Lead poisoning; a neglected potential diagnosis in abdominal pain

Commercially available mouthguards: Unearthing trace elements for the first time

The use of mouthguards is advocated by the American Dental Association for orofacial injury prevention and teeth protection. However, the chemical environment in the mouth may cause harmful substances within the mouthguard's polymer material to leach out and be absorbed by the user. Considering this, the present study for the first time analyzed commercially available mouthguards and disclosed the presence of trace elements. Specifically, an analytical method was developed based on closed-vessel microwave-assisted digestion and plasma-based atomic spectrometry for determining toxic trace elements in mouthguard samples. Initially, 75 elements were assessed and, thereafter, quantified cadmium (Cd), copper (Cu) and lead (Pb) in each sample by inductively coupled plasma mass spectrometry (ICP-MS). Method validation was carried out by analyzing a certified reference material of Low-Density Polyethylene, and by addition and recovery experiments. Results for copper were further validated by ICP optical emission spectrometry (ICP-OES). While most samples exhibited elemental levels beneath the method's limit of quantification, Cd, Cu and Pb were detected in four samples. Remarkably, one sample had Cu levels exceeding safe limits by 109 times, highlighting potential toxicity risks. This initial research underscores the need for stricter contamination control in mouthguard materials to minimize potentially health hazards.

Role of antioxidants in the neurobiology of drug addiction: An update

Relationships between protective enzymatic and non-enzymatic pro-antioxidant mechanisms and addictive substances use disorders (SUDs) are analyzed here, based on the results of previous research, as well as on the basis of our current own studies. This review introduces new aspects of comparative analysis of associations of pro-antixidant and neurobiological effects in patients taking psychoactive substances and complements very limited knowledge about relationships with SUDs from different regions, mainly Europe. In view of the few studies on relations between antioxidants and neurobiological processes acting in patients taking psychoactive substances, this review is important from the point of view of showing the state of knowledge, directions of diagnosis and treatment, and further research needed explanation. We found significant correlations between chemical elements, pro-antioxidative mechanisms, and lipoperoxidation in the development of disorders associated with use of addictive substances, therefore elements that show most relations (Pr, Na, Mn, Y, Sc, La, Cr, Al, Ca, Sb, Cd, Pb, As, Hg, Ni) may be significant factors shaping SUDs. The action of pro-antioxidant defense and lipid peroxidation depends on the pro-antioxidative activity of ions. We explain the strongest correlations between Mg and Sb, and lipoperoxidation in addicts, which proves their stimulating effect on lipoperoxidation and on the induction of oxidative stress. We discussed which mechanisms and neurobiological processes change susceptibility to SUDs. The innovation of this review is to show that addicted people have lower activity of dismutases and peroxidases than healthy ones, which indicates disorders of antioxidant system and depletion of enzymes after long-term tolerance of stressors. We explain higher level of catalases, reductases, ceruloplasmin, bilirubin, retinol, α-tocopherol and uric acid of addicts. In view of poorly understood factors affecting addiction, analysis of interactions allows for more effective understanding of pathogenetic mechanisms leading to formation of addiction and development the initiation of directed, more effective treatment (pharmacological, hormonal) and may be helpful in the diagnosis of psychoactive changes.

Unmasking herbal medication-induced lead poisoning in a geriatric patient with gastrointestinal symptoms

Lead poisoning, often associated with occupational exposure, can also arise from intake of traditional and herbal medicines with high lead content. Geriatric patients displaying gastrointestinal symptoms from such sources are frequently misdiagnosed. An individual in his 70s reported to our geriatric clinic with vomiting, constipation and anaemia. A meticulous history unveiled his recent intake of herbal remedies. Heavy metal assay indicated elevated lead levels in his blood and urine, consistent with the high lead content we measured in the herbal medication. Following supportive treatment, nutritional supplementation and chelation therapy with calcium disodium EDTA, he improved. Follow-up tests indicated a decrease in lead levels and resolution of anaemia. This case emphasises the importance of considering lead poisoning as a potential diagnosis in patients with unexplained symptoms, particularly when there is a history of herbal or alternative medication intake. Timely recognition and appropriate management can lead to better outcome.

