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Pain from a Bullet Lingers on: An Uncommon Case of Lead Toxicity.

Abraham A, Singh J, Mustacchia P, Rizvon K - Case Rep Gastroenterol (2012)

Bottom Line: Given its unpredictable latent period and nonspecific clinical symptoms, such cases are difficult to diagnose but may be fatal if unrecognized.His past history was significant for a gunshot wound to the left hip about 20 years before.Radiographic studies confirmed the same with the presence of numerous intra-articular bullet fragments and a calcified hemarthrosis surrounding the left femoral head.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Nassau University Medical Center, East Meadow, N.Y., USA.

ABSTRACT
Lead toxicity from a retained bullet as a cause for abdominal pain is rarely considered. Given its unpredictable latent period and nonspecific clinical symptoms, such cases are difficult to diagnose but may be fatal if unrecognized. We present the case of a 48-year-old man who presented with complaints of abdominal pain, weight loss and constipation. His past history was significant for a gunshot wound to the left hip about 20 years before. Radiographic studies confirmed the same with the presence of numerous intra-articular bullet fragments and a calcified hemarthrosis surrounding the left femoral head. Blood lead levels were elevated following which the patient was started on chelation therapy with succimer which resulted in symptomatic improvement. The aim of this paper is to highlight the importance of considering lead toxicity from a retained bullet as a cause of abdominal pain and to review the relevant literature.

No MeSH data available.


Related in: MedlinePlus

Computed tomography scan showing a bullet in the left hip with a calcified hemarthrosis surrounding the left femoral head.
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Figure 1: Computed tomography scan showing a bullet in the left hip with a calcified hemarthrosis surrounding the left femoral head.

Mentions: Laboratory investigations revealed a hemoglobin of 10.4 g/dl and a hematocrit of 30.4% with mean corpuscular volume 88.9 fl, mean corpuscular hemoglobin 30.3 pg and red cell distribution width 14.4%. Iron studies showed iron to be 111 μg/dl, total iron binding capacity 210 μg/dl, transferring saturation 53% and ferritin 613 ng/ml. Liver-related tests, blood chemistry and amylase as well as lipase levels were within normal limits. Computed tomography of the abdomen and pelvis confirmed the gunshot wound to the left hip with a calcified hemarthrosis surrounding the left femoral head (fig. 1, fig. 2). X-ray of the left hip showed advanced degenerative changes to the joint with numerous tiny intra-articular bullet fragments (fig. 3). Colonoscopy results revealed spastic colon with no other abnormality. The patient's prior workup was reviewed and showed normal upper endoscopy, normal TSH, uric acid and urine porphobilinogen levels. Given the history of the gunshot wound confirmed by computed tomography scan and the occupation of the patient, a blood lead level was sent which was reported back as being 63.4 μg/dl (elevated blood lead levels are defined as levels >25 μg/dl). The peripheral blood smear which was later viewed showed basophilic stippling. The Regional Toxicology Center and Department of Health were contacted and the patient was started on a 19-day oral succimer chelation therapy. His abdominal pain abated on the fourth day of therapy with improvement also in his bowel movements. He was later discharged with follow-up appointments at outpatient clinics and was advised not to join work till his next clinic visit.


Pain from a Bullet Lingers on: An Uncommon Case of Lead Toxicity.

Abraham A, Singh J, Mustacchia P, Rizvon K - Case Rep Gastroenterol (2012)

Computed tomography scan showing a bullet in the left hip with a calcified hemarthrosis surrounding the left femoral head.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC3369416&req=5

Figure 1: Computed tomography scan showing a bullet in the left hip with a calcified hemarthrosis surrounding the left femoral head.
Mentions: Laboratory investigations revealed a hemoglobin of 10.4 g/dl and a hematocrit of 30.4% with mean corpuscular volume 88.9 fl, mean corpuscular hemoglobin 30.3 pg and red cell distribution width 14.4%. Iron studies showed iron to be 111 μg/dl, total iron binding capacity 210 μg/dl, transferring saturation 53% and ferritin 613 ng/ml. Liver-related tests, blood chemistry and amylase as well as lipase levels were within normal limits. Computed tomography of the abdomen and pelvis confirmed the gunshot wound to the left hip with a calcified hemarthrosis surrounding the left femoral head (fig. 1, fig. 2). X-ray of the left hip showed advanced degenerative changes to the joint with numerous tiny intra-articular bullet fragments (fig. 3). Colonoscopy results revealed spastic colon with no other abnormality. The patient's prior workup was reviewed and showed normal upper endoscopy, normal TSH, uric acid and urine porphobilinogen levels. Given the history of the gunshot wound confirmed by computed tomography scan and the occupation of the patient, a blood lead level was sent which was reported back as being 63.4 μg/dl (elevated blood lead levels are defined as levels >25 μg/dl). The peripheral blood smear which was later viewed showed basophilic stippling. The Regional Toxicology Center and Department of Health were contacted and the patient was started on a 19-day oral succimer chelation therapy. His abdominal pain abated on the fourth day of therapy with improvement also in his bowel movements. He was later discharged with follow-up appointments at outpatient clinics and was advised not to join work till his next clinic visit.

Bottom Line: Given its unpredictable latent period and nonspecific clinical symptoms, such cases are difficult to diagnose but may be fatal if unrecognized.His past history was significant for a gunshot wound to the left hip about 20 years before.Radiographic studies confirmed the same with the presence of numerous intra-articular bullet fragments and a calcified hemarthrosis surrounding the left femoral head.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Nassau University Medical Center, East Meadow, N.Y., USA.

ABSTRACT
Lead toxicity from a retained bullet as a cause for abdominal pain is rarely considered. Given its unpredictable latent period and nonspecific clinical symptoms, such cases are difficult to diagnose but may be fatal if unrecognized. We present the case of a 48-year-old man who presented with complaints of abdominal pain, weight loss and constipation. His past history was significant for a gunshot wound to the left hip about 20 years before. Radiographic studies confirmed the same with the presence of numerous intra-articular bullet fragments and a calcified hemarthrosis surrounding the left femoral head. Blood lead levels were elevated following which the patient was started on chelation therapy with succimer which resulted in symptomatic improvement. The aim of this paper is to highlight the importance of considering lead toxicity from a retained bullet as a cause of abdominal pain and to review the relevant literature.

No MeSH data available.


Related in: MedlinePlus