Encephalopathy following ingestion of Lead-contaminated opium; magnetic resonance imaging findings

Take the lead

A 23-year-old previously healthy woman presented with headache, generalized seizures, ataxia, encephalopathy, abdominal pain, nausea, and vomiting culminating in a 40-pound weight loss. A contrasted magnetic resonance imaging scan of the brain showed T2/FLAIR hyperintensities in the sulci of the occipital and parietal lobes, a punctate focus of restricted diffusion along the inferior aspect of the left caudate head and an empty sella. A lumbar puncture showed an opening pressure of 55 cm H2O, and kidney, ureter, and bladder X ray showed a radiopaque particle in the colon. Serum lead level was 85 mcg/dL (<3.5). Blood smear showed foreign bodies identified as lead particles in the blood with basophilic stippling of RBCs. She was treated with chelation therapy and bowel irrigation and eventually recovered. Further investigation indicated that she was being slowly poisoned by her husband, a chiropractor who had access to lead.

Lead encephalopathy in an adult opioid abuser

A 38-year-old man presented at the emergency department with abdominal pain, vomiting, generalised weakness and altered consciousness. He had been ingesting opioids for over 5 years and had several past hospital admissions for abdominal pain. His investigations showed deranged liver function tests, anaemia and basophilic stippling on the peripheral blood smear. Further investigations revealed a significant increase in the serum lead level. We started chelation with peroral penicillamine 250 mg every 6 hours for 2 days and switched to intramuscular dimercaprol 4 mg/kg every 12 hours and intravenous calcium ethylenediamine tetraacetic acid 50 mg/kg in two divided doses daily for the next 5 days. We then discharged him home; he had become clinically stable by that time. We repeated his lead level and followed him up in the clinic. In this report, we emphasise the consideration of lead toxicity in opioid abusers and bring to attention a rare way of lead chelation in resource-limited settings.