Automated lead toxicity prediction using computational modelling framework

Background

Lead, an environmental toxicant, accounts for 0.6% of the global burden of disease, with the highest burden in developing countries. Lead poisoning is very much preventable with adequate and timely action. Therefore, it is important to identify factors that contribute to maternal BLL and minimise them to reduce the transfer to the foetus. Literacy and awareness related to its impact are low and the clinical establishment for biological monitoring of blood lead level (BLL) is low, costly, and time-consuming. A significant contribution to an infant's BLL load is caused by maternal lead transfer during pregnancy. This acts as the first pathway to the infant's lead exposure. The social and demographic information that includes lifestyle and environmental factors are key to maternal lead exposure.

Results

We propose a novel approach to build a computational model framework that can predict lead toxicity levels in maternal blood using a set of sociodemographic features. To illustrate our proposed approach, maternal data comprising socio-demographic features and blood samples from the pregnant woman is collected, analysed, and modelled. The computational model is built that learns from the maternal data and then predicts lead level in a pregnant woman using a set of questionnaires that relate to the maternal's social and demographic information as the first point of testing. The range of features identified in the built models can estimate the underlying function and provide an understanding of the toxicity level. Following feature selection methods, the 12-feature set obtained from the Boruta algorithm gave better prediction results (kNN = 76.84%, DT = 74.70%, and NN = 73.99%).

Conclusion

The built prediction model can be beneficial in improving the point of care and hence reducing the cost and the risk involved. It is envisaged that in future, the proposed methodology will become a part of a screening process to assist healthcare experts at the point of evaluating the lead toxicity level in pregnant women. Women screened positive could be given a range of facilities including preliminary counselling to being referred to the health centre for further diagnosis. Steps could be taken to reduce maternal lead exposure; hence, it could also be possible to mitigate the infant's lead exposure by reducing transfer from the pregnant woman.

Gastrointestinal Manifestations of Lead Poisoning: A Brief Report

Gastrointestinal (GI) manifestations of lead poisoning include abdominal pain, constipation, and diarrhea. Depending on the severity of a symptom, surgical consultation is required. The present study aimed to make a comparison between the mean blood lead levels of patients hospitalized for lead toxicity and the various Gl symptoms. A retrospective cross-sectional study was performed in 2020 at Khorshid Hospital, the main regional referral center for poisoned patients (Isfahan, Iran). A total of 82 patients aged ≥18 years who were hospitalized for lead poisoning during 2017-2018 were included in the study. Patients' information was extracted from hospital medical records, including demographic information, clinical manifestations, blood lead levels, and treatment outcome. The mean age of the patients was 48.18±11.9 years, 91.5% were men, and 62.2% suffered from multiple GI symptoms, with abdominal pain being predominant (31.7%). Blood lead levels in patients with multiple GI symptoms were higher than those with only one symptom (P=0.01). Surgical consultation was required in 14.6% of the patients. Multiple GI symptoms were the main predictive factor for blood lead levels above 70 mg/dL (P=0.03, Odds ratio=3.06, 95% CI=1.09-8.61). Given the prevalence of abdominal pain and its association with elevated blood lead levels, differential diagnosis of abdominal pain should include lead toxicity.

The Effect of the Flint Water Crisis Secondary to Increased Lead Levels in Drinking Water on Constipation in Children in the City of Flint, Michigan, USA

