LEAD POISONING

Lead poisoning
Absorption
Skin:
- little/no absorption

Inhalation (<1m):
- dust or lead fumes - absorb 50-70%

Oral:
- adults absorb 10% - children absorb 40-50%
- increased absorption if low Fe, Ca

Lead poisoning
Storage & Distribution
1 Rapid turnover soft tissue pool:
- T1/2 30-40 days; blood, liver, kidney, CNS

2 Slow turnover skeletal pool:

- T1/2 10-20 years; 75% - 90% in skeletal pool

- Chronic exposure results in a steady state distribution between bone and blood

Excretion: Renal (90%) and biliary (10%)

- Maximum excretion is ~ 3.5g/kg/day - If intake > 3.5 g/kg/day accumulation will occur

Lead poisoning
Occupational

Sources
Environmental

Lead smelters paint (walls, furniture, toys) Painter/decorators water Battery manufacturers food Stain-glass workers air (petrol, industry), dust/soil Jewellery makers Other Bronze workers etc... traditional remedies (Ayruvedic) surma & kohl cosmetics lead shot lead glazed ceramics foreign body ingestion
e.g. curtain/fishing weight, snooker chalk

Environmental lead exposure

Water
Lead in water:
- Largely from lead pipes/solderings/fittings - Water lead contamination from ground lead has occurred in Nepal - WHO max water lead content: 10g/l - ~ 20-30% UK homes exceed this limit

Environmental lead exposure

Paint
Pre 1960s up to 40% lead in paint - rapid drying, weather resistance, colouring

Domestic paint now <0.06% lead (600ppm)

BUT leaded paint remains in many homes - walls, furniture, toys Lead exposure from paint: - sanding, heat stripping, flaking, pica - contamination of carpets/curtains, dust

Ayurvedic Traditional Remedies

Numerous reports of lead, mercury, thallium, arsenic poisoning from Ayurvedic (& Chinese) remedies 40% of the >6000 medicines in Ayurveda contain at least one heavy metal Thought by practitioners to have therapeutic properties and/or to increase the efficacy of other herbal contents Used most commonly for chronic disorders and so there is a greater risk of heavy metal accumulation

Ayurvedic Traditional Remedies

Case 1: 68 mg/g lead i.e. 6.8 %

76 mg/g mercury i.e. 7.6 % 12 mg/g arsenic i.e. 1.2 % i.e. 15.5 % heavy metals
Case 2: 50 mg/g lead i.e. 5.0 % 39 mg/g mercury i.e. 3.9 %

i.e. 8.9 % heavy metals

Clinical features of lead poisoning

Results in variable effects on many systems The effects are well established at high levels Infants/children get symptoms at lower levels Treatable, but can cause chronic sequelae

Blood lead concentration (g/L)

Children: <400 Adults: <400 400-500 400-600
Abdominal pain Constipation

500-700 600-1000
Abdominal pain, constipation, weight loss, loss of appetite Mild anaemia

>700 >1000
Abdominal colic, vomiting

GI Tract Blood

Nil

Subclinical inhibition of RBC enzymes Effects on IQ in children?

Subclinical inhibition of RBC enzymes

Severe anaemia

CNS

Mild fatigue, irritability, slowed motor neurone conduction Muscle pain

Fatigue, poor concentration [Peripheral neuropathy] Hypertension, nephrotoxicity, lowered Vit D metabolism

Encephalopathy - delirium - ataxia - fits - coma Hypertension, nephrotoxicity, lowered Vit D metabolism

Other

Nil

Low level lead poisoning and childrens IQ

There have been many studies
5 prospective, 14 cross-sectional

The problem is allowing for multiple confounders

Three published metanalyses
100g/l blood lead IQ 2.5 points

Diagnosis of Lead Poisoning

Blood lead is the best test (normal <100g/l)
Other bloods
- FBC (film), U&E, LFT, Ca, Vit D, Ferritin

Radiology
- AXR ?lead in gut - Long bone XR in children

Other tests much less reliable

- Urine lead - variable, more useful for organic lead - RBC Zn protoporphyrin, Urine coproporphyrin, dALA

Management of Lead Poisoning

IDENTIFY & REMOVE from SOURCE
Treat coexisting iron (& calcium) deficiency Consider the use of chelation therapy - Good data for benefit with blood lead >450g/l

(children)

Chelating agents for lead poisoning

1. EDTA - Sodium calcium edetate 2. DMSA - Dimercaptosuccinic acid

3. BAL - Dimercaprol
- IM for severe toxicity only, particularly encephalopathy

4. Penicillamine - no longer recommended

EDTA and DMSA

EDTA - Sodium Calcium Edetate
- IV for severe toxicity, particularly encephalopathy - Well tolerated, <1% nephrotoxicity

DMSA - 2,3dimercaptosuccinic acid

The oral agent of choice for lead poisoning Given as a 19 day course Well tolerated The main problem is foul taste and smell !!

Treatment guidelines

Children

100-240g/l : Remove from source, repeat level 1 month 250-440g/l : Remove from source : DMSA only if persists at this level 450-690g/l : Remove from source
: DMSA chelation

>700g/l

: Remove from source : Urgent EDTA chelation

(with BAL if encephalopathy)

Treatment guidelines

Adults

100-400g/l : Remove from source (??)

: Repeat level 3-6 mths

400-500g/l : Remove from source (?)

: Repeat level 1-2 mths

450-690g/l : Remove from source : DMSA chelation IF symptomatic >700g/l

: Remove from source : DMSA chelation : EDTA if neurological features