Intoxicación por plomo de origen ocupacional en la rehabilitación de viviendas antiguas / Occupational lead poisoning in rehabilitation of old houses

Presentamos dos casos de intoxicación por plomo o saturnismo de origen ocupacional en trabajadores de la construcción, en los que la fuente de exposición probablemente fue la inhalación de polvo procedente de pintura tratada con plomo, durante la restauración de una vivienda antigua. Ambos presentaron cuadros clínicos similares con dolor abdominal; en uno de ellos se observaron además anemia normocítica e hipertensión. Ambos fueron tratados con EDTA cálcico disódico, con buena evolución clínica. Nuestros casos nos recuerdan que es preciso mantener un alto índice de sospecha para la intoxicación por plomo en el contexto clínico adecuado y subrayan la importancia de unas adecuadas medidas de prevención en entornos de trabajo potencialmente contaminados. (AU)

We present two cases of lead poisoning or saturnism in construction workers, which the source of exposure was probably the inhalation of dust coming from lead-treated paint during the refurbishing of an old house. Both patients had similar clinical symptoms such as abdominal pain; in one of them normocytic anaemia and hypertension were also observed. Both were treated with calcium disodium EDTA, with good clinical evolution. Our cases remark the importance of maintaining a high index of suspicion for lead poisoning in the appropriate clinical context and underline the importance of adequate preventive measures in potentially contaminated work environments. (AU)

Encephalopathy following ingestion of Lead-contaminated opium; magnetic resonance imaging findings.

BACKGROUND: Encephalopathy is an uncommon but serious presentation of lead toxicity. OBJECTIVE: We aimed to determine and follow-up the brain magnetic resonance imaging (MRI) abnormalities in the patients with lead encephalopathy due to ingestion of lead contaminated opium. METHODS: In a cross-sectional study during lead-contaminated opium outbreak, all lead-poisoned patients with any signs/symptoms of encephalopathy were included. RESULTS: Of 19 patients with lead encephalopathy, five died early and other five could not be sent to MRI during their hospitalization period. Mean age was 51 ± 11 years and males were dominant (89%). Median [IQR] blood lead level (BLL) was 101 [81, 108] µg/dL (range; 50 to 200 µg/dL). There was no correlation between MRI findings and signs/symptoms. MRI was normal in six and abnormal in three. Bilateral symmetric involvement of parieto-occipital lobes was observed. Gray matter, gray-white matter junction, and subcortical white matter were also affected. Follow-up MRI was performed in two with abnormal MRI which showed complete and near complete resolution of the abnormalities after cessation of opium use and treatment. CONCLUSION: There was no correlation between MRI findings and BLL. Complete recovery of brain MRI lesions was detected after cessation of opium use.

Lead poisoning due to ingestion of lead-contaminated opium: A diagnostic study on patients' imaging findings.

OBJECTIVES: Our study attempts to determine if for patients following ingestion of lead-contaminated opium, radiographs [plain X-ray (KUB)] or unenhanced computed tomography (CT scan) of the abdomen may be predictive of lead poisoning. METHODS: Our study is concerned with patients of >21 years with elevated lead concentrations, who had undergone KUB or CT. Patients with other toxicities who had undergone similar imaging profiles but who had low blood lead level (BLL) were enrolled as controls. RESULTS: We evaluated a total of 79 cases and 79 controls with median [IQR] BLLs of 126 [97.4, 160] µg/dL and 8.7 [5.5, 15] µg/dL. All cases and eleven controls (13.9%) were addicted to oral opium, and of these cases, anemia (94.9%) and abdominal pain (92.4%) were the two most common clinical manifestations. Two radiologists reviewed the X-ray and non-contrast CTs. Fifty (63.3%) and 53 (67.1%) cases and controls underwent CT scanning with 34 (68%) vs. 6 (11.3%) positive CTs (P < 0.001) while 43 (54.4%) and 39 (43.3%) underwent X-rays with 21 (48.8%) vs. 4 (11.8%) positive X-rays, respectively (P < 0.001). Positive CT is associated with BLL between 10 and 45 µg/dL with a specificity of 96.9%, 88.7% and positive predictive value of 97.5% and 85% respectively. CONCLUSIONS: In suspected cases of lead exposure due to ingested opium, and if BLL is not readily available, a positive imaging result may guide radiologists and physicians to consider lead poisoning.

