Lead poisoning

Chr. Lead poisoning = Plumbism = Saturnism = Saturnine poisoning– ALA in urine, Coproporphyrin in urine, facial pallor, Basophilic stippling/Punctate basophilia (dark blue, pin-head spots in cytoplasm of RBCs), Burtonian line (blue line gums’ margin, PbS, 50-70% cases, near carious/dirty teeth, Lead palsy, Pb encephalopathy, wrist drop, foot drop, Colic, Constipation, Menstrual irregularity, Sterility, Nephropathy, X-ray- radio-opaque bands at metaphyses of long bones, Pb >0.03mg% in blood is diagnostic.

Facial pallor particularly of the mouth is the earliest and most consistent sign of chronic lead poisoning and is due to vasospasm.

Chronic poisoning results from a daily intake of 1-2mg of lead.

Other characteristic features of chronic lead poisoning are anaemia (punctate basophilia), lead line, colic and constipation, lead palsy and encephalopathy.

Reference:
Essentials of Forensic Medicine and Toxicology by Dr K.S Narayan Reddy 27th edition page 479.

The occupational history and clinical features of this patient suggest that he is suffering from chronic lead poisoning. 

Characteristic features of chronic lead poisoning includes:

• Facial pallor: Particularly of the mouth is the earliest and most consistent sign.
• Anemia: Anemia associated with polychromasia, punctate basophilia, reticulocytosis, poikolocytosis, anisocytosis and sideroblastosis. Basophilic stippling refers to the presence of dark blue pin head sized spots in the cytoplasm of red blood cells. 
• Lead line or Burtonian line: seen on gums in 70% cases.
• Colic and constipation seen in 85% cases.
• Lead palsy: Radial nerve is most commonly involved resuling in wrist drop. 
• Encephalopathy: It is seen in every case of plumbism. Lead encephalopathy is irreversible and 85% have permanent brain damage.

Though lead poisoning is associated with anemia, polychromasia, punctate basophilia, reticulocytosis and increased mononuclear cells ; it may also be associated with polycythaemia and polychromatophilia in the early stages.

The facial pallor (mainly circum oral) seen in lead poisoning is believed to be due to vasospasm.

• Inhalation – Most cases of industrial lead poisoning is due to inhalation of fumes and dust of lead or its compounds.
• Ingestion – Small quantities of lead trapped in the upper respiratory tract may be ingested. Contaminated hands may also lead to ingestion.
• Skin – Only organic lead (e.g., tetraethyl lead) is absorbed dermally. 

• raise awareness about lead poisoning;
• highlight countries and partners’ efforts to prevent childhood lead poisoning; and
• urge further action to eliminate lead paint.

Ans. is ‘b’ i.e., Iron deficit

1. Causes of sideroblastic anemia

Hereditary

o X-linked recessive sideroblastic anemia.

Acquired

Hematological                                   Drugs & chemicals                            Others

Myelofibrosis                                         INH                                                        RA

Myelodysplasia                                     Penicillamine                                        Myxedema

Acute leukemia                                      Lead                                                       SLE

Lymphoma                                            Alcohol                                                  Iron overload

Myeloma                                                Pyridoxin dificiency                            Porphyria

Polycythemia vera                                Chloromphenicol

Hemolytic anemia

Ans. is ‘a’ i.e., Inhibiton of enzymes involved in Heme biosynthesis

o Lead interferes with the syntheiss of Heme by inhibiting the enzymes d Aminolevulinic acid dehydrase and Ferrochelatase. These two enzymes are involved in the synthesis of Heme.

A i.e. Lead

D i.e. Lead poisoning

A i.e. Lead poisoning

A i.e. Diarrhoea

C i.e. Punctate basophilia

Ans:D.)B and C.

CLINICAL FINDINGS of Lead Poisoning: 

• The clinical findings of lead poisoning are different in the inorganic and organic lead exposures. 
• Inorganic lead poisoning: Abdominal colic, constipation, loss of appetite, blue line on the gums, stippling of red cells, anemia, wrist drop and foot drop.
• Organic lead poisoning: The toxic effects of organic lead poisoning are mostly on the CNS causing insomnia, headache, mental confusion, delirium, etc.
• Characteristic features of chronic lead poisoning includes:
  • Facial pallor: Particularly of the mouth is the earliest and most consistent sign.
  • Anemia: Anemia associated with polychromasia, punctate basophilia, reticulocytosis, poikolocytosis, anisocytosis and sideroblastosis. Basophilic stippling refers to the presence of dark blue pin head sized spots in the cytoplasm of red blood cells. 
  • Saturnism = Saturnine poisoning– ALA in urine, Coproporphyrin in urine, facial pallor, Basophilic stippling/Punctate basophilia (dark blue, pin-head spots in cytoplasm of RBCs), Burtonian line (blue line gums’ margin, PbS, 50-70% cases, near carious/dirty teeth, Lead palsy, Pb encephalopathy, wrist drop, foot drop, Colic, Constipation, Menstrual irregularity, Sterility, Nephropathy, X-ray- radio-opaque bands at metaphyses of long bones, Pb >0.03mg% in blood is diagnosticLead line or Burtonian line: seen on gums in 70% cases.
  • Colic and constipation seen in 85% cases.
  • Lead palsy: Radial nerve is most commonly involved resuling in wrist drop. 
  • Encephalopathy: It is seen in every case of plumbism. Lead encephalopathy is irreversible and 85% have permanent brain damage.

