LEAD POISONING

Amal Biju
Roll No 14
INTRODUCTION
• Lead is the commonest heavy metal causing chronic poisoning.
• Lead is a steel-grey metal.
• Lead is used in storage batteries, solders, paints, hair dyes,
electric cable insulations, pottery and ceramics and petrol.
LEAD SALTS
• Lead Acetate (sugar of lead) Pb is white
crystalline substance.

• Lead Carbonate is white crystals.

• Lead Chromate is bright yellow powder

LEAD SALTS
• Lead Monoxide(litharge) is brick red or
orange

• Lead Tetroxide(red lead, vermillion, sindhur)

a scarlet colored crystalline powder.

Metallic lead and all it’s salts are poisonous.

ACTIONS
• Lead has got affinity for cell membrane and mitochondria and
interferes with mitochondrial oxidative phosphorylation.
• Lead causes degenerative changes in the extensor group of
muscles of the extremities and the peripheral nerves.
• Lead causes hemolysis of the mature red cells by depressing the
enzymes responsible for hemosynthesis.
• Leading to microcytic/normocytic hypochromic anemia.
ACTIONS
• It causes the rupture of nucleus and chromatin disintegration into
granules (karyorrhexis).
• It also depresses the bone marrow and affects erythropoiesis
and myelopoiesis.
• It causes basophilic stippling
of red cells.
DISTRIBUTION
• It is a cumulative poison and in chronic poisoning, mostly
deposited in the bones (90%), liver, kidneys and spleen.

ABSORPTION
• Metallic lead is absorbed through GIT since it is soluble in
gastric juice.
• Lead is absorbed through GIT, skin and respiratory tract.
EXCRETION
It is mainly excreted through
• Urine (70%)
• Feces
• Hair
• Nail
• Sweat
SIGNS AND SYMPTOMS OF ACUTE
LEAD POISONING
GIT
• When lead salt is consumed, it causes metallic taste in the
mouth, dry throat, intense thirst, abdominal pain, nausea and
vomiting.
• Sometimes there maybe diarrhea with offensive smell and
colored black due to lead sulphide.
CVS
• There may be peripheral circulatory collapse.

CNS
• Headache, lethargy, myalgia, arthralgia, paraesthesia,
insomnia, depression, coma, convulsions and death.
CAUSES OF DEATH
In acute poisoning, usually death is due to gastroenteritis and
subsequent shock. It can also be due to,
• Hepatorenal failure
• Encephalopathy
• Respiratory failure
Fatal dose : Lead acetate 20 g
: Lead carbonate 40 g
Fatal period : 1 to 2 days.
TREATMENT IN ACUTE POISONING
1. Gastric lavage with 1% magnesium or sodium sulphate.
2. Calcium Disodium Versenate (EDTA) and B.A.L(Dimercaprol)
can be given together and is more effective.
3. Calcium disodium versenate 1 gm (5cc ampoule 20%
solution) in 5% glucose i.v
4. BAL 2.5 to 5 mg/kg body weight deep intramuscular
injection in divided doses can be given
TREATMENT IN ACUTE POISONING
5. This followed by Penicillamine orally 0.3 to 1 gm daily in
divided doses for 4 to 5 days
6. Demulcents like castor oil or milk
7. Peritoneal or Hemodialysis
8. Symptomatic treatment
POSTMORTEM APPEARANCES IN ACUTE
POISONING
• Signs of acute gastroenteritis are seen
• Mucosa of the gastrointestinal tract will be thickened and
softened with eroded patches
• All the internal organs congested.
• Brain will be congested and edematous.
• Grayish-white deposits are seen sticking to the gastrointestinal
mucosa.
CHRONIC LEAD POISONING (PLUMBISM,
SATURNISM)
CAUSES OF CHRONIC LEAD POISONING
1. Inhalation of lead dust and fumes by makers of white lead.
2. Makers and users of lead paints, smelters, plumbers, glass-
polishers, printers, glass blowers, etc.
3. Continuous absorption of minute amounts from drinking water
stored in lead cisterns.
4. Use of food stored in brass or copper contaminated with lead
from the lead solder.
CAUSES OF CHRONIC LEAD POISONING
5. Vessels lined inside with tin in which oleate of lead is formed.
6. By taking food cooked in tinned vessel.
7. Constant use of hair dyes and cosmetics containing lead.
8. Absorption through raw or intact skin.
9. Absorption of vermilion applied to the scalp.
CAUSES OF CHRONIC LEAD POISONING
8. Children can be chronically poisoned through chewing or
licking toys, walls, furniture, etc. Painted with lead-based
compounds.

• Chronic poisoning results from a daily intake of one to two mg.