Pellets in the Eye: Cerebral Aneurysm and Encephalomyeloneuropathy as Presenting Syndromes.

Lead poisoning following retained gunshot pellets resulting in recurrent episodes of encephalomyeloneuropathy is rare and association of intracranial aneurysm with lead poisoning is interesting. The case report describes about a 58-year ayurvedic doctor who was hospitalized for recurrent abdominal pain and limb weakness appearing spontaneously and improving in a few days to weeks. He had 20 such attacks in last 30 years starting at 25 years after the gunshot wound that resulted in retention of 2 lead pellets in his skull. Cranial imaging demonstrated left posterior communicating aneurysm. His initial blood lead level was 206.10 µg/dl, and following chelation with oral d-penicillamine, the lead level declined and was asymptomatic. After 4-year follow-up, he developed subarachnoid hemorrhage, which was managed with intravascular coiling of the ruptured aneurysm. The gunshot pellets are generally not removed, especially, if they are in inaccessible location. Our patient highlights that such cases should be closely monitored.

Feasibility of a portable X-ray fluorescence device for bone lead measurements of condor bones.

Lead based ammunition is a primary source of lead exposure, especially for scavenging wildlife. Lead poisoning remains the leading cause of diagnosed death for the critically endangered California condors, which are annually monitored via blood tests for lead exposure. The results of these tests are helpful in determining recent exposure in condors and in defining the potential for exposure to other species including humans. Since condors are victim to acute and chronic lead exposure, being able to measure both would lend valuable information on the rates of exposure and accumulation through time. A commercial portable X-ray fluorescence (XRF) device has been optimized to measure bone lead in vivo in humans, but this device could also be valuable for field measurements of bone lead in avian species. In this study, we performed measurements of bone Pb in excised, bare condor bones using inductively coupled plasma mass spectrometry (ICP-MS), a cadmium 109 (Cd-109) K-shell X-ray fluorescence (KXRF) system, and a portable XRF system. Both KXRF and portable XRF bone Pb measurement techniques demonstrated good correlations with ICP-MS results (r=0.93 and r=0.92 respectively), even with increasing skin thickness (r=0.86 between ICP-MS and portable XRF at 1.54mm of soft tissue). In conclusion, our results suggest that a portable XRF could be a useful option for measurement of bone Pb in avian species in the field.

Correlation of brain Magnetic Resonance Imaging of spontaneously lead poisoned bald eagles (Haliaeetus leucocephalus) with histological lesions: A pilot study.

Six bald eagles with severe, acute lead poisoning based on blood lead values were analyzed by Magnetic Resonance Imaging (MRI) of the brain and histopathology. The aims of the study were to use MRI to locate brain lesions and correlate the changes in MRI signal with the histological character of the lesions at necropsy. All of the bald eagles presented with neurologic and non-neurologic signs suggestive of severe lead poisoning and had blood lead levels in excess of 1.0 ppm. Areas of change in image intensity in the brainstem, midbrain and cerebellum were detected in the MRI scans. Histopathology confirmed the presence of all suspected lesions. The character of the lesions suggested vascular damage as the primary insult. MRI was useful for detecting lesions and defining their three-dimensional distribution and extent. Future studies are needed to evaluate the utility of MRI for detection of lesions in less severely lead poisoned eagles and determining prognosis for treatment.

Systemic Lead Toxicity.

A 4-year-old girl with slow mentation had increasing knee tenderness and limping gait.

[Acute lead poisoning: a singular case of hemolytic anemia and lead colic]. / Intossicazione acuta da piombo: un caso singolare di anemia emolitica e colica saturnina.

