J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 5, Number 4, April 2014, pages 187-193

Lead Intoxication Treated With D-Penicillamine

Figure 1. (A) Abdominal X-ray on admission showed retention of feces suggesting constipation. There were no other abnormalities despite severe abdominal pain. (B) Blood smear on admission showed basophilic stippling in erythrocytes, leading to a suspicion of lead intoxication (original magnification × 400).

Figure 2. Daily urinary lead excretion (rectangles) and δ-aminolevulinic acid (δ-ALA) concentration in spot urine samples (triangles). The δ-ALA concentration peaked on day 2. Lead excretion increased significantly after administration of D-penicillamine, peaking on day 3. Both parameters gradually decreased after the peak.

**Table 1.** Laboratory Findings on Admission
*These values are outside the normal ranges. MCV: mean corpuscular volume; MCH: mean corpuscular hemoglobin; AST: aspartate aminotransferase; ALT: alanine aminotransferase; LDH: lactate dehydrogenase; ALP: alkaline phosphatase; g-GTP: gamma-glutamyltranspeptidase; CPK: creatine phosphokinase; UIBC: unsaturated iron binding capacity.
Hematology
Red blood cells*	268 × 10⁴/mm³
Hemoglobin*	8.1 g/dL
Hematocrit*	23.7%
MCV	88.4 fL
MCH	30.2 pg
White blood cells	6,900/mm³
Platelets	28.5 × 10⁴/mm³
Biochemistry
Total protein	7.2 g/dL
Albumin	5.0 g/dL
AST	32 IU/L
ALT*	74 IU/L
LDH	196 IU/L
ALP	217 IU/L
g-GTP	38 IU/L
Total bilirubin*	2.4 mg/dL
Direct bilirubin	0.2 mg/dL
Choline esterase	238 IU/L
CPK	120 IU/L
Amylase	106 IU/L
Total cholesterol	158 mg/dL
Blood urea nitrogen*	26.6 mg/dL
Creatinine	0.74 mg/dL
Uric acid	3.5 mg/dL
Sodium*	134 mEq/L
Potassium	4.5 mEq/L
Chloride	101 mEq/L
Glucose	108 mg/dL
Iron	157 mg/dL
UIBC*	74 mg/dL
Ferritin*	341 ng/mL
Haptoglobin	121 mg/dL

Table 1. Laboratory Findings on Admission

*These values are outside the normal ranges. MCV: mean corpuscular volume; MCH: mean corpuscular hemoglobin; AST: aspartate aminotransferase; ALT: alanine aminotransferase; LDH: lactate dehydrogenase; ALP: alkaline phosphatase; g-GTP: gamma-glutamyltranspeptidase; CPK: creatine phosphokinase; UIBC: unsaturated iron binding capacity.

