Hemolytic anemia associated with lead poisoning from shotgun pellets and the response to Succimer treatment

Succimer chelation does not produce lasting reductions of blood lead levels in a rodent model of retained lead fragments

Retained lead fragments from nonfatal firearm injuries pose a risk of lead poisoning. While chelation is well-established as a lead poisoning treatment, it remains unclear whether chelation mobilizes lead from embedded lead fragments. Here, we tested whether 1) DMSA/succimer or CaNa2EDTA increases mobilization of lead from fragments in vitro, and 2) succimer is efficacious in chelating fragment lead in vivo, using stable lead isotope tracer methods in a rodent model of embedded fragments. DMSA was > 10-times more effective than CaNa2EDTA in mobilizing fragment lead in vitro. In the rodent model, succimer chelation on day 1 produced the greatest blood lead reductions, and fragment lead was not mobilized into blood. However, with continued chelation and over 3-weeks post-chelation, blood lead levels rebounded with mobilization of lead from the fragments. These findings suggest prolonged chelation will increase fragment lead mobilization post-chelation, supporting the need for long-term surveillance in patients with retained fragments.

Retained bullets and lead toxicity: a systematic review

INTRODUCTION

Lead toxicity secondary to retained bullet(s) (RB) after a penetrating gunshot wound is a rare but likely underdiagnosed condition, given the substantial number of firearm injuries in the United States. There is currently no consensus on the indications for surveillance, chelation, or surgical intervention.

OBJECTIVE

The purpose of our review is to summarize the literature on systemic lead toxicity secondary to RBs to help guide clinicians in the management of these patients.

METHODOLOGY

The primary literature search was conducted in Medline (PubMed), EMBASE, Cochrane, and CENTRAL using the following MESH terms: "chelation" and "lead poisoning" or "lead toxicity" or "lead" and "bullet" or "missile" or "gunshot", or "bullet".

RESULTS

The search identified 1,082 articles. After exclusions, a total of 142 articles were included in our final review, the majority of which were case reports. Several factors appear to increase the risk of developing lead toxicity including the location of the RB, the presence of a fracture or recent trauma, number of fragments, hypermetabolic states, and bullet retention duration. Particularly, RBs located within a body fluid compartment like an intra-articular space appear to be at a substantially higher risk of developing lead toxicity. Even though patients with lead toxicity from RBs will have similar symptoms to patients with lead toxicity from other sources, the diagnosis of lead poisoning may occur months or years after a gunshot wound. Symptomatic patients with high blood lead levels (BLLs) tended to improve with a combination of chelation and surgical removal of RBs.

CONCLUSIONS

We suggest surveillance with serial BLLs should be performed. Patients with intra-articular RBs appear to be at increased risk of lead toxicity and if possible, early surgical removal of the RBs is warranted, especially given that signs of toxicity are vague, and patients may not have access to follow-up. Long-term chelation should not be used as a surgical alternative and management should be multidisciplinary.

Biosynthesized Iron Oxide Nanoparticles from Petroselinum crispum Leaf Extract Mitigate Lead-Acetate-Induced Anemia in Male Albino Rats: Hematological, Biochemical and Histopathological Features

This study aimed to investigate the ameliorative effects of iron oxide nanoparticles (IONPs) prepared from leaf extract of Petroselinum crispum compared to those prepared using a chemical method in lead-acetate-induced anemic rats. Twenty rats were divided into four groups (five rats each). Throughout the experimental period (8 weeks), the rats in group 1 were not given any therapy. The rats in groups 2, 3 and 4 were given 400 ppm lead acetate orally for 2 weeks to make them anemic. Following that, these rats were either left untreated, given 27 ppm of chemical IONPs orally or given 27 ppm of natural IONPs orally for the remaining 6 weeks of the experiment. TEM analysis indicated that the chemically and naturally prepared IONPs had sizes of 6.22–9.7  and 64–68 nm, respectively. Serum ferritin and iron concentrations were reduced, whereas the total iron-binding capacity (TIBC), ALT, AST, urea and creatinine were significantly increased in the non-treated lead-acetate-induced anemic rats compared to those of the control. In addition, congestion, hemorrhage, necrosis, vacuolation and leukocytic infiltration in the kidneys, liver and spleen were observed in non-treated lead-acetate-induced anemic rats compared to the control. The effects of lead acetate were mitigated by IONPs, particularly the natural one. In conclusion, IONPs produced from Petroselinum crispum leaf extract can be used as an efficient and safe therapy in lead-acetate-induced anemic rats.