Introduction  Constipation is a common condition in children, affecting almost one-third of the population at some point in childhood across the world. Functional constipation is the most common cause, with no clear etiology. From April 25, 2014, through October 16, 2015, the water source for the city of Flint residents was untreated Flint River water, which resulted in lead-contaminated drinking water. Lead poisoning has been associated with constipation and has multisystem sequelae, including neurological, muscular, and hematological impacts. Children may be especially vulnerable to this with their higher water intake-to-body weight ratio. There has been no previous study examining the possible relationship between the Flint water crisis and constipation in children. In our study, we aimed to see if the increased lead level in the water had any effect on constipation in children in Flint. Methods We included all children seen and diagnosed with constipation at Hurley Medical Center's Pediatric Gastrointestinal (GI) Clinic. We included only children seen in 2013 (pre-water crisis) and 2017 (post-water crisis). Children with chronic neurologic disorders, celiac disease, hypothyroidism, diabetes, Hirschsprung's disease, short bowel syndrome, and gastrointestinal surgeries were excluded. We looked at the age of presentation, associated symptoms, medications used, need for hospital admission or emergency department (ED) visits, and improvements at follow-up. Results  A total of 79 patients were included in the study. There were 29 patients from 2013 and 50 patients from 2017 (post-lead exposure period). The rate of constipation referrals to the GI clinic for the Flint population of children was significantly higher in 2017 (p=0.001). The most common associated symptom was abdominal pain in both groups. Straining was more prominent in the 2017 group (60%) compared to the 2013 group (34.5%, p=0.029). There was no clinical or statistically significant difference between the groups noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of urinary tract infection (UTI), abdominal distention, or stool impaction. Conclusions The number of patients referred to Hurley's Pediatric GI Clinic for constipation increased after the lead water crisis in Flint. Moreover, straining has significantly increased in post-lead exposure compared to pre-lead exposure. There was no clinical or statistically significant difference noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of UTI, abdominal distention, or stool impaction between both groups. A larger study would need to be done to confirm these findings, rule out other cofactors, and look into minerals in water and their effect on intestine innervations.

Comparison of Blood Lead Levels in Children and Adolescents with and without Functional Abdominal Pain

Background

Functional abdominal pain is a health concern with chronic abdominal discomfort without clear etiology. Several etiologic factors are raised in this regard, one related to environmental factors. This study aimed to compare blood lead levels between children and adolescents with and without functional abdominal pain.

Materials and Methods

This case-control study was performed in 2019-2020 in Isfahan, Iran. The sample size was calculated as 70 cases and an equal number of controls. Cases were children and adolescents with functional gastrointestinal disorder (FGID), and controls were grouped age- and sex-matched. Controls were randomly selected from those referred for routine health screening. Both groups obtained blood lead, iron, and calcium levels. All participants completed the FFQ Food Consumption and Environmental Pollutants Questionnaire.

Results

Participants were 139 children (68 cases and 71 controls). The mean (SD) age was 9.40 (3.91) years in the FGID group and 8.79 (3.46) years in the controls (P = 0.330). The mean (SD) blood lead level was not significantly different between the FGID group and the controls (3.98 ± 2.56 vs 3.81 ± 1.96 μg/dl, respectively, P = 0.670). We found that 55.3% of children with high lead levels had FGID, while 44.4% of children with lower lead levels had FGID, but the difference was not statistically significant (P = 0.33).

Conclusion

We found that the lead level was higher in patients with FGID than in the controls; however, this difference was not significantly different. This might be because of elevated lead levels in both groups. Future ecological studies with a large sample size are necessary in this regard.

A rare case report of lead encephalopathy due to high blood lead level

Here we report a case of lead poisoning having a serum lead level of 412 mcg dL^-1 who presented with decreasing level of consciousness and recurrent seizures. He responded well to treatment with chelation therapy.

Blood lead level evaluation in children presenting with chronic constipation in Tehran-Iran: a cross-sectional study

