Lead Poisoning

LEAD POISONING
Lead
• Commonest metal involved in chronic poisoning
• Heavy, steel grey-colored metal
• Lead is used for domestic, industrial and

therapeutic purposes
• Lead is abundant in soil, being distributed

throughout the earth’s crust
Toxic compounds of lead
• Lead tetra oxide (red lead or vermilion) : used as
sindoor
• Lead carbonate ( white lead): manufacture of

paints
• Lead sulfide (surma): applied on eyes
• Tetra ethyl lead: antiknock for petrol
• Lead acetate( sugar lead): used as an astringent

and local sedative for sprains
• Fatal dose: 20gm of lead acetate, 40 gm of lead
carbonate
• Fatal period: 1-2 days

Common sources of lead exposure
• Automobile exhaust ( previously, when leaded petrol was used
• Auto repair works
• Battery making
• House paint
• Glass and plastic manufacture
• Steel welding and cutting
• Indigenous medicines (especially ayurvedic)
• Toys and pencils painted with lead-based paint

Mode of action
• Lead combines with sulfhydryl enzymes leading
to interference with their action
• It decreases heme synthesis by inactivating

the enzymes involved such as aminolaevulinic
acid dehydrase and ferrochelatase. This results
in anemia
• It increases hemolysis as a result of which
immatured red cells are released into circulation
such as reticulocytes and basophilic stippled
cells. This is referred to as punctate
basophilia
Acute poisoning
• Rare
• Symptoms include metallic taste, abdominal

pain, constipation or diarrhea(stools may be
blackish due to lead sulphide), vomiting,
hyperactivity or lethargy, ataxia, behavioral
changes, convulsions, and coma
Chronic poisoning
Plumbism or saturnism
• Mild toxicity
• Moderate toxicity
• Severe toxicity
Mild toxicity
• Blood lead: 40 to 60 mcg/100mL
• Myalgia
• Parasthesia
• Irritability
• Abdominal discomfort
Moderate toxicity
• Blood lead: 60 to 100mcg/100mL
• Arthralgia
• Fatigue
• Tremor
• Headache
• Diffuse abdominal pain
• Anorexia, metallic taste, vomiting
• Constipation
• Weight loss
Severe toxicity
• Blood lead more than 100mcg/100mL
• Lead palsy: wrist or foot drop
• Burton’s line : A bluish black lead line on

gums due to the deposition of lead sulphide
• Lead colic: intermittent severe abdominal

cramps. There may be tenderness around the
umbilicus
• Lead encephalopathy: more common in
children and is often associated with organic
lead toxicity, especially tetraethyl lead or TEL
which is lipid soluble and is distributed widely in
lipophilic tissues such as the brain
• Facial pallor: circum-oral and is due to

vasospasm, though anemia may contribute to a
significant extent
Diagnosis: Laboratory tests
Blood:
• Complete blood count and peripheral smear:

microcytic, hypochromic and basophilic
stippling seen
• Blood lead level

Urine:
• Concentration of ALA (Aminolaevuinic acid) in
urine is widely used as a measure of lead toxicity
in workers who are exposed occupationally
• Urine lead level: above 150mg/litre (not very

reliable)
Radiology:
• Lead lines (dense transverse bands) extending
across the metaphyses of the long bones
TREATMENT
• Acute poisoning with encephalopathy:
BAL 4 mg/kg immediately

After the initial dose, repeat the same dose at 4
hourly intervals until blood lead level falls below 40
mcg/100mL
Stop chelation when BL falls below 20mcg/100ml
Cranial CT scan: to rule out cerebral edema
KUB: to rule out lead chips in GI tract

• Acute poisoning without encephalopathy
BAL 12mg/kg/day, EDTA 50 mg/kg/day

Discontinue BAL when the BL falls below
40mcg/100ml, but continue EDTA for 5 more
days
Change to oral chelation which may have to

be continued until the BL falls below
20mcg/100mL
Postmortem appearances
• Pale skin, conjunctiva and mucosa
• Emaciation
• Burtonian line
• Lead lines on X-ray

Medico legal aspects
• Homicide or acute cases are rare
• Chronic poisoning is common due to failure to

recognize the poisoning as the symptoms and
signs are subtle and easily overlooked
• Accidental: people working in lead factories,

lead oleate used as a local application for
abortion, due to lead bullets or projectiles
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• Heavy, steel grey-colored metal

• Lead is used for domestic, industrial and

• Lead is abundant in soil, being distributed

• Lead carbonate ( white lead): manufacture of

• Lead sulfide (surma): applied on eyes

• Tetra ethyl lead: antiknock for petrol

• Lead acetate( sugar lead): used as an astringent

• Fatal period: 1-2 days

• Auto repair works

• Glass and plastic manufacture

• Steel welding and cutting

• Indigenous medicines (especially ayurvedic)

• Toys and pencils painted with lead-based paint

• It decreases heme synthesis by inactivating

• Symptoms include metallic taste, abdominal

• Lead palsy: wrist or foot drop

• Burton’s line : A bluish black lead line on

• Lead colic: intermittent severe abdominal

• Facial pallor: circum-oral and is due to

• Complete blood count and peripheral smear:

• Blood lead level

• Urine lead level: above 150mg/litre (not very

BAL 4 mg/kg immediately

Cranial CT scan: to rule out cerebral edema

KUB: to rule out lead chips in GI tract

BAL 12mg/kg/day, EDTA 50 mg/kg/day

Change to oral chelation which may have to

• Lead lines on X-ray

• Chronic poisoning is common due to failure to

• Accidental: people working in lead factories,

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