Chronic lead poisoning induced abdominal pain and anemia: a case report and review of the literature

Background

Chronic lead poisoning (CLP) is a rare cause of abdominal pain and is common in young children, in whom the incidence is higher than it is in adults. As the symptoms of CLP are nonspecific, misdiagnoses or missed diagnoses often occur, especially in sporadic cases.

Case presentation

We report a 28-year-old young man who was misdiagnosed with renal colic due to sudden acute abdominal pain. After a detailed medical history and physical examination, other possible causes were excluded, CLP was finally diagnosed, and he recovered after chelation treatment.

Conclusion

Abdominal pain is a very common clinical symptom in adults, which has many causes. We should be vigilant against chronic poisoning, especially CLP. Detailed diagnosis and physical examination are crucial in early diagnosis and treatment.

Retained Shrapnel from a Blast Injury as a Rare Cause of Secondary Osteoarthritis of the Hip Joint: A Case Report and Review of Literature

Background

Complications related to intra-articular retained shrapnel are rare and primarily depend on the anatomical location and the reaction with the surrounding tissue. Retained bodies causing severe osteoarthritis with bone destruction and limb shortening are extremely rare. We describe a rare occurrence of retained shrapnel, possibly iron nails causing a late presentation of grade 4 secondary osteoarthritis of the hip joint with destruction of the femoral head and limb shortening.

Case Presentation

A 74-year-old otherwise healthy Sri Lankan male with a history of blast injury to the right hip 35 years ago presented with an isolated, right sided mild hip pain with a progressive limp for an 8-year duration. He had a true right limb shortening of 3.6 cm and limited range of motion. However, he had minimal functional disability. An X-ray of the pelvis and hip joints showed grade 4 osteoarthritis of the right hip joint with destruction of the right femoral head. There were three retained metallic nails (shrapnel) in the right hip joint of which two were intra-articular. Although he was offered a total hip arthroplasty, he opted for conservative management due to his minimal functional disability. Modified foot wear and simple analgesics were prescribed, and he had no worsening of symptoms at 6 months of follow up.

Conclusion

Late presentation due to shrapnel-induced osteoarthritis with bone destruction and limb shortening is extremely rare. Initial assessment with radiographs is essential following blast injuries to exclude intra-articular or periarticular foreign bodies. Such foreign bodies should be removed to prevent the associated local and systemic complications.

Examination of metal mobilization from a gunshot by scanning acoustic microscopy, scanning electron microscopy, energy-dispersive X-ray spectroscopy, and inductively coupled plasma optical emission spectroscopy: a case report

BACKGROUND

Projectile foreign bodies are known to cause chronic heavy metal toxicity due to the release of metal into the bloodstream. However, the local effect around the metallic object has not been investigated and the main goal of our study is to examine the influence of the object in close proximity of the object.

CASE PRESENTATION

A 36-year-old Caucasian woman with one metallic pellet close to her sciatic nerve due to a previous shotgun injury at the gluteal area presented with a diagnosis of recurrent lumbar disk herniation at L4-5 level. A physical examination confirmed chronic neuropathy and she underwent a two-stage surgery. The surgery included removal of the foreign body, followed by discectomy and fusion at the involved level. During the removal of the metallic foreign body, a tissue sample around the pellet and another tissue sample from a remote area were obtained. The samples were analyzed by scanning acoustic microscopy, scanning electron microscopy, and energy-dispersive X-ray spectroscopy. Lead, chromium, copper, cadmium, iron, manganese, selenium, and zinc elements in tissue, blood, and serum specimens were detected by inductively coupled plasma optical emission spectroscopy.

CONCLUSIONS

An acoustic impedance map of the tissue closer to the metallic body showed higher values indicating further accumulation of elements. Energy-dispersive X-ray spectroscopy results confirmed scanning acoustic microscopy results by measuring a higher concentration of elements closer to the metallic body. Scanning electron microscopy images showed that original structure was not disturbed far away; however, deformation of the structure existed in the tissue closer to the foreign body. Element analysis showed that element levels within blood and serum were more or less within acceptable ranges; on the other hand, element levels within the tissues showed pronounced differences indicating primarily lead intoxication in the proximity of the metallic body. We can state that residues of metallic foreign bodies of gunshot injuries cause chronic metal infiltration to the surrounding tissue and induce significant damage to nearby neural elements; this is supported by the results of scanning acoustic microscopy, scanning electron microscopy, energy-dispersive X-ray spectroscopy, and inductively coupled plasma optical emission spectroscopy.