BACKGROUND: Acute lead poisoning due to food intake is exceptional in adults and often associated with mental illness OBJECTIVES: to describe a case report of acute lead intoxication with haemolytic anemia and lead colic. METHODS: A 41-year old male patient was admitted to hospital for abdominal pain and persistent constipation. Abdominal X-ray showed a radiopaque mass in the caecum and progressive anaemia was observed The patient was discharged with a diagnosis of bowel obstruction. Due to persistence of the symptoms he was again hospitalized; abdominal X-ray showed diffuse radiopaque particles in the colon and haemoglobin (hb) had dropped to 8.7 g/dl. Blood levels of lead and zinc protoporphryin were 106.7 microg/dl and 6.6 microg/gHb, respectively. The timely start of chelating therapy led to a rapid return to normal peripheral blood counts and a decline in blood lead levels. RESULTS: Although acute lead poisoning due to intake with food is exceptional in adults and often associated with mental illness, in this case, it was not possible to clarify the route and vehicle of ingestion of the toxic. Lead body burden was shown as a caecal mass, probably as a result of ingesting a single bolus of lead dust which, considering the size and density of the mass, was estimated as weighing several grammes. This acute lead intake induced an acute haemolysis due to enhanced fragility of the erythrocyte membrane. CONCLUSIONS: In the course of acute lead intoxication, the critical organ is not the bone marrow, but rather the red blood cell, leading to haemolysis and anaemia.

Lead poisoning associated with Ayurvedic drug presenting as intestinal obstruction: a case report.

INTRODUCTION: Lead poisoning is most commonly caused by occupational exposure. It presents with a myriad of signs and symptoms ranging from mild anemia to frank encephalopathy, depending on the blood lead levels as well as the duration of exposure. Intake of herbal/Ayurvedic medicine may also lead to plumbism as heavy metals are often incorporated in such medications with the belief that such metals have medicinal properties. METHODS: We report a case of lead poisoning caused by Ayurvedic medication. The patient presented with symptoms of intestinal obstruction to the surgical casualty. RESULTS: The patient presented with symptoms that mimicked intestinal obstruction. No specific etiology could be determined. Serum lead levels were determined and diagnosis of lead poisoning ascertained. The lead content of the medicine was analyzed and it contained 30% w/w lead. CONCLUSIONS: The diagnosis of heavy metal poisoning consequent to intake of alternative medicine must be kept in mind when a patient presents with vague complaints.

Lead poisoning by intradiscal firearm bullet: a case report.

STUDY DESIGN: The report of a rare case of lead poisoning by an intradiscal firearm bullet is presented. OBJECTIVE: To describe and discuss the clinical and radiologic features (by computed tomography and magnetic resonance imaging) of a gunshot wound in the L2-L3 space which caused lead poisoning 5 years afterwards. SUMMARY OF BACKGROUND DATA: Lead poisoning from firearm bullets is rare, but the possibility should be investigated in the case of bullets lodged in the joints. METHODS: A 30-year-old man presented to the emergency room with an intense lumbar pain complaint, colic, intestinal constipation, insomnia, and progressive headache for 20 days. He had a history of a gunshot wound 5 years previously, and the bullet was left in situ, in the intravertebral disc between L2 and L3, as confirmed by radiographs, computed tomography, and magnetic resonance imaging. The hypothesis of lead poisoning was confirmed by the laboratory results. Chelation treatment with calcium versenate (disodium ethylenediaminetetraacetate, or CaNa (2) EDTA) was indicated. The patient was admitted and treated once again, before surgical removal of the bullet. RESULTS: After removal of the bullet, the patient had an episode of recurrence, and a new chelation cycle was performed, with complete resolution. CONCLUSION: Lead poisoning can result in severe clinical disorders that require rapid treatment. In this case, both clinical and surgical treatments led to complete resolution of the symptoms.

Lead poisoning following ingestion of pieces of lead roofing plates: pica-like behavior in an adult.

