images in clinical medicine
The new england journal of medicine
n engl j med 367;10 nejm.org september 6, 2012
recycling factory for the past year. Examination revealed diffuse abdominal tender-
ness, as well as a bluish line around the gums, known as Burton’s line. Results of
routine hematologic, liver-function, and kidney-function tests were normal. Ultraso-
nography of the abdomen was unrevealing. The blood lead level was elevated at 81 ng
per deciliter (3.9 nmol per liter) (reference range, <10 ng per deciliter [0.5 nmol per
liter]). The patient was admitted to the hospital and started on chelation therapy
with penicillamine. He was discharged in 2 weeks, after the pain had subsided and the
blood lead level had declined; the Burton’s line had disappeared. He was counseled
regarding potential occupational exposure. In developing countries, occupational
exposure is the main cause of lead poisoning. Persons working at sites where bat-
teries or plastics are manufactured, at printing or recycling factories, or in the paint
or ceramics industries are at greatest risk. Preventing exposure is the most critical
intervention. In developing countries such as India that have a growing recycling
industry, education regarding the hazards of heavy-metal poisoning is important.
n 18-year-old nonsmoking man presented to the emergency de-
partment with a 1-week history of diffuse, colicky abdominal pain. He had
had no change in his bowel or bladder function. He had worked in a battery-
Copyright © 2012 Massachusetts Medical Society.
M.P.S. Chawla, M.D.
Post Graduate Institute of Medical
Education and Research at Dr. Ram
Manohar Lohia Hospital
New Delhi, India
Deepak Sundriyal, M.D.
Himalayan Institute of Medical Sciences
The New England Journal of Medicine
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