Lead poisoning due to gunshot bullet in contact with cerebrospinal fluid: case report

Abstract

CONTEXT: Lead poisoning due to retained gunshot bullets is a well-known clinical problem that is fairly frequently described in the literature. The risk factors for this occurrence relate mainly to whether the lead bullet is in contact with the joint fluid or cerebrospinal fluid (CSF). The treatment for these cases entails chelation therapy while symptoms are shown and definitive surgical removal of the bullet as a potential source of lead. The aim of this paper is to describe a clinical case of lead poisoning due to a retained gunshot bullet in contact with CSF. CASE REPORT:A 42-year-old male was hit by gunshot bullets during a holdup, and one of them was retained in the spinal cord. Six years later, he developed intense low back pain and underwent laminectomy. Nine years later, he then underwent arthrodesis on L5-S1, but he developed intense abdominal pain after the surgical procedure. For five years, he was treated with calcium versenate in five-day cycles, with a good response. The chelation therapy cycles showed great efficacy during symptomatic periods, thus reducing the symptoms and signs of poisoning and promoting great amounts of lead excretion, thereby reducing the total lead burden responsible for the symptoms. Fortunately, over the last four years, the symptoms have improved and the urine levels of aminolevulinic acid (ALA) have declined, to reach complete normalization. This shows that a healing process is probably taking place on the spinal wound, thereby isolating the bullet fragments from CSF contact. RESUMOCONTEXTO: A intoxicação por chumbo devida a projétil retido em ferimento por arma de fogo é uma complicação já conhecida e descrita na literatura.O risco de intoxicação endógena por chumbo está associado ao contato do projétil com o líquido sinovial ou líquido o cefalorraquidiano. O tratamento requer terapia de quelação e retirada cirúrgica do projétil como tratamento definitivo. Este artigo descreve caso clínico de paciente que desenvolveu intoxicação por chumbo devida a projétil retido em contato com líquido cefalorraquidiano. RELATO DE CASO:Paciente masculino, 42 anos, foi baleado durante assalto e teve projéteis que se alojaram no abdômen, perna direita e coluna lombosacra. Seis anos depois, desenvolveu intensa lombociatalgia e foi submetido a laminectomia. Nove anos após o acidente, foi submetido a artrodese de L5-S1, quando foi tentada a retirada do projétil, sem sucesso, desenvolvendo no pós-operatório intensa dor abdominal. Foi então feito diagnóstico de intoxicação por chumbo, que foi tratada com gluconato de cálcio, com boa resposta. Durante os cinco anos seguintes, fez ciclos de quelação com ácido etilenodiaminotetracético (EDTA) cálcico, com boa evolução. Os ciclos de quelação mostraram grande eficácia na redução dos sinais e sintomas da intoxicação, promovendo um grande aumento da excreção de chumbo e reduzindo a carga corpórea total de chumbo responsável pelos sintomas. Nos últimos quatro anos, apresentou melhora dos sintomas de intoxicação, com diminuição dos níveis de A...

Treatment strategy in a child with a retained bullet in the cerebellomedullary cistern

“…10,11 If migration has been recognized, bullet removal is justified given the increased risk of obstructive hydrocephalus and additional injury to the CNS, especially for intraventricularly retained bullets. 15 It is worth noting that before proceeding with surgical removal, plain skull roentgenograms are indicated after final positioning of the head to ensure the location of the fragment.…”

“…13 Lead poisoning is a well-recognized complication of retained bullets, with fairly frequent description even though only about 80 cases have been reported. 10,11 Despite several descriptions, the clinical significance of artificially implanted inorganic lead as a source of lead poisoning was not addressed until the recent study by McQuirter et al 11 These authors demonstrated in blood assays and lead measurements of trabecular and cortical bone that blood lead increases over time after an injury in cases of a retained bullet. This increase is mostly related to bone fracture caused by the gunshot.…”

“…11 An additional risk factor is contact with the joint fluid or CSF. 10 It is believed that the acidic pH of theses fluids induces lead solubilization and subsequent mobilization into plasma. 10 As yet, a proposed guideline for the surgical management of GSWs to the spine has not been considered.…”

Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons

“…Furthermore, Richards [6] emphasized that there was no consensus among different spine centers about whether bullets in patients with spinal cord injuries should be removed, despite some evidence that those at or below T12 have higher re-ambulation rates after bullet removal [27]. Bullets in contact with cerebrospinal fluid may undergo electrolysis and cause plumbism, which is again a reason for bullet removal [28].…”

Penetrating cranial injury due to gunshot in a dog: a case report

“…There are several human cases of lead poisoning owing to gunshot bullets (Coon et al, 2006;de Madureira et al, 2009). Lead poisoning mostly results when the lead bullet is put into contact with cerebrospinal fluid or joint fluid.…”