Of lead.
• Lead vapour is more dangerous than dust.
SIGNS AND SYMPTOMS OF CHRONIC LEAD
POISONING
1. FACIAL PALLOR
• This is seen due to vasospasm and low Hb

2. ANAEMIA
• This is due to decreased survival of red cells.
• The red cells first show Cabot's ring and then punctate
basophilia or basophilic stippling
• This is the presence of dark blue pin head sized spots in the
cytoplasm of red cells.
2. ANAEMIA

CABOT RING BASOPHILIC STIPPLING

2. ANAEMIA
• These spots are aggregated ribosomes which contain iron-
condensed ribonucleic acid
• Basophilic stippling and anemia are the earliest and constant
finding in chronic lead poisoning.
• It is seen in 25% of cases of lead poisoning.
• There may be polycythemia, polychromasia, reticulocytosis,
poikilocytosis, anisocytosis and nucleated RBCs.
3. LEAD LINE (BURTONIAN LINE)
• A blue line is seen on the gums in 50 to 70% of cases of chronic
lead poisoning.
• The line is formed due the subepithelial deposition of lead
sulphide on the gum usually on the upper jaw.
• Formed by the action of hydrogen sulphide from the decayed
food in the mouth, within a week of exposure.
• Burt in 1840 recognized this in patients with chronic lead
poisoning.
3. LEAD LINE (BURTONIAN LINE)
• This is seen in persons with poor oral hygiene.
• If the person is edentulous(lacking teeth) no Burtonian line is
seen.

A similar blue line can be seen in cases of poisoning by mercury,

cooper, bismuth, iron and silver
4. LEAD COLIC
• Abdominal pain can occur in 75% cases.
• Colic occurs in night and may be severe (saturnine colic).
• Constipation is the usual symptom.
• During pain there is desire for defecation and sometimes
diarrhea may occur.
• Breath may be foul smelling
5. LEAD PALSY
• This occurs in 10% of cases.
• This is due to peripheral neuritis and muscular atrophy.
• There will be numbness, paraesthesia and cramps of the
muscles of the extremities.
• Later there may be paralysis of the muscles.
• The muscle groups affected are those most prone to fatigue.
• The extensor groups of muscles are affected.
5. LEAD PALSY
• When the extensor muscles of the wrist are affected (when
radial nerve is affected), there will be wrist drop.
• When the anterior tibial muscles are affected there will be foot
drop.
• Intrinsic muscles of the hands are also affected causes claw-
shaped hands.
• Adults are mostly affected.
• Recovery is usually slow but complete.
6. LEAD ENCEPHALOPATHY
• This is seen in almost all cases in one form or other.
• It is common in children and often associated with
tetraethyl lead
• The symptoms are headache, vomiting, insomnia, visual
disturbances, vertigo, restlessness, delirium, hallucinations,
convulsions, coma and death.
6. LEAD ENCEPHALOPATHY
• Lead encephalopathy is irreversible in most of the cases and
there may be permanent brain damage and residual symptoms
in survivors.
• Death occurs in one third of cases
7. CARDIOVASCULAR SYSTEM
• Lead causes vascular constriction, leading to hypertension and
permanent arteriolar degeneration.
• Chronic arteriosclerotic nephritis and interstitial nephritis occur.
8. GENITO-URINARY SYSTEM
• Lead causes nephritis, renal colic and renal failure.
• It causes menstrual derangement like amenorrhea,
dysmenorrhea and menorrhagia.
• Sterility in both sexes.
• Abortion in a in early stages of pregnancy.
• In males there may be loss of libido.
9. OPTIC ATROPHY
• This is seen due to vasospasm and low Hb.

10. RETINAL STIPPLING

• Grayish glistening lead particles seen on the retina.

