Disclosures: Ohmin Kwon, MD: No financial relationships or conflicts of interest

Case Diagnosis: Lead poisoning from retained bullets in chronic spinal cord injury.

Case Description or Program Description: Chronic spinal cord injury patient with nonspecific symptoms found to have significantly elevated blood lead level (BLL) from retained bullet fragments (RBF).

Setting: A 36-year-old male who sustained a traumatic spinal cord injury (SCI) from gunshot wound 7 years ago with RBF in T11 presented with persistent mid-back pain, progressively worsening left sided abdominal pain and significant weight loss that started within 1 year of injury. He underwent extensive gastrointestinal workup and was diagnosed with visceral hypersensitivity and disorders of brain-gut axis. Given his persistent symptoms, BLL was evaluated and found to be significantly elevated at 63 mcg/dL. No other sources of lead exposure were identified. Case was discussed with medical toxicologist who recommended removal of retained bullet fragments and was subsequently scheduled for surgery.

Assessment/Results: The symptoms of lead toxicity are nonspecific and show large variations among individuals that make it difficult to identify and differentiate from sequelae of SCI. Threshold for elevated BLL is 5 ug/dL but symptoms such as fatigue, headache, anemia, abdominal pain or “lead colic”, nausea, renal failure, encephalopathy, peripheral neuropathy typically occur at BLL > 24 ug/dL. Prompt education and removal from exposure are of primary importance as well as evaluation for end-organ damage. Chelation therapy are reserved for > 80 ug/dL or > 50 ug/dL with signs or symptoms of lead toxicity.

Discussion (relevance): RBF removal is not routinely indicated unless causing significant morbidity and symptoms. Currently, there are no guidelines regarding BLL surveillance for RBF. Some risk factors associated with increased risk of elevated BLL in setting of RBF include concomitant fracture at the time of injury and increased number of RBF.

Conclusions: Lead toxicity from RBF may be easily overlooked in spinal cord injury patients due to its nonspecific symptoms.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/lead-poisoning-from-retained-bullets-in-chronic-spinal-cord-injury/