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Case R eport
REVISTA PAULISTA DE MEDICIN ALe ad poisoning afte r gunshot wound
Intoxication Control Center, Hospital das Clínicas,
Universidade Estadual de Campinas, Campinas, Brazil
a b s t r a c t
CO N TEX T: Despite the absence o f sympto ms in the majo rity o f pa-tients carrying lead bullet frag ments in their bo dies, there needs to be an awareness o f the po ssible sig ns and sympto ms o f lead into xi-catio n when bullets are lo dg ed in larg e jo ints like knees, hips and sho ulders. Such patients merit clo ser fo llo w-up, and even surg ical pro cedure fo r remo ving the frag ments.
O BJECTIV E: To describe a patient who develo ped clinical lead in-to xicatio n several years after a g unsho t wo und.
DESIGN : Case repo rt.
CASE REPO RT: A sing le white 2 3 -year-o ld male, reg ular jo b as a bricklayer, with a histo ry o f chro nic alco ho l abuse, sho wed up at the emerg ency department co mplaining o f abdo minal pain with co lic, weakness, vo miting and diarrhea with black feces. All the sympto ms had a duratio n o f two to three weeks, and had been recurrent fo r the last two years, with calming during interval perio ds o f two to three weeks. Abdo minal radio g rams sho wed a bullet lo dg ed in the left hip, with a neat burso g ram o f the who le syno vial capsule. A co urse o f chelating treatment using calcium versenate (EDTACaN a2) intraveno usly was started. After the chelatio n therapy the patient had recurrence o f his sympto ms and a radical so lutio n fo r the chro nic mo biliz atio n o f lead was co nsidered. A hip arthro plasty pro cedure was perfo rmed, leading to co mplete substitutio n o f the left hip.
KEY W O RDS: Lead into xicatio n. G unsho t wo und. Jo int.
• Paulo Ro berto de Madureira • Eduardo Mello De Capitani • Ro nan Jo sé Vieira
INTRODUCTION
Usually, gunsho t wo unds are managed co nser-vatively because the hazard linked to surgical pro ce-dures is greater than the risk o f later systemic lead into xicatio n.1
In the so ft tissue and bo nes, the retained bullets are encased by fibro tic scar tissue with po o r vascularizatio n, avo iding lead disso lutio n.2 Ho wever,
the medical literature has sho wn up so me cases o f arthro pathy3 and systemic lead into xicatio n in patients
who se bullets are in co ntact with syno vial and cere-bral spinal fluids.4 Recently, we to o k care o f a patient
who develo ped clinical lead into xicatio n several years after a gunsho t wo und.
CASE REPORT
A single white 23-year-o ld male, regular jo b as a bricklayer, with a histo ry o f chro nic alco ho l abuse, sho wed up at the Emergency Department co mplain-ing o f abdo minal pain with co lic, weakness, vo mitmplain-ing and diarrhea with black feces. All the sympto ms had a duratio n o f two to three weeks, and had been recur-rent fo r the last two years, with calming during inter-val perio ds o f two to three weeks. During clinical ex-aminatio n the patient sho wed facial pallo r and ab-do minal tenderness. Labo rato ry blo o d examinatio n sho wed hemo glo bin = 7.4 g%; hemato crit = 23.3%; serum amylase = 123 U/L, ALT = 299 U/L; AST = 248 U/ L, bilirubin = DB = 3.83; IB = 1.62; BUN = 23 mg%; serum creatinine = 0.79 mg%. An abdo minal ultra-so und examinatio n was no rmal, and gastric endo s-co py sho wed ero sive eso phagitis.
