A 39 y.o. immigrant from Colombia resents with auditory hallucinations and behavioral disinhibition.

His only medical history is a gun shot wound to the ankle 13 years prior.

any clues in his mouth?

Our patient had lead poisoning with neuropsychiatric effects.  Most modern bullets contain lead in their core because  it is heavy, easy to shape and inexpensive. The small explosive cap at the back of a cartridge which ignites when struck, also contains lead styphnate.  Firing a weapon creates airborne lead which must be filtered out with HEPA(High-Efficiency Particulate Air) systems.

Retained bullets cause lead poisoning in about 1% of cases but cause a high percentage of the cases of severe lead poisoning.  The risk increases in those with a bone fracture or when the bullet is lodged in a joint.   In fact, prolonged contact with any bodily fluids can dissolve lead, even the pericardium. 

In addition to retained bullets: old paint or dust from old paint during rehab projects is a major source.  Contaminated soil  along road ways from leaded gas, and older plumbing with lead solder are all sources of contamination. Mining, smelting and battery manufacturing result in occupational exposure.  

Southeastern MO is called the lead belt because of the numerous lead mines there. the lead is even mined from the surface in tiff mines.

CLINICAL EFFECTS OF LEAD

Dental- Lead lines appear on the gums as grayish mucosa. Bacteria on the gums create hydrogen sulfide. If there is enough circulating lead in the blood, lead sulfide forms.

Neurologic- The effect of lead on development of the nervous system is profound. It causes neurotransmitter interference  with dopamine and serotonin causing mood and attention disorders.  It disrupts internal cell signaling by activating protein kinases and blocking calcium channels.  This results in behavioral disorders; aggression, learning disabilities and even psychosis.  Peripheral neuropathy and seizures can result as well.

Hematologic- Lead poisoning results in anemia. Lead blocks the creation of hemoglobin by blocking enzymes that make heme  and increases red cell destruction.

basophilic stippling

Osteologic- Lead is stored in bones as a substitute for calcium causing lower bone density.  It can remain for decades and leach out slowly.  When a woman becomes pregnant  the body breaks down maternal bone to supply the calcium needed by the fetus.  This releases lead into the bloodstream where it crosses the placenta to the fetus causing toxicity.

Lead accumulates in the tubules of the kidneys causing renal failure and damages sperm causing infertility.

 Our patient had a lead level of 199 mcg/dL.  His initial hemoglobin was 7.8.  Chelation was begun CaNa₂ ethylenediaminetetraacetic acid (EDTA)) chelation therapy was initiated at a dose of 1 g/m²/day in 0.9% saline solution for three days .After removal of the bullet his lead level dropped to 9mcg/dL over one week and his behavior improved.

FUN FACTS

There is a correlation between living near a lead smelter and being a serial killer.   Ted Bundy, Dennis Rader, Gary Ridgway  and Charles Manson lived near lead smelters.  Charles Manson had a documented lead level of 190 ppm. Did lead poisoning contribute to their behavior?

Lead was removed from paint in 1978 and gas in the 1970’s. Lead remains in the soil in many places like southeastern Missouri especially along highways.

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Yang Y, Raine A, Lencz T, et al.  Volume reduction in prefrontal gray matter in unsuccessful criminal psychopaths   Biol Psychiatry 2005 May 14;57(10):1103-8.

Lead poisoning: a persistent health hazard - general and oral aspects. Saeed S, Hasan S, Kuldeep K, Choudhury P. Biomed Pharmacol J. 2017;10:1–6

Marginean C, Melit L, Moldovan N, et al Medicine 95(38:pe4916, September 2016.

https://www.nejm.org/doi/abs/10.1056/NEJMicm1801693

Morita T, Nishizawa t, Morikawa T. Burton line and basophilic stippling in lead poisoning.  CMAJ 2024 Apr 15;196(14):E487.