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Special Feature |

Radiological Case of the Month FREE

Arch Pediatr Adolesc Med. 2000;154(1):84. doi:.
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DENOUEMENT AND DISCUSSION: LEAD POISONING

Figure 1Anteroposterior radiograph of the skull shows wide sutures.

Figure 2. Radiograph of the hands in which radiodense lines are seen in the metaphyses.

Basophilic stippling was seen on the blood smear. Levels of serum lead (Pb) and free erythrocyte protoporphyrin were 9.66 µmol/L (200 µg/dL) and 2.78 µmol/L, respectively. A cranial computed tomogram showed no abnormalities. At hospital admission, no cosmetic products were seen on the face; however, the mother did note regularly applying kohl, a Pb-containing eye cosmetic, to the infant's eyelids. Hypocalcemia was corrected with intravenous calcium gluconate, and chelation therapy with intravenous calcium sodium edetate was given for 5 days. The infant rapidly improved, and the serum Pb value dropped to reference levels over the next few weeks. The family was educated to avoid using Pb-containing products.

Lead is a neurotoxic metal, and acute encephalopathy may be the first sign of Pb poisoning.1 The fatality rate is high, and survivors often suffer permanent neurological sequelae.2 Several cases of Pb poisoning from traditional Pb-containing medicine or cosmetics have been reported in developing countries.3 Kohl, or surma, is an eye cosmetic applied to the conjunctival margins of the eyes or, medicinally, to the umbilical stumps of infants in Middle Eastern countries. The Pb content is variable and may reach 91.8%. Lead ingestion from kohl may result from hand-to-mouth activities in children whose fingers are contaminated or from absorption from the nasolacrimal mucosa. The presence of kohl on an infant's eyelids suggests Pb exposure.49 Although washing off the product removes the characteristic dark staining, the product may remain on the conjunctival margins. The heavy metal coating of the palpebral edges is seen on radiographs of the skull.

Lead poisoning should always be considered in children who present with acute encephalopathy. A history of Pb exposure or the visualization of kohl on the eyelids are helpful evidence. Microcytic anemia and basophilic stippling of the red blood cells suggest Pb poisoning, and elevated levels of serum Pb and erythrocyte protoporphyrin confirm the diagnosis. Heavy metal poisoning as metaphyseal bands on bone radiographs is a helpful finding that may aid in dating Pb exposure onset time.10,11

Specific treatment of Pb encephalopathy is by chelation therapy with dimercaprol and calcium sodium edetate.

Accepted for publication September 9, 1998.

Corresponding author: Hassib Narchi, MD, FRCP, FRCPCH, Al-Hasa Specialty Services Division, Saudi Aramco– Al-Hasa Health Center, Saudi Aramco Medical Services Organization, Box 6030, Mubarraz 31311, Kingdom of Saudi Arabia (e-mail: hassibnarchi@hotmail.com).

Al Khayat  AMenon  NSAlidina  MR Acute lead encephalopathy in early infancy: clinical presentation and outcome. Ann Trop Paediatr. 1997;1739- 44
Abdullah  MA Lead poisoning among children in Saudi Arabia. J Trop Med Hyg. 1984;8767- 70
Abu Melha  AAhmed  NAel Hassan  AY Traditional remedies and lead intoxication. Trop Geogr Med. 1987;39100- 103
Ali  ARSmales  ORAslam  M Surma and lead poisoning. BMJ. 1978;2915- 916
Link to Article
Salamah  MMAsha  M Lead poisoning: a report from Saudi Arabia. AJDC. 1988;142252- 253
Rahman  Hal Khayat  AMenon  N Lead poisoning in infancy: unusual causes in the U.A.E. Ann Trop Paediatr. 1986;6213- 217
Al-Saleh  IMustafa  ADufour  LTaylor  AHiton  R Lead exposure in the city of Arar, Saudi Arabia. Arch Environ Health. 1996;5173- 82
Link to Article
Sprinkle  RV Leaded eye cosmetics: a cultural cause of elevated lead levels in children. J Fam Pract. 1995;40358- 362
Fernando  N-PHealy  MAAslam  MDavis  SSHussein  A Lead poisoning and traditional practices: the consequences for world health: a study in Kuwait. Public Health. 1981;95250- 260
Link to Article
Pearl  MBoxt  LM Radiographic findings in congenital lead poisoning. Radiology. 1980;13683- 84
Sachs  HK The evolution of the radiologic lead line. Radiology. 1981;13981- 85

Tables

References

Al Khayat  AMenon  NSAlidina  MR Acute lead encephalopathy in early infancy: clinical presentation and outcome. Ann Trop Paediatr. 1997;1739- 44
Abdullah  MA Lead poisoning among children in Saudi Arabia. J Trop Med Hyg. 1984;8767- 70
Abu Melha  AAhmed  NAel Hassan  AY Traditional remedies and lead intoxication. Trop Geogr Med. 1987;39100- 103
Ali  ARSmales  ORAslam  M Surma and lead poisoning. BMJ. 1978;2915- 916
Link to Article
Salamah  MMAsha  M Lead poisoning: a report from Saudi Arabia. AJDC. 1988;142252- 253
Rahman  Hal Khayat  AMenon  N Lead poisoning in infancy: unusual causes in the U.A.E. Ann Trop Paediatr. 1986;6213- 217
Al-Saleh  IMustafa  ADufour  LTaylor  AHiton  R Lead exposure in the city of Arar, Saudi Arabia. Arch Environ Health. 1996;5173- 82
Link to Article
Sprinkle  RV Leaded eye cosmetics: a cultural cause of elevated lead levels in children. J Fam Pract. 1995;40358- 362
Fernando  N-PHealy  MAAslam  MDavis  SSHussein  A Lead poisoning and traditional practices: the consequences for world health: a study in Kuwait. Public Health. 1981;95250- 260
Link to Article
Pearl  MBoxt  LM Radiographic findings in congenital lead poisoning. Radiology. 1980;13683- 84
Sachs  HK The evolution of the radiologic lead line. Radiology. 1981;13981- 85

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