A 2-year-old boy is brought to the office by his father because of a 3-month history of decreased activity, poor appetite, sporadic vomiting, clumsiness and speech regression. Since his birth his family has lived in an old area of the city where there is demolition of old buildings.
Examination of a peripheral blood smear is likely to show which of the following?
Correct Answer A: This child suffers from lead poisoning. Prior to the 1970s, lead was used in paint, gasoline, water pipes, and many other products. During the demolition of older structures, lead is released and can become ingested by humans, primarily children. Exposure to excessive levels of lead can cause brain damage; affect a child’s growth; damage kidneys; impair hearing; cause vomiting, headaches, and appetite loss; and cause learning and behavioral problems. Lead eventually becomes associated with mitochondria in red blood cells and appears as basophilic granules via H & E staining. This is a form of sideroblastic anemia.
A 12-month-old girl presents to your office for a well-child examination. She has been growing and developing well. She is taking solids well and has not had any gastrointestinal problems. She is happy and playful, and there are no abnormalities on physical examination. Routine screening reveals a lead level of 50 μg/dl. The child lives in a home built in 1980 and there is no peeling paint.
The most appropriate initial management is:
Correct Answer D:
For lead levels over 45 μg/dl, chelation treatment is usually needed (choice D). No treatment is recommended for blood lead levels below this threshold. This child's lead level is 50 microgram/dl which is higher than the threshold for treatment. If oral chelation with succimer is used as an outpatient, there must be assurance that the home environment is free of lead.
→ A repeat lead level (choice A) within 3 months is acceptable for children with lead levels between 10 and 14 μg/dl, but is not adequate management for a lead level this high. Action should be taken within 48 hours.
→ A complete investigation must be done to identify whether or not the home is actually the source of lead. It is less common for a house built as late as 1980 to contain lead paint (choice B). Lead can also come from pottery, soil, home remedies, plumbing, automobile repair supplies, batteries, and various solvents.
→ Any patient who has a blood lead level over 20 μg/dl needs careful evaluation and repeated blood lead levels (choice C).
→ Emergency hospitalization (choice E) and intravenous chelation is usually reserved for children with lead levels over 70 μg/dl.
A father brings in his 5-year-old boy who complains of fatigue, terrible stomach aches and weakness in his right hand (wrist drop).
His blood results will likely reveal:
Correct Answer A:
Lead poisoning.
High levels of lead in the body are toxic to bone marrow, the central and peripheral nervous system, the kidneys, heart, intestinal tissue, and reproductive system. Symptoms can include abdominal pain, headaches, vomiting, confusion, muscle weakness, seizures, hair loss and anemia.
A particularly vulnerable patient population are children younger than 6 years of age. Canadian homes, in particular those built prior to 1960, do contain lead paint so it is conceivable that lead dust from paint poses an on-going risk to children. The CDC recommends: 1) screening virtually all children for lead exposure at 12 and 24 months; 2) screening children at high risk every 6 months beginning at 6 months of age; and 3) using direct measurement of BPb (annual blood lead levels) rather than erythrocyte protoporphyrin (EP) to screen.
PEARL:
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