Emerg Radiol DOI 10.1007/s10140-014-1207-3
CASE REPORT
Systemic plumbism following remote ballistic injury Matthew Rheinboldt & Kirenza Francis
Received: 22 October 2013 / Accepted: 11 February 2014 # Am Soc Emergency Radiol 2014
Abstract We report an unusual case of systemic lead poisoning, i.e., plumbism, following a remote gunshot injury to the right femur. Plumbism is a rare side-effect of penetrating projectiles and has been shown to be directly related to the degree of ballistic fragmentation, as well as to the impact location, with intra-synovial, intra-osseous, head, spine and maxillofacial injuries having the highest correlation. Our patient, a 44-year-old male, presented to the ER with a 3-week history of mid epigastric cramping abdominal pain and intermittent vomiting as well as mild mental status changes. Abdominal radiographs and ultrasound were noncontributory. Laboratory findings were notable for underlying microcytic anemia with basophilic stippling observed on peripheral blood smear. Serum iron studies were normal. Lead levels were found to be elevated at 306 μg/dl. Prior EGD had demonstrated mild erosive gastritis with subsequent multiple negative gastric lavages. The patient’s past medical history was notable for a previous gunshot injury to the right femur with open fracture 2 years previously. Radiographs of the proximal right lower extremity, subsequent ultrasound and CT demonstrated an uncomplicated healed fracture of the mid right femoral diaphysis with an adjacent partially cystic lesion, an approximately 7-cm collection in the medial soft tissues containing internal ballistic fragments. Mottled surrounding capsular density was observed with mural calcific and micrometallic fragments. Systemic plumbism was suspected in relation to the remote ballistic injury and chelation therapy was initiated. Following surgical removal of the encapsulated fluid collection, systemic lead levels were observed to decline precipitously. The abdominal and CNS symptoms resolved in due
M. Rheinboldt (*) : K. Francis ER division, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA e-mail: [email protected]
course and the patient was discharged on oral chelation therapy. Keywords Plumbism . Lead . Bullet . Gunshot
Introduction First described in 1867, systemic lead poisoning, also known as saturnism or plumbism, following ballistic injury is a relatively uncommon though well-described occurrence in the medical literature with over 100 cases reported to date [1, 2]. Without a high clinical index of suspicion, the diagnosis however can be problematic due to the often vague, wideranging and nonspecific nature of the presenting symptoms as well as the inconsistent time interval from exposure to manifestation [3]. A multitude of systems are affected with vomiting, constipation, abdominal cramping, fatigue, arthralgias, headache, mental slowing or delirium, parkinsonian-like symptoms, and peripheral neuropathy, as well as hypertension and anorexia all reported [3, 4]. Laboratory findings are typically noteworthy, in addition to elevated lead levels, for a microcytic anemia with basophilic stippling on peripheral smear in the presence of normal serum iron studies [3]. Review of systems may be contributory, in addition to the findings of prior penetrating ballistic injury, for the so-called Burton lines, a distinctive blue gingival discoloration [4]. Symptomatic presentation can be delayed for decades after the initial injury, up to 52 years in one reported instance [2, 5]. Numerous case reports and series have attested to the farfrom-inert behavior of intracorporeal lead bullet fragments, particularly when in proximity to joint or CNS fluid or when highly fragmented in distribution [1, 2, 6]. Clinical management of such cases is typically multidisciplinary with surgical removal of the metallic debris performed when feasible coupled with chelation therapy [2]. Radiological reporting
Emerg Radiol
may aid in and potentially direct the initial diagnosis especially when, in the appropriate clinical context, highly fragmented or intra-synovial ballistic fragments are identified.