B i.e. Peripheral neuropathy (Don’t get astonished this is the correct answer guys)

C i.e. Cutaneous blister

B i.e. Coproporphyrin

A i.e. Lead poisoning

Plumbism (Saturism) or chronic lead poisoning presents with Lead poisoning is indicated by            

Facial pallor is the earliest sign of chronic lead poisoning (plumbism)(2. Colic pain & Constipation are most commonQ features found in about 85% of cases. Anemia & Encephalopathy are very common manifestation; minor degree of encephalopathy & anemia is seen in all most all cases. Lead palsy or Peripheral neuropathy is rather late & unconunon phenomenon seen in < 10% cases Bilsters & rain drop pigmentation is seen in chronic arsenic poisoning not lead poisoning.(2

Lead sulphide is least toxic salt of lead(2. In non exposed persons coproporphyrin (CPU) levels is <150pg/literQ

Ans. :D.)Appendicitis.

The most common medical cause of Acute abdominal pain in children  is gastroenteritis, and the most common surgical cause is appendicitis

Ans is ‘d’ i.e., Peripheral Neuropathy

Acute lead poisoning

The most serious manifestation of lead poisoning in children is

ACUTE ENCEPHALOPATHY.

Encephalopathy includes ‑

o Persistant vomiting                o Papilloedema o Lethargy          o Impaired consciousness and coma

o Ataxia                                   o Seizures         o Irratibility

Peripheral Neuropathy which is common in adults is rarely seen in children except with those of sickle cell disease.

Ans. is ‘c’ i.e., Inhalation 

Lead poisoning (plumbism) may occur in 3 ways : ‑

1)     Inhalation – Most cases of industrial lead poisoning is due to inhalation of fumes and dust of lead or its compounds.

2)     Ingestion – Small quantities of lead trapped in the upper respiratory tract may be ingested. Contaminated hands may also lead to ingestion.

3)     Skin – Only organic lead (e.g., tetraethyl lead) is absorbed dermally.

Ans. D i.e. Coproporphyrin III

Ans. Insomnia

Ans. Lead poisoning

Ans. Lead poisoning

Ans. 6-amino levulinic acid

Ans. is ‘a’ i.e., Chronic Lead poisoning

The patient works in welding factory and is in continuous contact with lead. Blood examination showing anemia and basophilic stippling are consistent with lead poisoning. So the suspected diagnosis is lead poisoning.

Chronic Lead poisoning

It is characterized by :

• Facial pallor particularly around the mouth is one of the earliest and most consistent feature.
• Anemia with punctate basophilia (basophilic stippling) is also an early feature. There is reticulocytosis, poikilocytosis, anisocytosis, sideroblasts and eosinophilia.
• Burtonian line (stippled blue line) is seen on the gums on upper jaw. Similar blue line is also seen in poisoning with mercury (Hg), copper (Cu), silver (Ag), Bismuth (Bi) and iron (Fe).
• Colic (abdominal pain) and constipation (dry belly ache) : is a late manifestation.
• Encephalopathy is more in children and in poisoning with tetraethyl lead.
• Paralysis in the form of wrist and foot drop is a late manifestation, called lead palsy and is due to peripheral neuropathy. It occurs only in less than 10% of cases.
• Renovascular manifestations (nephropathy) : Hypertension, arteriolar degeneration and arteriosclerotic nephritis may occur. Rarely, lead poisoning may cause proximal tubular necrosis.
• Other features include optic atrophy, CVS and reproductive anomalies.

Investigations include :

• Blood tests : (1) > 200 punctate basophilic stippling cells per mm³ is diagnostic; (2) zinc protoporphyrin and free erythrocyte protoporphyrin > 50 mg/100 ml; and (3) increased lead and aminolaevulinic acid (> 25 mg/100 cc).
• Urine tests : (1) Increased coproporphyrin (CPU) levels, of 0.25 mg/L of lead is diagnostic.
• X-ray : (1) Radioopaque matter in GIT (if ingested within 48 hours), and (2) radioopaque lines at metaphysis oflong bones in children.
• Calcium disodium edetate is specific antidote for treatment of lead poisoning.

Basophilic Stippling is seen in the image.

• Basophilic Stippling is the term used to indicate the presence of irregular basophilic granules in the cytoplasm of erythrocytes. The granules are composed of unstable RNA.

Basophilic stippling can be seen in a variety of hematologic disorders like:

• Thalassemias

• Heavy metal poisoning, particularly lead or arsenicals

• Dyserythropoietic anemias

• Megaloblastic anemia

• Thrombotic thrombocytopenic purpura 

• Pyrimidine 5′-nucleotidase deficiency.

Ans. a. Lead poisoning