A 37-year-old man was admitted to hospital after complaining of abdominal pain for the past two weeks. On admission the abdominal radiograph showed multiple radio-opaque flecks dispersed throughout the gastrointestinal tract. Blood testing showed hemoglobin level 8.7 g/dL and a blood lead level of 112.4 microg/dL. The family interview revealed that the patient had pica-like behavior since childhood. He was a site foreman and had been ingesting pieces of roofing plates for a few weeks. The patient was treated with laxatives and CaNa(2)EDTA therapy was initiated. The blood lead level then dropped to 69.9 microg/dL. The patient received two subsequent courses of oral succimer and the blood lead level decreased to 59 microg/dL 21 days after the first course. The follow-up abdominal X-ray 20 days after the first examination was normal. Four months later, an outpatient follow-up visit showed a blood lead level within normal limits (14.5 microg/dL) and a psychiatric follow-up was initiated. Lead poisoning following the ingestion of lead-containing foreign bodies is particularly rare in adults, while it is sometimes observed in children. Pica behavior is a well-identified risk factor of lead intoxication in children but is quite exceptional in adults, where it is usually considered to be a psychiatric condition. Other unusual sources of lead poisoning include the ingestion of lead bullets, ceramic lead glaze or glazed earthenware, lead-contaminated candies, ethnic or herbal remedies.

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.

Intoxication from an accidentally ingested lead shot retained in the gastrointestinal tract.

A 45-year-old woman was referred to the Department of Occupational and Environmental Health in January 2002 because of increased blood lead concentrations of unknown origin. She suffered from malaise, fatigue, and diffuse gastrointestinal symptoms. She had a blood lead level of 550 microg/L (normal range < 40 microg/L). The patient had not been occupationally exposed to lead, and no potential lead sources, such as food products or lead-glazed pottery, could be identified. Her food habits were normal, but she did consume game occasionally. Clinical examination, including standard neurologic examination, was normal. No anemia was present. Laboratory tests showed an increased excretion of lead in the urine, but there were no signs of microproteinuria. An abdominal X ray in October 2002 revealed a 6-mm rounded metal object in the colon ascendens. Before the object could be further localized, the patient contracted winter vomiting disease (gastroenteritis) and the metal object was spontaneously released from the colon during a diarrhea attack. The object was a lead shot pellet, possibly but not normally used in Sweden for hunting wild boar or roe deer. Blood lead levels slowly decreased. Nine months later the patient's blood lead levels were almost normal (approximately 70 microg/L) and her symptoms had almost completely disappeared. In this case, a rare source of lead exposure was found. In investigations of blood lead elevations of unknown origin, we recommend abdominal X ray in parallel with repeated blood lead determinations.

Childhood lead poisoning from paint chips: a continuing problem.

Although lead poisoning (plumbism) has been recognized for centuries, lead exposures still occur frequently today because of its varied uses and persistence in the environment. Despite the awareness of the adverse effects of lead on adults, childhood plumbism was first reported only about a century ago. Young children are one of the most vulnerable groups to the adverse effects of lead because of their rapidly developing central nervous systems. Federal regulations in the 1970s have been successfully implemented to decrease the amount of environmental lead by decreasing the content of lead in gasoline and indoor paint. However, almost 30 years after these laws were passed, inner-city housing with leaded paint still exists. We describe three children living in New York City who developed plumbism from the ingestion of leaded paint chips.

Factors affecting in vivo measurement precision and accuracy of 109Cd K x-ray fluorescence measurements.

109Cd K x-ray fluorescence (XRF) measurement systems from two research centres were used to measure tibia lead content in a population (n = 530) of young adults. The group mean bone lead contents (+/-SEM) determined by McMaster University (n = 214) and the University of Maryland (n = 316) were 2.80 +/- 0.51 and 2.33 +/- 0.50 microg Pb/(g bone mineral) respectively. The mean difference of 0.47 +/- 0.71 microg Pb/(g bone mineral) was not significant. There was no evidence of a systematic difference between measurements from the two systems. Measurement uncertainties for the young adults were poorer overall than uncertainties for a population of occupationally exposed men. This was because obese subjects and women were included in the study. Regressions of precision against body mass index (BMI, defined as weight/height2) determined that uncertainties increased with BMI and were poorer for women than men. Measurement uncertainties (1sigma) were >8 microg Pb/(g bone mineral) for women with a BMI > 0.004 kg cm(-2). Poor-precision data affected population estimates of bone lead content; an inverse correlation was found between precision and bone lead content. A small number (0.4%) of individual measurements with poor uncertainties were inaccurate to within the precision. It is suggested that obese subjects, whose BMI > 0.004 kg cm(-2), should be excluded from 109Cd K XRF studies, as the measurement provides limited information and may be inaccurate.