Acute Elevation of Blood Lead Levels Within Hours of Ingestion of Large Quantities of Lead Shot

Department of Emergency Medicine, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque 87131, USA.
Clinical Toxicology (Impact Factor: 3.67). 07/2000; 38(4). DOI: 10.1081/CLT-100100954


Background: Ingestion of elemental lead foreign bodies is felt to have a low risk of clinically significant lead absorption unless gastrointestinal pathology and/or prolonged transit time are present. We present a case of ingestion of a large quantity of small diameter lead shot accompanied by rapid elevation of blood lead levels. Case Report: A 5½-year-old previously healthy girl was found eating the pellets from an ankle weight. She vomited and complained of abdominal pain. In the emergency department, she had no complaints and normal vital signs. An abdominal X-ray showed thousands of small, round, metallic density objects in the stomach. Her white blood cell count was 14,700/mm3, and the hemoglobin, mean corpuscular volume, free erythrocyte protoporphyrin, zinc protoporphyrin, biochemistry panel 21, and urinalysis were normal. She had no prior lead level for comparison. Whole-bowel irrigation was begun and she passed over 11 stools with pellets as well as other foreign bodies (erasers, bead, etc.) in the first 24 hours. Pellets were still seen on X-ray the following day so she received a high-fiber diet and bisacodyl tablets 10 mg/d. On hospital day 2, her admission blood lead (drawn 13 hours after ingestion) was reported as 57 μg/dL (2.7 μm/L) and chelation was begun with oral 2,3-dimercaptosuccinic acid 10 mg/kg 3x/d for 5 days, then 2x/d for 14 days. Her peak measured lead level was 79 μg/dL approximately 36 hours after ingestion. She excreted 2273 μg lead in the urine during her first 24 hours of chelation. Her blood lead dropped to 14.3 μg/dL by the end of chelation. She did not develop any apparent signs of lead poisoning. Conclusion: Acute elevations of blood lead concentrations may occur rapidly after ingestion of multiple small elemental lead objects.

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    • "In order to identify the source of exposure, a careful environmental and occupational history should be obtained and the appropriate public health agencies should be involved. For acute oral lead exposures (such as ingestion of paint chips), gastrointestinal decontamination may be performed [1,62]. Chelation therapy involves the administration of a chelating agent that binds lead and forms a chelate that is subsequently excreted from the body. "
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    • "The results suggest that Pb-acetate when administered by oral gavage is rapidly absorbed, since peak blood Pb concentrations were attained within 30 min to 1 h post-dosing. This rapid absorption in the rat following an oral gavage dose is consistent with the absorption (peak 2 h post-dosing) seen in a human that ingested 100 mg Pb-acetate on two separate occasions (Marcus, 1985), or following the clinically reported acute ingestion of elemental Pb objects (McKinney, 2000). Within the blood, Pb is rapidly partitioned between RBC and plasma with >95% of the blood Pb being associated with the RBC component. "
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    • "Using x-rays to identify the presence and approximate the location of these objects can help direct management of their removal with wholebowel irrigation [70] [71] [72] [73] and endoscopy [72] [73]. Prompt removal is crucial because elevated blood levels have been shown to occur within hours of ingesting lead pellets [71]. Another situation in which plain radiography may prove useful is with body packers. "
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