic status increases the risk of heavy metal exposure and the diseases associated with cadmium and lead toxicity. Concurrent toxicity with both cadmium and lead is likely but has not often been assessed. There is now substantial evidence linking cadmium and lead to many diseases including hypertension, diabetes mellitus, obesity, cancer, coronary artery disease, chronic kidney disease (CKD) and lung disease. Both chronic renal failure and ischemic heart disease patients have been treated separately in recent studies with calcium disodium ethylenediaminetetraacetic acid (Ca EDTA) chelation therapy. In patients with CKD, serum creatinine 1.5-4.0 mg/dL, and increased body lead burden, weekly low dose chelation with Ca EDTA slowed the rate of decline in renal function in diabetics and non-diabetics. In patients with a history of myocardial infarction, the Trial to Assess Chelation Therapy (TACT) study showed that Ca EDTA chelation decreased the likelihood of cardiovascular events, particularly in diabetics. Ca EDTA chelation administered carefully at lower dosage (<50 mg/kg per week) is generally safe. In the past, acute renal failure associated with much higher dosage was reported. We suggest that the preponderance of the evidence favors a more activist approach towards diagnosis and possible intervention in heavy metal toxicity.

Lead Poisoning Prevention Efforts in High-Risk Environments: Follow-up Testing Rates among Preschool Children in Flint, Michigan, 2013-2015.

OBJECTIVES: Despite the importance of screening in efforts to address lead poisoning, many children in the United States have never been tested for lead, even when required to receive blood lead testing by state and federal healthcare policy. Fewer children gain access to follow-up or confirmatory testing when elevated blood lead levels are detected. METHODS: In response to previous research that illustrates the extent to which follow-up treatment services have been underutilized and poorly coordinated, this retrospective cohort study examines follow-up testing trends for lead poisoning among Medicaid-enrolled children 6 years and younger in Flint, Michigan, between 2013 and 2015. RESULTS: These findings illustrate that compliance with follow-up testing procedures was less than adequate during the period of study. CONCLUSION: As illustrated in this bivariate analysis, subpopulations in Flint most likely to have lead poisoning were least likely to receive follow-up testing. Evidence also demonstrates that the likelihood that children with lead poisoning received follow-up testing was overwhelmingly associated with their blood lead concentration level than other indicators including socioeconomic status in this high-risk environment.

Lead poisoning due to incense burning: an outbreak in a family.

BACKGROUND: In Asia and some other regions of the world, incense burning is an important folk and cultural activity. However, this ritual can cause health impacts, such as chronic respiratory diseases and neoplasms. Herein, we describe a family with lead poisoning possibly related to the frequent use of incense sticks at home. CASE REPORT: A 65-year-old homemaker with severe anemia, pitting edema of the lower legs, bone pain, abdominal pain, and exertional dyspnea for several months presented to our clinic. Her blood workup indicated severe anemia with basophilic stippling in red blood cells and blood lead level (BLL) of 59.75 µg/dL. Her husband, three children, and four grandchildren who lived with her also had high BLLs. As a Daoist clergy person, she had been exposed to a large amount of smoke from every day use of incense for >30 years. In the field investigation, the chronic dust deposited in hidden corners of their home had considerably higher lead content and other toxic metals. DISCUSSION: Our observations indicated chronic, frequent exposure to smoke from incense burning may be a cause of lead poisoning. Strict avoidance of incense smoke is a significant step toward preventing lead poisoning in children in societies with the custom of incense burning.

A Rapid Mercury Droplet Electrode Polarography Method for Determination of Blood Lead Level in Lead Poisoned People.

BACKGROUND: Lead is a hazardous heavy metal, which causes many problems in the human body. Unfortunately, recent reports showed that smugglers and opium sellers add lead to drugs during the production procedure in order to increase its weight and cost. PURPOSE: The aim of this study was development of a rapid and accurate method for measurement of blood lead levels (BLL) in the oral and inhaled opiate abuser people. METHODS: BLL in samples obtained from the oral and inhaled opium addicted patients referring to Sina Hospital in Tabriz, Iran, during 2017 was compared with healthy control group (N=15). The wet digestion method was used to prepare whole blood and Mercury Droplet Electrode Polarography (MDEP) method was utilized for measurement of the lead content of digested samples. RESULTS: Results showed that there were significant differences between the BLL of samples obtained from oral (17.12±74.61 µg/dL, p<0.0003) and inhaled (19.33±2.257 µg/dL, p<0.0001) opium addicted groups in comparison with healthy control group (4.669±0.3367 µg/dL). CONCLUSION: Based on the results of this study it was observed that BLL in opium addicted people needs to be measured as soon as possible. Furthermore, screening of blood lead concentrations in opium-addicted people with a rapid and accurate MDEP method is very necessary and important.

