Discussion
Lead poisoning is one of the medical diagnoses usually forgotten,
especially when there is no history of exposure. Many cases with lead
poisoning were studied for other causes of abdominal pain and anemia
with unknown causes. These patients underwent many unnecessary medical
procedures such as endoscopy, colonoscopy, and bone marrow aspiration,
in which lead poisoning can be confirmed with a high blood lead level.
In the presented family, due to recurrent abdominal colic and other
symptoms, they had been worked up for many causes of such symptoms. They
attributed their signs and symptoms to mild coronavirus (COVID- 19)
infection considering the recent worldwide pandemic. During a few
months, they visited many specialists due to chronic pain and muscle
weakness. This situation postponed the correct diagnosis. Ultimately,
the oldest child who bought the swamp stone powder suspected that they
were using this powder by mistake in their food and explained the
scenario to their physician. Their BLL was tested, and the results
confirmed the diagnosis of lead poisoning. They were referred to our
lead poisoning clinic for further evaluation and treatment.
In the presented cases, five people with the same exposure experienced
different signs and symptoms. Their BLL was different. They even have
different outcomes after receiving the treatment. The parents’ response
to treatment was significant comparing to children. All five cases
remained symptomatic with toxic BLL and underwent a second course of
therapy with an oral chelating agent (Succimer or di-mercaptosuccinic
acid). Case 2 also received a third course of therapy
with D-penicillamine till she became symptoms-free. The adult cases
(parents) had higher BLL than children, but they showed better response
to first chelating therapy to see a 32.5 and 26.2% reduction in BLL for
parents. As table one shows, the mean reduction in BLL in children under
18 was 1.6%. The youngest patient with age 8 (case 5) had significant
resistance to therapy and underwent a third course of
oral chelating therapy.
One theory is that because of higher bone density in children; they
absorb more lead than adults. After chelation therapy, children have a
higher lead body burden and excessive lead release in the bloodstream.
This can explain the children’s higher lead level, compared to the
parents, after chelation therapy. The younger daughter and son were
experiencing attention deficit and difficulty in concentration. One of
the reasons for this finding could be that these children were students,
and their families and teachers monitored their function at school. So
any changes in their cognitive and intellectual function would be
noticed.
These findings showed that every patient with vague complaints and
suspicious exposure needs to be evaluated for lead poisoning. As
clinicians, we should consider heavy metal poisoning as a proper
differential diagnosis. Case 2 (mother) used more swamp stone powder and
had more symptoms than the other cases. She remained symptomatic after
the first session of therapy ( 2 gram intravenous CaNa2 EDTA for five
days). She received two following oral Succimer (dimercaptosuccinic
acid) courses for 19 days and D-penicillamine 250mg QID for ten days.
After five-month exposure to swamp powder, all cases had a toxic BLL,
and they became symptomatic. The high level of lead oxide in this
product makes it a potential source for severe lead poisoning. It is
important to find the source of the lead poisoning and report it to the
responsible organization. Acknowledging the responsible organization can
prevent many people from having exposure to lead sources. Physicians
should keep in mind the source of the new or unusual ways of lead
poisoning like traditional medicine. Many people believe that all herbal
or traditional medicine is safe for them and may overuse it. Physicians
should ask their patients about traditional medicine when making a
diagnosis of lead poisoning with unknown origin. They should warn their
patients about the use of dangerous traditional medicine like Swamp
powder.