[Left ventricular projectile migration after an accidental close-range gunshot wound]

We report the case of a 24-year-old female after sustaining a shotgun wound in the left upper extremity and chest. Initial emergency diagnostics revealed numerous shotgun pellets scattered throughout the left-side soft tissue, chest and upper lung lobe with one pellet having migrated into the left ventricle of the heart.Due to the devastating injury pattern, gunshot wounds are interdisciplinarily challenging and should include extended initial diagnostics, such as contrast agent CT. The potential toxicity of elevated lead blood levels have to be taken into further account.

Oral Administration of Ganoderma lucidum to Lead-Exposed Rats Protects Erythrocytes against Hemolysis: Implicates to Anti-Anemia

We studied the effect of chronic oral exposure to lead acetate (PbA) on the sensitivity of RBC to hemolysis and whether the sensitivity could be decreased by feeding the rats with extract of medicinal mushroom Ganoderma lucidum. Three groups of rats, control, PbA-exposed, and G. lucidum (Gl)+PbA, were used. PbA (3 mM) was administered via drinking water and G. lucidum extract by gavage at 300 mg/Kg BW/day for 12 weeks. Afterwards, the rats were killed and washed RBCs were subjected to hemolysis in the presence of Fenton's reagents. Hemolysis was determined by estimating the amount of released hemoglobin. The levels of lipid peroxide (LPO) and GSH were determined from RBC membranes and whole RBCs, respectively. The levels of TNFα and LPO also were determined from hepatic tissues. The RBCs of PbA-exposed rats displayed significantly higher sensitivity to hemolysis than those of the Gl+PbA rats. The levels of LPO increased and GSH decreased in the RBCs, with concomitant increases in the levels of hepatic TNFα and LPO in the PbA-exposed rats. The degree of hemolysis was significantly low in the RBCs of Gl+PbA rats, concurrently with amelioration of hepatic parameters. Finally, the study suggests that PbA-induced-hemolysis and related oxidative-toxicity might be minimized by consumption of G. lucidum.

Investigation of lead mobilization from the buckshot residues to the critical organs

Lead exposure causes neurotoxicity, reproductive system dysfunction, renal failure, and blood and endocrine system disorders in human and experimental animals. In this study, we investigated lead mobilization from gunshot fragments to the critical organs (brain, heart, liver, and kidney) and its interaction with essential trace elements on experimental rat model. Thirty-five rats were randomly divided in five groups. The first group was a control and the others were subjected to buckshot implantation in their skeletal muscles (second and third groups) and abdomen (fourth and fifth groups). The control group and the second and fourth groups were sacrificed 1 month after the onset of experiment while the third and fifth groups were followed after 2 months. Blood lead levels were significantly elevated in both 2 month-followed groups and 1 month-followed intraabdominal group. There were significant increases in brain lead levels of both 2 month-followed groups. For the 1 month-followed groups, kidney lead levels were also significantly higher than those of controls. Results show that lead mobilizes from the buckshot residues in distance tissues to the critical organs and interacts with iron, copper, and zinc even though blood lead level sometimes remains unchanged. Our findings are crucial in revealing lead accumulation in critical organs of subjects carrying any gunshot fragments. These subjects and physicians should be in alert for emergence of lead-induced manifestations.

Elevation of Blood Lead Levels in Emergency Department Patients with Extra-articular Retained Missiles

BACKGROUND

Patients who survive gunshot wounds often have retained missiles. Unlike intra-articular retained missiles, extra-articular retained missiles (EARMs) are not routinely removed. Cases of lead toxicity from EARMs have been described. This study seeks to determine whether blood lead levels are elevated in emergency department patients with EARMs compared with matched controls, whether clinical symptoms of lead toxicity are more prevalent in patients with EARMs than in controls, and whether longer missile retention times or recent hypermetabolic conditions are associated with higher blood lead levels.

