Symptomatic Lead Toxicity and Joint Pain Because of Migration of Shotgun Pellets into the Hip 12 Years After Injury: A Case Report.

CASE: We describe a case of mild lead poisoning in a 25-year-old woman because of intra-articular migration of lead shot 12 years after gunshot injury to the left hip, ameliorated by arthroscopic foreign body removal. Retained lead can cause systemic symptoms of lead toxicity, supranormal blood lead concentration, and increasingly painful and destructive local arthritis even years after gunshot injury. CONCLUSION: This report shows that lead fragments should be monitored closely if located near joint spaces. We demonstrate curative therapy for lead poisoning through the use of minimally invasive arthroscopic techniques for removal of retained intra-articular lead missiles.

Pseudotumor Caused by a Retained Intra-articular Bullet: A Case Report.

CASE: A 54-year-old man presented with systemic lead poisoning due to a gunshot wound to the hip suffered 35 years prior to presentation. He urgently underwent removal of the bullet with total hip arthroplasty and was found to have a pseudotumor. This case highlights the team-based approach to manage systemic lead poisoning caused by an intra-articular bullet. CONCLUSION: We report on the first documented case of systemic lead toxicity and a pseudotumor caused by an intra-articular bullet. An expeditious, team-based approach is necessary for appropriate treatment. Our treatment algorithm can guide future teams on the management of this reversible disorder.

Systemic plumbism following remote ballistic injury.

We report an unusual case of systemic lead poisoning, i.e., plumbism, following a remote gunshot injury to the right femur. Plumbism is a rare side-effect of penetrating projectiles and has been shown to be directly related to the degree of ballistic fragmentation, as well as to the impact location, with intra-synovial, intra-osseous, head, spine and maxillofacial injuries having the highest correlation. Our patient, a 44-year-old male, presented to the ER with a 3-week history of mid epigastric cramping abdominal pain and intermittent vomiting as well as mild mental status changes. Abdominal radiographs and ultrasound were noncontributory. Laboratory findings were notable for underlying microcytic anemia with basophilic stippling observed on peripheral blood smear. Serum iron studies were normal. Lead levels were found to be elevated at 306 µg/dl. Prior EGD had demonstrated mild erosive gastritis with subsequent multiple negative gastric lavages. The patient's past medical history was notable for a previous gunshot injury to the right femur with open fracture 2 years previously. Radiographs of the proximal right lower extremity, subsequent ultrasound and CT demonstrated an uncomplicated healed fracture of the mid right femoral diaphysis with an adjacent partially cystic lesion, an approximately 7-cm collection in the medial soft tissues containing internal ballistic fragments. Mottled surrounding capsular density was observed with mural calcific and micrometallic fragments. Systemic plumbism was suspected in relation to the remote ballistic injury and chelation therapy was initiated. Following surgical removal of the encapsulated fluid collection, systemic lead levels were observed to decline precipitously. The abdominal and CNS symptoms resolved in due course and the patient was discharged on oral chelation therapy.

Lead toxicity and management of gunshot wounds in the lumbar spine.

INTRODUCTION: Gunshot wounds are one of the commonest causes of spinal injury. Management of these patients differs from other blunt trauma injuries to the spine. We present a case of a gunshot wound to the lumbar spine that occurred in 1985 which was treated non-operatively. METHODS: In the last 10 years, the patient was admitted multiple times for confusion and lead toxicity with blood levels over 100 µg/dl. Inpatient chelation therapy was implemented. After multiple recommendations for surgery, the patient agreed to have as much of the bullet removed as possible. The patient successfully underwent decompression and fusion from both anterior and posterior approaches. Lead levels subsequently declined. CONCLUSION: The purpose of this paper is to show a case of a gunshot wound to the spine that ultimately caused plumbism and required surgery. Technical aspects of the surgery are described as well as pre- and post-procedural imaging. Recommendations for the general management of spine gunshot wounds are also described.

Ingluviotomy tube placement for lead-induced crop stasis in the California condor (Gymnogyps californianus).

Six free-flying California condors (Gymnogyps californianus) were diagnosed with acute lead toxicosis that caused crop distension and stasis. Between January 2006 and January 2007, the birds were referred to the Phoenix Zoo in Arizona for emergency treatment. In 5 birds, an ingluviotomy was performed to place a feeding tube from the crop to the proventriculus, which allowed a temporary bypass of the dysfunctional esophagus until normal function and motility were regained. A crop-support pressure bandage was placed in 4 birds to improve crop emptying into the proventriculus and to prevent crop distension. Although chelation therapy is the gold standard treatment for lead toxicosis, severe cases of lead-induced crop stasis are not acutely reversible with pharmaceuticals. In these condors, placement of a feeding tube was deemed prudent to ensure a viable enteric route of nutritional support during the standard treatment and recovery period in acute lead toxicosis with crop stasis.

Arthropathy caused by a lead bullet in a dog.