Case report Our patient, a 44-year-old male with a past medical history noteworthy for ORIF of a right mid femoral diaphyseal fracture following gunshot injury 2 years previously, presented to the ER, mildly encephalopathic with a 3-week history of intermittent cramping abdominal pain localizing to the mid epigastric region and occasional vomiting. EGD performed at the time of a prior admission had demonstrated mild erosive gastritis, though multiple subsequent gastric lavages were negative. There was no reported associated diarrhea, anorexia, or nausea. Review of systems was otherwise negative and initial abdominal radiographs and ultrasound performed in the ER were noncontributory. Laboratory findings were remarkable for microcytic anemia with basophilic stippling on peripheral blood smear. Serum iron studies were normal and a subsequently obtained serum lead level was markedly elevated at 306 μg/dl (normal range
CASE REPORT
Systemic plumbism following remote ballistic injury Matthew Rheinboldt & Kirenza Francis
Received: 22 October 2013 / Accepted: 11 February 2014 # Am Soc Emergency Radiol 2014
Abstract We report an unusual case of systemic lead poisoning, i.e., plumbism, following a remote gunshot injury to the right femur. Plumbism is a rare side-effect of penetrating projectiles and has been shown to be directly related to the degree of ballistic fragmentation, as well as to the impact location, with intra-synovial, intra-osseous, head, spine and maxillofacial injuries having the highest correlation. Our patient, a 44-year-old male, presented to the ER with a 3-week history of mid epigastric cramping abdominal pain and intermittent vomiting as well as mild mental status changes. Abdominal radiographs and ultrasound were noncontributory. Laboratory findings were notable for underlying microcytic anemia with basophilic stippling observed on peripheral blood smear. Serum iron studies were normal. Lead levels were found to be elevated at 306 μg/dl. Prior EGD had demonstrated mild erosive gastritis with subsequent multiple negative gastric lavages. The patient’s past medical history was notable for a previous gunshot injury to the right femur with open fracture 2 years previously. Radiographs of the proximal right lower extremity, subsequent ultrasound and CT demonstrated an uncomplicated healed fracture of the mid right femoral diaphysis with an adjacent partially cystic lesion, an approximately 7-cm collection in the medial soft tissues containing internal ballistic fragments. Mottled surrounding capsular density was observed with mural calcific and micrometallic fragments. Systemic plumbism was suspected in relation to the remote ballistic injury and chelation therapy was initiated. Following surgical removal of the encapsulated fluid collection, systemic lead levels were observed to decline precipitously. The abdominal and CNS symptoms resolved in due
M. Rheinboldt (*) : K. Francis ER division, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA e-mail: [email protected]
course and the patient was discharged on oral chelation therapy. Keywords Plumbism . Lead . Bullet . Gunshot
Introduction First described in 1867, systemic lead poisoning, also known as saturnism or plumbism, following ballistic injury is a relatively uncommon though well-described occurrence in the medical literature with over 100 cases reported to date [1, 2]. Without a high clinical index of suspicion, the diagnosis however can be problematic due to the often vague, wideranging and nonspecific nature of the presenting symptoms as well as the inconsistent time interval from exposure to manifestation [3]. A multitude of systems are affected with vomiting, constipation, abdominal cramping, fatigue, arthralgias, headache, mental slowing or delirium, parkinsonian-like symptoms, and peripheral neuropathy, as well as hypertension and anorexia all reported [3, 4]. Laboratory findings are typically noteworthy, in addition to elevated lead levels, for a microcytic anemia with basophilic stippling on peripheral smear in the presence of normal serum iron studies [3]. Review of systems may be contributory, in addition to the findings of prior penetrating ballistic injury, for the so-called Burton lines, a distinctive blue gingival discoloration [4]. Symptomatic presentation can be delayed for decades after the initial injury, up to 52 years in one reported instance [2, 5]. Numerous case reports and series have attested to the farfrom-inert behavior of intracorporeal lead bullet fragments, particularly when in proximity to joint or CNS fluid or when highly fragmented in distribution [1, 2, 6]. Clinical management of such cases is typically multidisciplinary with surgical removal of the metallic debris performed when feasible coupled with chelation therapy [2]. Radiological reporting
Emerg Radiol
may aid in and potentially direct the initial diagnosis especially when, in the appropriate clinical context, highly fragmented or intra-synovial ballistic fragments are identified.
Case report Our patient, a 44-year-old male with a past medical history noteworthy for ORIF of a right mid femoral diaphyseal fracture following gunshot injury 2 years previously, presented to the ER, mildly encephalopathic with a 3-week history of intermittent cramping abdominal pain localizing to the mid epigastric region and occasional vomiting. EGD performed at the time of a prior admission had demonstrated mild erosive gastritis, though multiple subsequent gastric lavages were negative. There was no reported associated diarrhea, anorexia, or nausea. Review of systems was otherwise negative and initial abdominal radiographs and ultrasound performed in the ER were noncontributory. Laboratory findings were remarkable for microcytic anemia with basophilic stippling on peripheral blood smear. Serum iron studies were normal and a subsequently obtained serum lead level was markedly elevated at 306 μg/dl (normal range
