The Poison Lab

Episode #2- The Other Problem With Bullets (Lead and Lead Poisoning from Bullets)

Episode Summary

Get ready for a HEAVY subject, literally. Ryan and Toxo talk about the toxic mechanisms, signs of poisoning, and treatment of one of the worlds most ubiquitous poisons. This is a long, but interesting one, consider listening in chunks.

Episode Notes

• Excellent review of sources, clinical effects, and management
  • Calello DP, Henretig FM. Lead. In: Goldfrank's Toxicologic Emergencies, 10th ed, Hoffman RS, Howland MA, Lewin NA, et al (Eds), McGraw Hill Education, New York 2015. p.1219.
  • Toxic substances database for lead https://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=96&tid=22
• Clinical Case from today's show
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353372/
    • Weiss D, Lee D, Feldman R, Smith KE. Severe lead toxicity attributed to bullet fragments retained in soft tissue. BMJ Case Rep. 2017;2017:bcr2016217351. Published 2017 Mar 8. doi:10.1136/bcr-2016-217351
• History
  • More lead exists now than at the dawn of time due to radioactive decay of heavier chemicals. https://iopscience.iop.org/article/10.1086/375492
  • Lead has been deeply intertwined with human culture, used as currency, building material. cosmetics and innumerable other uses. It has  has even been proposed to be the fall of Rome due to use in their aqueducts and wine.https://pubmed.ncbi.nlm.nih.gov/14261844
• Lead in society - Great review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522252
  • Lead Paint, up to 50% lead until 1940, tens of millions of houses still have lead paint which crumbles and creates lead dust
  • Soil,  from tetra ethyl leaded gasoline contamination, added to gasolone by Thomas Midgley https://interestingengineering.com/thomas-midgley-jr-the-man-who-harmed-the-world-the-most
  • Lead piping- https://www.epa.gov/sites/production/files/2016-10/documents/508_lcr_revisions_white_paper_final_10.26.16.pdf
    • The 1986 amendment to the Safe Drinking Water Act required lead-free solder, flux, fittings, and pipes as of June 1988.
    • The Lead and Copper Rule originally required replacement of the public and private service pipelines; however, the rule was revised in 2000 to allow for only partial service line replacement in the publicly owned sectors
  • Older homes, higher soil lead burden, and unjust housing discrimination have led to disparities in lead racial/ethnic and socioeconomic disparities in lead exposure https://scholar.harvard.edu/files/alixwinter/files/sampson_winter_2016.pdf
  • https://pubmed.ncbi.nlm.nih.gov/22752852/.
• Other lead sources
  • Traditional medicines- Ayurveda (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2538609/)
  • Kohl- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1567936/
  • BULLETS-https://pubmed.ncbi.nlm.nih.gov/30939573/
• "Lead crime hypothesis"- https://pubmed.ncbi.nlm.nih.gov/27035924/
• Lead and the economy
  • https://pubmed.ncbi.nlm.nih.gov/23797342/
  • https://pubmed.ncbi.nlm.nih.gov/29134344/
• Clinical effects from
  • "Ben Franklins dangles and bellyach(gripes) https://pubmed.ncbi.nlm.nih.gov/22910081/
    • Lead colic/constipation (gripes)
    • Neuropathy (dangles)
    • Easy to access origiinal letter on lead from Ben Franklin- https://bit.ly/2Yqgoze
• Neurocognitive/Behavioral, especially in exposed young- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909981/
  • Lower IQ
  • Visual spatial effect
  • Processing speed reduction
  • Irritable affect
  • May contribute to cognitive and behavioral disorder
• Chronic kidney and vascular disease- https://www.atsdr.cdc.gov/toxprofiles/tp13-c2.pdf
• Hematologic- https://www.atsdr.cdc.gov/toxprofiles/tp13-c2.pdf
  • Hemolytic anemia- From fragility due to decreased calcium/magenisum ATPase acitivity
  • Basophillic stippling- Pyrimidine 5 nucleotidase inhibtion causes RNA clumping
  • Build up of zinc and erythrocyte Protoporphyrin  (ZPP/EPP) from ferrochetalase inhibition of heme synthesis
• Muscoloskeletal
  • Burton lines- Lead sulfate deposition between teeth and gums in mouth- https://www.amjmed.com/article/S0002-9343(12)00286-0/pdf
  • Lead lines- ostoclast inhibition leading to osteoblast induced hypercalcification at the metaphys https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1912933/
• Toxic mechanism- (gold franks)
  • Binding of sulfhydryl groups
  • Appearance as a divalent cation
• Good resources for broad overview and some nitty gritty info on mechanisms and effects
  • Calello DP, Henretig FM. Lead. In: Goldfrank's Toxicologic Emergencies, 10th ed, Hoffman RS, Howland MA, Lewin NA, et al (Eds), McGraw Hill Education, New York 2015. p.1219.
  • https://www.atsdr.cdc.gov/csem/csem.asp?csem=34&po=10
  • https://www.atsdr.cdc.gov/toxprofiles/tp13-c2.pdf
• Treatment
  • Chelators
    • BAL- IM, painful, peanut oil, hemolysis if G6PD defcient
    • CA2NAEDTA- IV, usually given with other chelator if level >70 or encephalopathic- https://www.sciencedirect.com/science/article/pii/S0041008X99987252
    • Succimer- PO, may increase lead absorption, ensure lead i s past small intestine before starting https://www.sciencedirect.com/science/article/abs/pii/S0013935184710632
  • What to do with your lead level (if its a capillary blood lead make sure you confirm it with venous blood lead!)
    • Kids https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm
      • > history, abatement, education
      • >20 x ray and anemia labs
      • >45 X ray, anemia labs, decon, oral chelation
      • >70 consider x ray, labs, decon IV chelation + oral or IM 4 h before
    • Adults
      • https://pubmed.ncbi.nlm.nih.gov/17431500/

If you have an elevated blood lead level- call your toxicologist or poison center. Thanks for listening!