Hematology

Red blood cells*

268 × 10⁴/mm³

Hemoglobin*

8.1 g/dL

Hematocrit*

23.7%

MCV

88.4 fL

MCH

30.2 pg

White blood cells

6,900/mm³

Platelets

28.5 × 10⁴/mm³

Biochemistry

Total protein

7.2 g/dL

Albumin

5.0 g/dL

AST

32 IU/L

ALT*

74 IU/L

LDH

196 IU/L

ALP

217 IU/L

g-GTP

38 IU/L

Total bilirubin*

2.4 mg/dL

Direct bilirubin

0.2 mg/dL

Choline esterase

238 IU/L

CPK

120 IU/L

Amylase

106 IU/L

Total cholesterol

158 mg/dL

Blood urea nitrogen*

26.6 mg/dL

Creatinine

0.74 mg/dL

Uric acid

3.5 mg/dL

Sodium*

134 mEq/L

Potassium

4.5 mEq/L

Chloride

101 mEq/L

Glucose

108 mg/dL

Iron

157 mg/dL

UIBC*

74 mg/dL

Ferritin*

341 ng/mL

Haptoglobin

121 mg/dL

**Table 2.** Reported Adult Patients with Acute-Onset Symptoms of Lead Intoxication
Case	Author	Age, sex, occupation	Exposure period	Illness period	Symptoms	Blood lead level (µg/dL)	Hb (g/dL)	Chelation therapy
M: male; F: female; Hb: hemoglobin; EDTA: intravenous calcium-ethylenediaminetetraacetic acid; DMSA: oral meso-2,3-dimercaptosuccinic acid.
1	Ziegler [14]	16, F, unknown	Unknown	6 months	Abdominal pain, weight loss	91.9	9.2	EDTA
2	Bennett [8]	40, M, painter	Unknown	6 weeks	Abdominal pain, malaise, arthralgia, mental impairment	87.1	9.4	EDTA DMSA
3	Bennett [8]	51, M, decorator	Unknown	4 weeks	Headache, nausea, dizziness, constipation, hand weakness	84.2	13.2	EDTA DMSA
4	Bennett [8]	22, M, painter	Unknown	2 weeks	Abdominal pain, malaise, nausea, headache	85.2	9.7	EDTA DMSA
5	Ogawa [17]	34, M, painter	1 month	Unknown	Abdominal pain	73.1	10.5	EDTA
6	Ogawa [17]	30, M, painter	2 months	2 months	Chest, back and abdominal pain, nausea	96.3	12.4	EDTA
7	Dounias [18]	33, F, battery worker	3 months	2 weeks	Abdominal pain, malaise	90.0	8.0	DMSA
8	Barber [5]	26, M, unknown	Unknown	2 weeks	Abdominal pain, vomiting, erratic behavior	157.8	Unknown	(-)
9	Verheiji [19]	40, M, unknown	Unknown	A few weeks	Abdominal pain	86.0	9.2	EDTA
10	Shamshirsaz [20]	Unknown, F, unknown	Unknown	9 days	Abdominal pain, diarrhea, loss of appetite	102.0	9.3	DMSA

Table 2. Reported Adult Patients with Acute-Onset Symptoms of Lead Intoxication

Case

Author

Age, sex, occupation

Exposure period

Illness period

Symptoms

Blood lead level (µg/dL)

Hb (g/dL)

Chelation therapy

M: male; F: female; Hb: hemoglobin; EDTA: intravenous calcium-ethylenediaminetetraacetic acid; DMSA: oral meso-2,3-dimercaptosuccinic acid.

Ziegler [14]

16, F, unknown

Unknown

6 months

Abdominal pain, weight loss

91.9

9.2

EDTA

Bennett [8]

40, M, painter

Unknown

6 weeks

Abdominal pain, malaise, arthralgia, mental impairment

87.1

9.4

EDTA
DMSA

Bennett [8]

51, M, decorator

Unknown

4 weeks

Headache, nausea, dizziness, constipation, hand weakness

84.2

13.2

EDTA
DMSA

Bennett [8]

22, M, painter

Unknown

2 weeks

Abdominal pain, malaise, nausea, headache

85.2

9.7

EDTA
DMSA

Ogawa [17]

34, M, painter

1 month

Unknown

Abdominal pain

73.1

10.5

EDTA

Ogawa [17]

30, M, painter

2 months

Chest, back and abdominal pain, nausea

96.3

12.4

EDTA

Dounias [18]

33, F, battery worker

3 months

2 weeks

Abdominal pain, malaise

90.0

8.0

DMSA

Barber [5]

26, M, unknown

Unknown

2 weeks

Abdominal pain, vomiting, erratic behavior

157.8

Unknown

(-)

Verheiji [19]

40, M, unknown

Unknown

A few weeks

Abdominal pain

86.0

9.2

EDTA

Shamshirsaz [20]

Unknown, F, unknown

Unknown

9 days

Abdominal pain, diarrhea, loss of appetite

102.0

9.3

DMSA