Constipation is a common reason for children seeking medical care worldwide. Abdominal complaints and constipation are also common in lead-poisoned children. This study evaluates the prevalence of abnormal blood lead levels (BLL) among pediatric and adolescent patients and examines the association of constipation with elevated BLL. This was a prospective data collection of patients younger than 18 years old with the chief complaint of constipation seen in the Mofid Children's Hospital gastroenterology clinic and Loghman Hakim pediatric and pediatric gastroenterology clinics were eligible for enrollment in this study. Constipation was defined as infrequent or difficult defecation according to ROME IV criteria lasting 2 months or more. BLL was measured with a fresh capillary whole blood capillary sample. The LeadCare II device assays BLL using an electrochemical technique (anodic stripping voltammetry). A total of 237 patients were enrolled in the study. 122 (51.48%) were female and 115 (48.52%) were male. About one fifth of patients (49; 20.67%) had BLL ≥ 5 µg/dL. The mean BLL in the sample was 3.51 µg/dL. Abdominal pain was the most common symptom accompanying constipation (134; 56%). Multivariate analysis found endoscopic evaluation (P values 0.024, OR 3.646, 95% CI 1.189-11.178), muscle pain (P values 0.020, OR 24.74, 95% CI 1.67-365.83), and maternal education (P values 0.02, OR 4.45, 95% CI 1.27-15.57) with significant differences in groups of patients with normal and elevated BLL. Elevated BLL necessitates an assessment and plans to reduce childhood lead exposure. BLL screening in childhood constipation with refractory chronic abdominal pain may also eradicate the need for invasive procedures like endoscopic evaluation.

Asymptomatic Lead Poisoning in a Pediatric Patient

Lead poisoning is a harmful condition, potentially resulting in irreversible impairments in neurocognition and behavioral development in the pediatric population. Rarely, life-threatening complications may ensue. We report a case of an asymptomatic four-year-old patient presenting with elevated lead levels (74.7 µg/dL) detected on routine blood lead screening at a well-child examination. The patient has a history significant for atopic disease, namely atopic dermatitis, seasonal allergic rhinitis, and food allergies. Overall, the asymptomatic nature of lead poisoning warrants judicious screening in the pediatric population due to the potential for neurologic complications.

[Severe lead poisoning caused by ayurvedic medicine]

HISTORY

 We report the case of a young patient who presented to our emergency department with reduced general condition, anemia, and crampy abdominal pain. A previous inpatient workup including abdominal imaging and bone marrow aspiration had not yielded a diagnosis. On inquiry, the patient reported oral ingestion of an Ayurvedic remedy over the course of one month.

FINDINGS

 24-year-old circulatory stable patient in reduced general condition with gray skin coloration and a dark gingival margin. Laboratory testing revealed an increase in transaminases and normocytic anemia. A peripheral blood smear showed basophilic stippling of the erythrocytes. Significantly elevated lead levels were detected in the patient's blood and hair. Toxic lead levels were detected in the ingested preparation.

DIAGNOSIS

 Severe lead poisoning caused by self-medication with an Ayurvedic remedy. Analysis revealed a daily oral lead load of 136 times the maximum permissible dose.

THERAPY AND COURSE

 By means of chelation therapy, the blood lead levels were significantly reduced, and there was a complete regression of the complaints as well as a normalization of the laboratory findings.

CONCLUSION

 Lead has toxic effects on all organ systems of the body and is stored in the bone for decades. Symptoms of poisoning are nonspecific; a thorough history and generous indication for measuring lead levels are helpful for the diagnosis.

And the Oscar Goes to Peripheral Blood Film for the Detection of Lead Poisoning in a Complicated Toxic Patient: A Case Report with a Review of Laboratory Clues

Background. Peripheral blood smear examination is an invaluable laboratory test, which provides the complete hematologic and/or nonhematologic picture of a case. In addition to verifying the results of automated cell counters, it has the potential to identify some pathologic and morphologic changes that remain hidden using the cell counters alone. Case Presentation. A 40-year-old man with a three-year history of alcohol intake and marijuana abuse presented with severe lower extremities of the bone and abdominal pain. Physical examination showed high blood pressure, high pulse rate, and abdominal tenderness. He underwent extensive laboratory and imaging tests, and cholecystectomy and bone marrow studies were associated with no definite diagnosis. Right after all these invasive, expensive, and time-consuming investigations during a month, finding coarse basophilic stippling in the red blood cells in the peripheral blood smear by an expert led to the final diagnosis. Elevated blood lead level and the presence of ring sideroblasts in the bone marrow study confirmed the diagnosis of lead poisoning, and the patient responded well to chelator therapy in a short period. Conclusion. This case clearly showed the value of peripheral blood smear review and its impact on patient care. In order not to lose the cases, laboratories are recommended to design their own policy for peripheral blood smear review. The peripheral blood smear is the fastest, simplest, and most available screening test, which can prevent many misdiagnoses and malpractices. It provides rich morphological information, among which basophilic stippling is highly suggestive of lead poisoning.