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Abdo minal radio grams sho wed a bullet lo dged in the left hip, with a neat burso gram o f the who le syno vial capsule (Figure). The patient gave the info r-matio n that a gunsho t accident had o ccurred seven years ago . Lead into xicatio n was then co nsidered and blo o d samples were drawn fo r lead (PbB) and zinc pro -to po rphyrin (ZPP) do sages. A urine sample was also co llected fo r delta aminulevulinic acid (U-ALA) mea-surement. The fo llo wing results co rro bo rated the di-agno sis o f lead into xicatio n: PbB = 40.1
µ
g/dl (refer-ence value fo r no n-expo sed po pulatio n = 40 mg/dl); ZPP = 84.3µ
g/dl (reference value = 75µ
g/dl); and U-ALA = 49.2 mg/dl (reference value fo r no n-expo sed po pulatio n = 6 mg/dl).A co urse o f chelating treatment using calcium versenate (EDTACaNa2) intraveno usly was started at a do sage o f 1 g per day, and co ntinued fo r 6 days. Dur-ing the first ho urs o f infusio n o f the specific treatment, the patient sho wed go o d impro vement, being free fro m any abdo minal pain by the seco nd day o f treatment. Chelatio n was assessed by measuring the to tal amo unt o f lead excreted in urine during each day o f treatment. The to tal amo unt o f lead excreted in the 6 days was 20792 mg (mean 3465 mg each day), exceeding the cuto ff o f 2000 mg per day that is co nsidered to be an efficacio us treatment.
After the chelatio n therapy the patient had recurrence o f his sympto ms and a radical so lutio n fo r the chro nic mo bilizatio n o f lead was co nsidered. A hip arthro plasty pro cedure was perfo rmed, leading to a co mplete substitutio n o f the left hip. Histo patho lo gic examinatio n o f the hip and the part o f the femur re-m o ve d , sho we d inte nse re-m e tal ire-m p re gnatio n with granulo mato us fo reign bo dy reactio n aro und the bo ne tissue and syno vial capsule. Osteo necro tic areas with bo ne marro w fat sapo nificatio n were also present, and disseminated calcificatio n was no ticed. Afterwards, during clinical fo llo w-up, the patient no lo nger pre-sented any sympto ms related to lead into xicatio n.
DISCUSSION
The present clinical case brings to light the im-po rtance o f lead im-po iso ning as a diagno sis fo r severe abdo minal pain in emergency department units. Of co urse, o ccupatio nal so urces o f expo sure to lead are by far the mo st co mmo n o nes, but retained bullets must be tho ught o f as a po ssible so urce o f lead if this is the case. The great number o f peo ple carrying lead bullets in so me part o f their bo dies may increase the risk o f “endo geno us” into xicatio n by this heavy metal. It has been o bserved that lead bullets in muscle
o r bo ne tissues, do no t bring much tro uble, as the tis-sue aro und the fo reign bo dy creates a fibro us capsule, avo iding disso lutio n o f lead into the blo o d circulatio n2.
Due to physical chemical pro perties, metallic lead tends to disso lve in acidic media, thereby pro mo ting abso rp-tio n, distriburp-tio n, and to xic effects in its target o rgans and tissues, such as the central and peripheral nervo us systems, the enzymatic system fo r heme synthesis, and kidneys. This is the case when the bullet is lo dged in the jo ints, in direct co ntact with syno vial liquid, o r in the central nervo us system o r spinal co rd canal, in co n-tact with cerebro spinal fluid.4 In the case o f big jo ints,
like hips and sho ulders, patients must no t be lo st to fo llo w-up after emergency first care, and do cto rs must plan o n early excisio n o f the bullet, to avo id the risk o f late disso lutio n and chro nic clinical lead into xicatio n. The chro nic syno vial inflammato ry pro cess generally leads to great damage o f the syno vial capsule and jo int cartilage surface, as seen in this case. Our case is very educatio nal in this respect, as seven years elapsed be-tween the sho t accident and the surgical pro cedure that fo llo wed the diagno sis o f into xicatio n. The patient’s hip co uld pro bably have been spared if early interventio n had been perfo rmed.
Figure - Radiograph of the left hip showing a fragment of the bullet and bursogram.
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r e s u m o
CO N TEX TO : Apesar da ausência de sinto mas na maio ria das pesso as que alberg am pro jéteis o u frag mento s de pro jéteis de arma de fo g o e m a lg uma p a rte d o c o rp o d e vid o a a c id e nte s p a ssa d o s, a o co rrência de sinais e sinto mas de into xicação po r chumbo po de ser freqüente em pacientes o nde o pro jétil está alo jado em g randes articulaçõ es co mo jo elho , quadril e o mbro s, merecendo maio res c uida do s de seg uimento c línic o e pro c edimento s c irúrg ic o s de retirada.