METHODS

One hundred twenty adults with EARMs and 120 age- and gender-matched controls with no history of gunshot wound were prospectively enrolled on presentation to a large urban emergency department. Whole blood lead (WBL), zinc protoporphyrin, and hemoglobin levels were obtained. Patients completed a questionnaire regarding time since gunshot injury; symptoms of lead toxicity; and occurrence within 30 days of any surgery, alcohol abuse, illicit drug abuse, diabetic ketoacidosis, hyperthyroidism, infection, fracture, pregnancy, or lactation.

RESULTS

Five EARM patients (4%) and no control patients (0%) had WBL greater than our threshold for medical follow-up (20 microg/dL). Mean WBL was 6.71 microg/dL (95% confidence interval [CI], 5.68-7.74 microg/dL) in EARM patients and 3.16 mug/dL (95% CI, 2.79-3.53 microg/dL) in controls. This difference was statistically significant when analyzed by matched pairs t test (p = 0.0001). There was no difference in the number of symptoms associated with lead toxicity that were noted by EARM patients versus controls (p = 0.377). Longer duration of missile retention was not associated with higher blood lead levels (r = 0.125, p = 0.172). Of the five hypermetabolic conditions analyzed, only fractures were associated with elevated blood lead levels (9.95 microg/dL [95% CI, 5.77-14.13 microg/dL] in EARM patients with fractures vs. 6.23 microg/dL [95% CI, 5.23-7.23 microg/dL] in EARM patients without fractures).

CONCLUSION

Patients with EARMs have significantly elevated blood lead levels compared with matched controls. The occurrence of a bony fracture within the past 30 days is associated with a higher lead level. In 96% of patients with EARMs, elevated lead levels were not clinically significant and did not change patient management.

Surgical issues in the poisoned patient

Some toxicologic emergencies require immediate or urgent surgical intervention in addition to routine medical care. The EP must be familiar with the indications for operative care, even though many of these poisonings and exposures are relatively rare. The EP must also be knowledgeable regarding the various means of surgical decontamination that are available, including temporary cardiopulmonary bypass. Finally, a high level of vigilance must be maintained for patients who have delayed presentation and fulminant organ failure necessitating early involvement of the transplantation team.

The Effects of Retained Lead Bullets on Body Lead Burden

BACKGROUND

Numerous case reports have demonstrated that lead poisoning with potentially fatal consequences can result from retained lead projectiles after firearm injuries. To assess the impact of retained projectiles on subsequent lead exposure in the population, one cannot rely on self-selected cases presenting with symptoms of lead intoxication. This preliminary study seeks to identify increased lead burden and identify risk factors of elevated blood lead levels for individuals with retained lead bullets.

METHODS

Forty-eight patients were originally recruited from gunshot victims presenting for care at the King/Drew Medical Center in Los Angeles, California. An initial blood level was measured for all recruited patients and repeated for the 28 participants available for follow-up, 1 week to 8 months later. Medical history, including a history of prior firearm injuries and other retained projectiles, was taken, along with a screening and risk factor questionnaire to determine other sources of lead (occupational/recreational) to which the patient might have been, or is at present, exposed. The participants also had K-shell x-ray fluorescence determinations of bone lead in the tibia and calcaneus in order to determine past lead exposures not revealed by medical history and risk factor questionnaire. Multivariate models of blood level were made using risk factor and bone lead concentration data.

RESULTS

We demonstrated that blood lead tends to increase with time after injury in patients with projectile retention, and that the increase in significant part depended on the presence of a bone fracture caused by the gunshot.

CONCLUSION

We encountered evidence suggesting that the amount of blood lead increase in time after injury is also dependent on the tibia lead concentration. There were too few cases in the study to fully test the effects of bullet location, or the interaction of bullet location with bone fracture or bullet fragmentation.

The treatment of lead poisoning from gunshot wounds with succimer (DMSA)

Lead poisoning is an unusual complication of gunshot wounds that occurs when retained lead bullet fragments are in contact with body fluids capable of solubilizing lead. The epidemic of violence by gunfire may result in increasing numbers of lead poisoning cases from this exposure. The use of oral chelation for toxicity resulting from this mode of exposure has not been previously discussed. Cases of lead poisoning arising from bullet lead in the synovial cavity of the hip, synovial cavity of the chest, and pleural space are reported. A combination of surgical debridement and chelation therapy with oral succimer produced a satisfactory outcome in all three cases. Oral succimer may be a safe and effective chelation agent for treating lead toxicity in adults with high lead levels secondary to gun shot wounds.