Accidental ingestion of swamp stone: A new and hazardous source of lead poisoning

It is important to find sources for lead poisoning and educate the population about the danger of this heavy metal. The epidemiologic studies for evaluating BLL can help develop a guideline for screening endangered populations and providing treatment.

A Systematic Review and Meta-analysis on Blood Lead Level in Opium Addicts: an Emerging Health Threat

This meta-analysis was conducted aiming to summarize the results obtained from the previous studies so that the effect of opium on blood lead levels (BLLs) can be investigated. Scopus, Embase, PubMed, and Web of Science (ISI) were systematically searched up to June 2020. Heterogeneity of the included studies was evaluated using Cochrane's Q test and the I² statistic. A random-effects model was used to pool the weighted mean differences (WMDs) and their 95% confidence intervals (CIs). Out of a total of 2372 citations, eleven articles with 916 participants (487 opium addicts and 429 controls) were included in the study. The meta-analysis results showed that there were higher lead levels (WMD = 14.59 μg/dL, 95% CI = 11.59 to 17.92, Z = 8.60, P < 0.001) in opium addicts than in the control group. The degree of heterogeneity observed (P < 0.001, I² = 98.1%) might be mainly the result of the type of sampling and of consumption. Moreover, the findings of meta-regression analyses indicated that publication year (β = 1.23, P = 0.287), total sample size (β = 0.05, P = 0.728), and quality scores (β = - 2.91, P = 0.546) had no effects on lead levels in opium addicts. In the sensitivity analysis, it was found that the pooled WMDs remained stable after excluding one by one study. Oral opium consumption increased the amount of lead in the bloodstream, and the measurement of lead levels in opium addicts' blood may be regarded as a useful test to diagnosis and prognosis of disorders that may lead poisoning causes.

Adult Lead Poisoning Caused by Contaminated Opium: A Two-Year Longitudinal Follow-Up Study

Background:

A major episode of lead poisoning caused by lead-adulterated opium occurred in Iran in 2016. Patients were removed from exposure and treated with chelating agents. A subset of those patients was evaluated in this follow-up study to evaluate treatment efficacy in relation to patient outcome.

Methods:

Between March 2016 and December 2017, thirty-five male cases of lead poisoning due to ingestion of lead-adulterated opium were followed for two years. There are three patient groups: 1) those who abstained from opium use; 2) those who continued to use potentially contaminated opium; and 3) those who abstained from opium and were placed on maintenance therapy. Maintenance therapy included: methadone and opium tincture, offered by the Opioid Maintenance Therapy (OMT) clinics. Amongst the three patient groups Blood Lead Levels (BLL), complete blood count, and kidney and liver function tests were compared.

Findings:

The results of BLL, hemoglobin, hematocrit, and aspartate aminotransferase were significantly different between the admission time and follow-up. Of the three patient groups, no difference was detected in these measures.

Conclusions:

Treatment of lead poisoning combined with OMT proved an effective method to prevent recurrent lead poisoning.

Acute lead poisoning: a diagnostic challenge in the emergency department

Acute abdominal pain is a common presentation to the emergency department (ED). Ruling out life-threatening causes and giving pain relief are the most important tasks in ED. We describe a 32-year-old man who presented to ED with abdominal pain and vomiting which was unrelieved by usual doses of analgesic. Extensive investigations revealed no significant abnormalities. On further probing, he admitted taking traditional medications for infertility. The toxicological panel revealed a high blood lead level, leading to a diagnosis of acute lead toxicity. Chelation therapy with D-penicillamine was initiated and the patient's abdominal pain resolved within 4 days.