CASE DESCRIPTION: A 3-year-old spayed female Labrador Retriever was evaluated for progressive lameness of the left forelimb 21 months after being shot in the elbow with a lead bullet. CLINICAL FINDINGS: Physical examination findings were consistent with moderate osteoarthritis of the left elbow joint. Orthogonal radiographic views of the elbow revealed multiple metallic fragments in and around the joint space as well as signs of osteoarthritis. TREATMENT AND OUTCOME: The elbow joint was evaluated arthroscopically. A lead-based bullet fragment was seen in the lateral synovial compartment and removed in multiple pieces. Excess fibrin and synovium were removed, and microfractures were created in exposed subchondral bone to stimulate neovascularization and fibrocartilage formation. In a follow-up telephone conversation 4 months after surgery, the owner reported a marked improvement in the lameness. CLINICAL RELEVANCE: Removal of lead intra-articular foreign bodies may be indicated even if the material is not believed to mechanically interfere with joint motion.

Severe lead poisoning and an abdominal foreign body in a mute swan (Cygnus olor).

The mute swan (Cygnus olor) is common on British waterways and frequently presents to wildlife hospitals with fishing tackle-related problems. Many of these birds have abnormally high blood lead levels after the ingestion of lead fishing weights. The ingestion of fishing line and tackle is also commonly seen. This case report describes the treatment of a swan with a particularly severe case of lead poisoning and the subsequent removal of an abdominal foreign body.

Arthroscopic treatment of gunshot wounds to the shoulder.

Two cases are presented that demonstrate the utility of arthroscopic intervention for the management of gunshot wounds to the shoulder. The first report involves a 24-year-old man with a retained bullet in his glenohumeral joint after a drive-by shooting The intra-articular bullet was retrieved arthroscopically avoiding chondral injury from the mechanical effects of a loose body as well as the potential local and systemic effects of lead toxicity. Irrigation and debridement was performed to evacuate joint debris, which could have served as a nidus for infection or inflammation. The other case describes a 19-year-old man who sustained a gunshot wound to the lateral portion of his upper arm resulting in a proximal humerus fracture along with a retained bullet in his subacromial space. The bullet was successfully removed arthroscopically avoiding a traditional exposure, which would have complicated his fracture care.

[Surgical management of type III thoracic shotgun injury]. / Chirurgisches Management des thorakalen Schrotschusses Typ III.

Reporting the case of a short-range severe thoracic shotgun injury the differentiated management of this trauma is discussed. Indication for operative exploration under emergency conditions is hemorrhagic shock, perforation of esophagus/stomach and pericardial tamponade. Even under a toxicological point of view there is no indication for emergency revisions.

[Severe lead poisoning caused by an ingested fishing weight]. / Lenyelt horgásznehezék okozta súlyos ólommérgezés.

Authors describe the case-history of a 17 year old male who accidentally ingested a fishing weight that was retained in the stomach and caused a serious lead poisoning. It is worth mentioning that beside the wellknown symptoms and signs of lead intoxication also the liver was seriously affected. The histologically verified toxic lesion of the liver presumably can be attributed to the large quantities of lead absorbed within a short period. This also explains the appearance of symptoms and signs indicating to encephalopathy beside the young age of the patient. The foreign body could not be removed by means of gastroscopy, therefore a gastrotomy was carried out followed by chelating treatment with i.v. CaNa2EDTA that resulted in complete clinical and laboratory recovery. The case history draws the attention to the importance of the quick removal of the retained lead containing objects out of the gastrointestinal tract.

Symptomatic lead toxicity secondary to retained shotgun pellets: case report.

Symptomatic lead toxicity has only rarely been associated with retention of foreign bodies. Recently a patient was seen who had sustained a shotgun wound to the left upper extremity 10 years previously without apparent nerve injury at the time of injury. The patient was asymptomatic for 9 years. During the tenth year, classic symptoms of lead toxicity, as well as increased blood levels, were documented. Removal of the majority of the lead pellets resulted in substantial decrease in the serum lead level and improvement of symptoms.

An unusual case of lead poisoning in a honey buzzard (Pernis apivorus).

The diagnosis and treatment of a case of lead poisoning in a honey buzzard (Pernis apivorus) are described. Presenting signs were diarrhoea and weakness. Lead poisoning was suspected after radiography and confirmed by measuring the lead concentration in a venous blood sample. Comparison values of venous lead concentrations in healthy racing pigeons (Columba livia) were established. A method for the removal of lead shor from the gizzard of birds with a bronchoscope and grasping forceps under fluoroscopic control is described.

Bullets, joints, And lead intoxication. A remarkable and instructive case.

A retired teamster with abdominal pain and anemia was found to have lead intoxication presumably due to and old bullet in his ankle. Most lead particles within the body need not be removed. Lead solubility characteristics exemplified by this case cuase us to recommend that bullets and lead particles facing synovial spaces should be removed.