Systemic plumbism following remote ballistic injury

Inflammatory low back pain with radiculopathy revealing epidural disintegration of a bullet complicated by lead poisoning

Inflammatory low back pain with radiculopathy is suggestive of cancer, infection or inflammatory diseases. We report a unique case of a 42-year-old patient with an acute inflammatory low back pain with bilateral radiculopathy associated with weight loss and abdominal pain, revealing the disintegration of a lead bullet along the epidural space and the S1 nerve root complicated by lead poisoning. Because of the high blood lead level of intoxication (>10 times over the usual lead levels) and the failure of repeated lead chelator cycles, a surgical treatment to remove bullet fragments was performed. It resulted in a significant decrease of pain and lead intoxication.

Lead toxicity due to retained intracranial bullet fragments: illustrative case

BACKGROUND

Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors' knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments.

OBSERVATIONS

The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms.

LESSONS

Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.

A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports

Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.

Ischaemic Stroke Caused by a Gunshot Wound to the Chest

Introduction

Pneumatic weapons rarely cause severe trauma. However, pellet embolisation can cause severe and unexpected injuries.

Report

This is the case study of a 32 year old man, who was shot in the chest with a pneumatic rifle. Initially, urgent damage control surgery was performed to resolve pneumothorax and pericardial tamponade, but no projectile was found. Subsequent atypical symptomatology led to more extensive imaging that found a pellet embolised into the right carotid artery, thrombosis of the middle cerebral artery, and development of a large right hemispheric ischaemic area. After an unsuccessful endovascular intervention, the projectile was removed during an open surgical procedure. The right hemisphere oedema required decompressive hemicraniectomy, but long term intensive care and physiotherapy resulted in a satisfactory recovery with moderate neurological sequelae.

Conclusion

An unusual clinical presentation in combination with an absent exit wound might be symptomatic of projectile embolisation and should lead to a search for it. When the projectile position is convenient, surgical removal is the treatment of choice while an endovascular approach should be reserved for inaccessible locations or asymptomatic cases.

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Projectile embolisation can lead to severe and unexpected pathologies.

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Unusual clinical signs and an absent exit wound are suspicious of embolisation.

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For symptomatic emboli, urgent projectile removal is necessary.

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Surgical rather than endovascular removal is preferred for symptomatic emboli.

Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature

BACKGROUND

Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 μg/dL and 40 μg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. CASE 

REPORT

We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

Firearms, bullets, and wound ballistics: an imaging primer

Based on its intrinsic mass and velocity, a bullet has an upper limit of wounding potential. Actual wound severity is a function of the bullet construction and trajectory, as well as the properties of the tissues traversed. Interpreting physicians must evaluate the bullet trajectory and describe patterns of injury resulting from the effect of energy transfer from the projectile into living tissue. A basic understanding of firearms, projectiles, and wound ballistics can help the interpreting physicians in conceptualizing these injuries and interpreting these cases.