O BJETIV O : Descrever un do ente que desenvo lveu into xicação po r chumbo vário s ano s apó s um ferimento po r arma de fo g o .
TIPO DE ESTUDO : Relato de caso .
RELATO DE CASO : Um ho mem, 2 3 ano s, branco , pedreiro , co m histó ria de uso abusivo de bebidas alco ó licas, fo i atendido no pro nto -so co rro co m do r abdo minal intensa em có lica, fraquez a, vô mito s e diarréia co m fezes escurecidas. To do s o s sinto mas tinham a duração de duas a três semanas, tendo sido reco rrentes no s último s do is ano s, co m perío do s de acalmia de duas a três semanas. Radio g rafia de abdô me mo stro u um pro jétil incrustrado na articulação femo ral esquerda, co m imag em tipo “ burso g rama” co mpro metendo to da a cápsula sino vial. Tratamento quelante usando versenato de cálcio (EDTA C a N a2) e ndo ve no so fo i e ntã o inic ia do . Apó s a te ra pia q ue la nte , o p a c ie nte te ve re c o rrê nc ia d o s sinto ma s d e vid o a remo biliz ação do chumbo do s tecido s teciduais. a artro plastia da a rtic ula ç ã o fo i rea liz a da c o mo fo rma de so luç ã o definitiva do pro blema.
PA LAV RA S- CH AV E: Sinto ma s d e into xic a ç ã o p o r c humb o . Ferimento s de pro jétil. Articulaçõ es.
Paulo Robe rto de Madure ira, MD, PhD. Assistant Pro fesso r, Department o f So cial and Preventive Medicine, Asso ciate Pro fesso r o f the Into xicatio n Co ntro l Center o f the Ho spital das Clínicas, Universidade Estadual de Campinas, Campinas, Brazil.
Eduardo Me llo De Capitani, MD, MSc, PhD. Assistant Pro fesso r, Depart-ment o f Clinics and Asso ciate Pro fesso r o f the Ho spital das Clínicas, Universidade Estadual de Campinas, Campinas, Brazil.
Ronan José Vie ira, MD, MSc, PhD. Assistant Pro fesso r, Department o f Clinics and Asso ciate Pro fesso r o f the Ho spital das Clínicas, Universidade Estadual de Campinas, Campinas, Brazil.
Source of funding: No t declared
Conflict of inte re st: No t declared
Last re ce ive d: 5 July 1999
Acce pte d: 1 September 1999
Addre ss for corre sponde nce :
Paulo Ro berto de Madureira Rua Meno tti Arthur Grigo l, 83 Campinas/SP - Brasil - CEP 13085-840 E-mail: madull@ fcm.unicamp.br
p u b lis hin g in fo r m a t io n
REFERENCES
1. Kikano GE, Stange KC. Lead po iso ning in a child after a gunsho t injury. J Farm Pract 1992;34:498-500.
2. Greenberg SR. The histo patho lo gy o f tissue lead retentio n. Histo l Histo patho l 1990;5:541-6.
3. Jansen DL, Tirman PF, Rabassa AE, Kumar S. Lead burso gram and
fo cal syno vitis seco ndary to a retained intrarticular bullet fragment. Skeletal Radio l 1995;24:142-4.
4. Cavalieri Co sta R, Stape CA, Suzuki I, Targa WH, Batista MA, Bernabe AC, Miranda FG, Lage LA. Lead po iso ning caused by bullet in the hip. Repo rt o f 2 cases. Rev Ho sp Clin Fac Med São Paulo 1994;49:124-7.
It is also wo rth mentio ning the ro le o f chela-tio n therapy, with calcium versenate, o r so dium EDTA, as a sympto matic and palliative treatment during the who le pro cess o f o rtho pedic and clinical evaluatio n befo re surgery. The great abdo minal pain, and
gen-eral sympto m relief during chelatio n therapy, warrant the use o f this pro cedure, no t as a permanent treat-ment, as the so urce o f endo geno us lead is still there, but as a go o d way o f impro ving the patient’s clinical status in the lead-up to definite remo val o f the bullet.