11. LEAD OSTEOPATHY
• In children and young adults lead is deposited in the epiphysis
and is promoted by vitamin D and calcium.
• Lead deposition can be detected in the X-ray
as radio-opaque bands seen at the epiphyseal
ends (metaphyseal lines).
• Affected may get joint pain due to inhibition of
uric acid excretion by lead (saturnine gout).
12. OTHER SYSTEMS
• Dyspepsia • Foul breath
• Anorexia • Headache
• Emaciation • Vertigo
• General weakness • Loss of hair
• Exhaustion • Drowsiness
• Irritability • Peripheral neuritis is rare
DIAGNOSIS
1. History
2. Clinical features
3. Coproporphyrin in urine (CPU) more than
150micrograms/litre
4. Aminolevulinic acid in urine (ALAU) more than 5mg. The
blood level of delta - Aminolevulinic acid will rise.
5. Blood lead concentration more than 1mg/100ml.
6. Lead concentration more than 0.25mg/litre of urine.
DIAGNOSIS
7. X-ray evidence of increased radio-opaque bonds or lines at
the metaphyses of long bones and along margins of iliac crest
is seen in children.
8. The width of each lines seen in X-ray depends on the period of
exposure.
9. Basophilic stippling of RBCs
10.Zinc protoporphyrin and erythrocyte protoporphyrin levels
above 50mg/ 100ml
DIAGNOSIS
11. X-ray may show radiopaque material in the Gl tract, if lead is
ingested during preceding 36 to 48 hours.
Prophylaxis
To prevent chronic lead poisoning in factory workers, the following
measures should be taken.
1. Maintenance of proper ventilation in factories.
2. Maintenance of personal hygiene of the workers and periodical
medical examination.
3. A diet rich in calcium.
4. Small amount of sulphuric acid in water.
5. Weekly saline purgative.
TREATMENT IN CHRONIC POISONING
• EDTA(Ethylene Diamine Tetra Acetate)is the treatment of choice.
• EDTA 1 gm(5 ml of 20% solution) is diluted with 500 ml of
normal saline or 5% glucose and given by drip over a period of
1 hour twice daily for 5 days, repeated after 2 days.
• BAL(British Anti-Lewsite)4mg /kg body weight every 4 hours is
given via intramuscular injections.
• It is the treatment of choice when there is renal failure
because the main excretion route of BAL-Lead complex is bile.
TREATMENT IN CHRONIC POISONING
• PENICILLAMINE 300 to 500 mg is given orally daily in
divided doses.
• All the above are chelating agents which combine with lead to
form non toxic complexes.
• Poor calcium diet and thiamine, and symptomatic
management can be given.
POSTMORTEM APPEARANCES
• A blue line may be seen on the gums.
• Paralyzed muscles show fatty degeneration.
• The stomach and intestines may show ulcerative or hemorrhagic
changes and are contracted and thickened.
• The liver and kidneys are contracted.
• The brain is very pale and greatly swollen.
• PAS-positive, pink-staining, homogeneous material may be seen
in the perivascular spaces in the brain.
POSTMORTEM APPEARANCES
• The heart may be hypertrophied and there may be atheroma of
the aorta and aortic valves.
• Bone marrow shows hyperplasia of leucoblasts and
erythroblasts with a decrease in fat cells.
• Segmental demyelination of peripheral nerves may be seen.
• Eosinophilic intranuclear inclusions may be seen in hepatocytes
and cells of the proximal tubules of the kidneys.
CAUSES OF DEATH IN CHRONIC LEAD
POISONING
In chronic cases
• malnutrition
• intercurrent infection
• respiratory failure
• Chronic renal failure
• Hepatic failure
• Encephalopathy
CIRCUMSTANCES OF LEAD POISONING
1. Acute poisoning is very rare.
2. Chronic poisoning is more common and is regarded as an
industrial disease.
3. Homicidal poisoning is rare.
4. Accidental chronic poisoning occurs in workers with the metal.
5. It is not used for suicide.
6. Diachylon paste (lead oleate), or red lead is used locally
for abortion.
CIRCUMSTANCES OF LEAD POISONING
6. Red lead is sometimes used alone or mixed with arsenic as a
cattle poison.
7. Lead missiles remaining embedded in the tissues due to
gunshot injuries may produce poisonous symptoms
in 12 to 48 days.
SUMMARY
• Lead is the commonest heavy metal causing poisoning
• Lead can enter the body via various means by inhaling lead
dust, storing food in lead containers, using lead toys and
pencils, lead containing paints etc.
• Once entering the body lead gets absorbed through GIT, skin,
and lungs.
SYMPTOMS – anaemia, lead line on gums, abdominal pain,
constipation or diarrhoea, lead palsy, encephalopathy, renal
failure, sterility, abortion, optic atrophy etc.
SUMMARY
DIAGNOSIS – basophilic stippling of RBC, X-ray, zinc
protoporphyrin levels etc. can be used
TREATMENT – gastric lavage, using chelating agents like EDTA,
BAL, penicillamine etc.
• POST MORTEM FINDINGS
• Acute Poisoning – thick and inflamed GI tract, congested brain
and other internal organs, grayish white deposits in GI mucosa
SUMMARY
POST MORTEM FINDINGS
Chronic Poisoning – lead lines on gums, pale organs, fatty or
cirrhosis liver, nephritic changes, pale and edematous brain.
CAUSE OF DEATH – in acute poisoning usually is due to
gastroenteritis leading to shock. In chronic poisoning, various
causes like malnutrition, infection, failure of organs and
encephalopathy can lead to death