Investigación de la intoxicación secundaria por plomo de un proyectil por arma de fuego retenido en el cuerpo: reporte de caso / Investigation of secondary lead poisoning of a projectile by firearm retained in the body: case report

Resumen El plomo es un metal que encontramos depositado en el ambiente a causa de la contaminación o la explotación mineral. Debido a que este componente ha tenido una gran diversidad de usos en su historia, los medios y formas de intoxicación ha generado un cambio en la perspectiva de los componentes que pueden generar una intoxicación por plomo. Durante la investigación de la intoxicación por plomo mediante proyectiles de arma de fuego se analizó la posibilidad de que se produzca intoxicación por plomo en un caso de una femenina con retención del proyectil por arma de fuego en hueso occipital con más de 50 años, abordando desde una revisión bibliográfica, la historia de formas o productos en que este metal producía intoxicación, los mecanismos de absorción, distribución y metabolismo en el cuerpo, el mecanismo de acción, el daño a los órganos, los hallazgos clínicos, la composición de la bala y su relación médico legal para confirmar la presencia de un proyectil por arma de fuego retenido en el cuerpo con la finalidad de descartar si es posible una intoxicación por plomo por un proyectil de arma de fuego retenido en hueso occipital.

Abstract Lead is a metal that we find deposited in the environment because of pollution or mineral exploration. In reason that this component had a great diversity of uses in its history, the means and forms of intoxication have generated a change in the perspective of which components could generate a lead poisoning. During the investigation of lead poisoning through firearm projectile it was analyzed the possibility that a lead poison gets produced in a feminine that holds a firearm projectile for more than 50 years in the occipital bone, addressing from a bibliographic review, the history of forms or products in which this metal produced intoxication, the mechanisms of absorption, distribution and metabolism in the body, the mechanism of action, damage to the organs, the clinical findings, the composition of the bullet and its legal medical relationship to confirm the presence of a projectile by firearm retained in the body in order to rule out if lead poisoning is possible by a firearm projectile retained in occipital bone.

Rare cases of severe life-threatening lead poisoning due to accident or chronic occupational exposure to lead and manganese: Diagnosis, treatment, and prognosis.

BACKGROUND: Chronic long-term, low-dose environmental and occupational exposure to lead (Pb) has been extensively studied in large cohorts worldwide among general populations, miners, smelters, or battery workers. However, studies on severe life-threatening Pb poisoning due to accidental or chronic occupational exposure to Pb and manganese (Mn) were rarely reported. METHODS: We present one case of acute severe Pb poisoning and compare it with another severe chronic occupational exposure case involving Pb and Mn. A 27-year-old woman mistakenly took a large quantity of pure Pb powder as an herbal remedy; she developed abdominal colic, severe nausea, vomiting, fatigue, and cutaneous and sclera icterus. Laboratory tests showed her blood lead level (BLL) of 173.5 µg dL-1 and urinary lead level (ULL) of 1240 µg dL-1. The patient was diagnosed with acute Pb poisoning and acute liver failure. In another chronic exposure case, a 56-year-old man worked in a Pb and Mn smelting factory for 15 years. He was brought to the emergency room with severe nausea, vomiting, and paroxysmal abdominal colic, which was intolerable during the onset of pain. His BLL was 64.8 µg dL-1 and ULL was 38 µg dL-1, but his blood and urinary Mn levels were normal. The patient was diagnosed with chronic Pb poisoning. Both patients received chelation therapy with calcium disodium ethylene-diamine-tetraacetate (CaNa2EDTA). The woman with acute severe Pb intoxication recovered well and was discharged from the hospital after treatment, and the man who survived severe Pb poisoning was diagnosed with lung cancer. CONCLUSION: Clinical manifestations of acute and chronic severe Pb poisoning are different. Chelation therapy with CaNa2EDTA is proven to be an effective life-saving therapy in both cases by reducing BLL. Occupational exposure to both Pb and Mn does not appear to increase Mn neurotoxicity; however, the probability that co-exposure to Mn may increase Pb toxicity in the same patient cannot be excluded.

Lead poisoning associated with illicit opium use.

Lead poisoning is an uncommon and challenging diagnosis to make. In 2018, The Victorian Department of Health issued a health warning following four cases of lead poisoning associated with illicit opium use in Melbourne, Australia. We present these cases to highlight clinical features and the relevant investigations leading to diagnosis. All cases occurred in recent immigrants to Australia, who had access to non-traditional sources of opioids. Health care professionals should consider lead poisoning in patients with appropriate symptoms and a history of illicit opium use.

More Guidelines than states: variations in U.S. lead screening and management guidance and impacts on shareable CDS development.

BACKGROUND: Pediatric lead exposure in the United States (U.S.) remains a preventable public health crisis. Shareable electronic clinical decision support (CDS) could improve lead screening and management. However, discrepancies between federal, state and local recommendations could present significant challenges for implementation. METHODS: We identified publically available guidance on lead screening and management. We extracted definitions for elevated lead and recommendations for screening, follow-up, reporting, and management. We compared thresholds and level of obligation for management actions. Finally, we assessed the feasibility of development of shareable CDS. RESULTS: We identified 54 guidance sources. States offered different definitions of elevated lead, and recommendations for screening, reporting, follow-up and management. Only 37 of 48 states providing guidance used the Center for Disease Control (CDC) definition for elevated lead. There were 17 distinct management actions. Guidance sources indicated an average of 5.5 management actions, but offered different criteria and levels of obligation for these actions. Despite differences, the recommendations were well-structured, actionable, and encodable, indicating shareable CDS is feasible. CONCLUSION: Current variability across guidance poses challenges for clinicians. Developing shareable CDS is feasible and could improve pediatric lead screening and management. Shareable CDS would need to account for local variability in guidance.