Radiology Cases in Pediatric Emergency Medicine Volume 3, Case 8 Joan C. Meister, MD

This is a 7-1/2 year old boy who loves to juggle. One day he was juggling dice and accidentally swallowed one of the dice. He did not tell his mother until 3 days later. She brought him to the emergency department where a radiograph was obtained.

Is there anything we should be concerned about? If dice are inert, then it is likely that it would pass spontaneously in the stool after it passes into the stomach.
The radiograph revealed that the die (a single dice) was in his stomach. For the next 7 days, he was ordered to strain his stool to recover the die. This was unsuccessful. After 7 days, he was given a polyethylene glycol and saline cathartic to accelerate passage of the die. Still... "No dice." At this point, a second radiograph was taken.

This follow-up radiograph shows that the die has not moved much. Although dice may seem inert, some dice contain lead. This may not be immediately obvious. A serum lead level was 84 mcg/dL (high) and his RBC's showed basophilic stippling. He was, however, asymptomatic, now 11 days post ingestion. A gastroenterologist was then consulted for endoscopic retrieval but the die was then passed in his stool.Ten days later (21 days post ingestion) he presented with abdominal pain, diarrhea, and emesis. He also was noted to have gingival discoloration and speckling at the tip of the tongue.He was hospitalized at this point. His serum lead level was now 48 mcg/dL and his urine lead level was 253 (nl<80). He was thus treated with EDTA (ethylenediaminetetraacetic acid) chelation for 3 days. He then became asymptomatic and was discharged home in stable condition.

Lead Poisoning (Plumbism)

In the past 20 years, the incidence of lead poisoning in children has decreased, however, there are still significant numbers of children with toxic lead levels.Case detection is best done by screening populations at risk, including children of lead industry workers, the workers themselves and children living in homes that were painted before 1980. The Center for Disease Control recommends universal screening beginning at age 6 months.

Risk Factors are as follows:

Exposure:
Air/dust/water/paint
Lead curtain weights
Fishing weights, dice
Retained bullets/shrapnel
Bootleg whiskey, hair spray

Absorption:
Through lungs if inhaled.Symptoms develop more quickly through GI tract.
Toxicity is more severe in the presence of concomitant iron, zinc, or calcium deficiency.

Children are at higher risk:

They absorb 50% of their exposure and retain 30%.Adults absorb 5-15%, and retain less than 5%.

Signs and Symptoms:

Acute toxicity: Anorexia, vomiting, malaise, convulsions, permanent brain injury and reversible renal injury.Chronic toxicity: Weight loss, weakness, anemia, neurobehavioral deficit, hypertension, wristdrop and colic (Most are slow in onset).

By systems:

Neuro: Levels > 10 mcg/dL. Learning disability, decreased IQ, Mental retardation, encephalopathy, motor deficit, seizures, cerebral edema, hearing loss.GI: Abdominal pain, nausea, vomiting, diarrhea, constipation, anorexia, metallic taste in mouth, ileus.Renal: Tubular damage, azotemia, gout.
Heme: Levels > 15 mcg/dL. Affects heme synthesis, hemolysis, RBC stippling, iron deficiency.Musculoskeletal: Muscle and joint pain, lead lines in metaphysis.Soft tissue: Blue black line in gum margins.Endocrine: Decreased stature, decreased growth hormone, decreased vitamin D levels.

Identification and abatement of lead exposure sources is first and foremost in treatment. Ingestion of a known or visible lead foreign body is okay to leave untreated if eliminated within 2 weeks. If not, removal becomes necessary.The San Francisco Poison Center states that lead absorption is only a problem when in gastric acid, however, this is not documented in other sources.Acute ingestion: Consider ipecac within 30 minutes if neurologically intact. Activated charcoal/cathartic and/or cleansing enema if lead is seen in the lower bowel. However, activated charcoal has a limited ability to absorb lead and it is of questionable efficacy. Whole bowel irrigation may also be beneficial.

Obtain a blood lead level (mcg/dL)

Category I (level< 9): Education about lead hazards and rescreen.Category IIA (level 10-14): Education about lead hazards and rescreen.Category IIB (level 15-19): Recheck in one month by venipuncture rather than capillary. Correct Fe deficiency. Treat if the level is greater than 15 for 3 months. Determine the source of lead exposure and prevent further exposure. Correct Fe deficiency.Category III (level 20-44): Same as category IIB.Category IV (level 45-69): Recheck in 48 hours. Correct Fe deficiency, Chelation therapy.Category V: (level> 70): Recheck now, and if confirmed, treat immediately (chelation).

There are some inconsistencies in the chelation treatment recommendations of various sources. These recommendations should be considered as guidelines. A toxicologist or a current version of the Poisindex should be consulted for treatment recommendations in individual cases. Surgical removal of bullets and shrapnel is indicated if they are located near synovial spaces. Surgical removal of lead foreign bodies in the gut is indicated if not eliminated within 2 weeks.Chelation is indicated if the level is greater than 45 mcg/dL even if asymptomatic. One should first correct any iron deficiency. Chelating agents include EDTA, BAL, D-Penicillamine, and Succimer.

EDTA:

A provocation test can be done to determine the lead excretion ratio. Give the EDTA dose, then collect urine for 8 hours. Total urine lead (mcg)/Total CaNa2EDTA (mg) dose given. This test is positive if > 0.5. There is no need to do this if the lead level is greater than 40 mcg/dL. EDTA can also be used as a chelator for lead removal over 5 days.BAL (dimercaprol) 3-5 mg/kg/dose IM every 4 hours over 2-10 days. D-Penicillamine 10/mg/kg/dose orally x 5 days. This was first used as a copper chelator in Wilson's Disease. This can be used long term. It is good for levels between 20-35.

Succimer (DMSA) is the first oral agent approved by the FDA. Because of the oral administration route, this can be used for outpatient chelation therapy, 30 mg/kg/day x 5 days. Patients may need multiple courses.

Lead. In: Poisindex Volume 84, Expires 5/31/95, Micromedex, Inc.
Glotzer DE. Management of Childhood Lead Poisoning: Strategies for Chelation. Pediatric Annals 1994;23(11):608-615.
Liebelt EL, Shannon MW. Oral Chelators for Childhood Lead Poisoning. Pediatric Annals 1994;23(11):616-626.

Copyrighted:Radiology Cases in Pediatric Emergency Medicine Volume 3, Case 8
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine
loreny@hawaii.edu