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Alan M. Ducatman, MD, MSc West Virginia University School of Medicine.

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Presentation on theme: "Alan M. Ducatman, MD, MSc West Virginia University School of Medicine."— Presentation transcript:

1 Alan M. Ducatman, MD, MSc West Virginia University School of Medicine

2 What is Lead? Lead is a blush gray metallic element which occurs naturally (in small amounts) in the earth’s crust. It is dense, hence its use as a ballast, ammunition, or radiation shield. Lead is insoluble in water, but some salts are soluble.

3 Significant Health Characteristics of Lead Lead has a low melting point and can easily be aerosolized by heating. Lead can be formed into organic compounds by some organisms, and some organic compounds (such as “leaded gasoline”) have industrial uses.

4 Historic Production of Lead BC-1450 AD: Mostly mined as a byproduct of silver extraction, and mostly converted to… SMOKE AD: Byproduct of copper smelting. 3.Industrial Revolution: Byproduct of coal and combustion. Taller stacks spread pollution. Peak emissions (400,000 tons/yr).

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6 Historic Production of Lead Lead in paints (never permitted in some alert countries). Banned 1978 in the U.S. Automobile ( depends on country) Emission byproduct of leaded gasoline.

7 Improved Lead Levels in the US Blood lead levels in children <6 years old showed an approximately 80% decline from the 1970’s to 1994, and a continuing drop from % with elevated BLLS Geometric Mean >10 >15 >20μg/dL Approximate # of children tested= 1.2 million yearly From: MMWR 2000;49:

8 Childhood Risk Factors for Elevated BLLs (>10 μ g/dl) Pre-1946 Housing Non-Hispanic Black 21.9% Mexican American13.0% White 5.6% Low Income16.4% High Income 0.9% NHANES III, and CDC Recommendations for BL Screening of Young Children (Dec. 2000)

9 Lead- It’s Everywhere USES OF Pb Storage batteriesAutomobile radiators Cable Brass and bronze Production Radiation shielding Construction GalvanizingAmmunition AnnealingPrinting Plating PaintPlastics Soldering Television electronics GlassPetroleum Insecticides

10 Sources of Lead- Air UncontaminatedContaminated 1-2 μg/m34-16 μ g/m3 Near Smelter

11 SOURCES OF LEAD- Water Uncontaminated Standards vary Internationally. In U.S. <15 μg/L 99% of water supplies

12 SOURCES OF LEAD- Food Uncontaminated Mixed Diet 9.43 μ g/kg/day Bottled Baby Food 3.5 μ g/L Contaminated Older Canned Baby Food 202 μ g/L Bone Meal μ g/g _______________________________________________ Compare this to a paint chip 100,000 μg/g or more Paint Chip 100,000 μ g/g or more

13 Lead- It’s Everywhere Unusual oral sources of lead: Ceramic glazes, art pottery, primitive equipment for making maple syrup, crystal glass used to contain alcohol products, certain cosmetics applied to hands or face, some candle wicks, folk medicines, used lead radiators, moonshine liquor.

14 Lead- It’s Everywhere What is Lead Paint? Lead paint uses LEAD as a pigment. It was advantageous to do this because it “sticks” (coats or penetrates) well. There are 2 types- White lead (basic lead carbonate) Red lead (a form of lead oxide)

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16 SOURCES OF LEAD- Soil Uncontaminated Remote area µg/g Contaminated Urban residential mean 585 µg/g City parks ,357 µg/g Near smelter mean 7,600 µg/g

17 SOURCES OF LEAD- House Dust Uncontaminated- New inner-city home Floor Surface µg/sq ft Contaminated- Old inner-city home Floor Surface µg/sq ft

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21 How does lead enter the body? 1.Respiratory Breathing in dust that contain lead. Lead is absorbed and distributed to other parts of the body via the bloodstream.

22 How Does Lead Enter the Body? 2. Ingestion Adults absorb about 6% of ingested lead. Fasting adults absorb more. Children absorb much more lead (30-50% if well fed, and more, if fasting or malnourished).

23 How Does Lead Enter the Body? 3. Skin Skin is relatively impervious to lead, lead oxides, or lead salts. Some may get through scrapes or wounds, but organic leads (such as in leaded gasoline), will go through skin into the bloodstream quite well.

24 Does the Route of Entry Matter? Lead, lead salts, lead oxide, all have same toxicity (whether inhaled or ingested), but more is absorbed when inhaled. Organic lead has greater affinity for CNS – therefore skin absorption may be SERIOUS

25 Lead Metabolism and Nutrition Low dietary intake of vitamin D, vitamin C, and iron enhance absorption and retention of lead in the body. It is believed that vitamin D modifies lead- bone metabolism, while vitamin C and iron may also modify excretion. Cheny L, et al AJ Epi 1998:147:

26 Where does lead go once in the body? 1.Lead is absorbed into the bloodstream rapidly. 2.It then travels to “soft tissue” such as kidneys, lungs, brain, spleen, muscles, and heart. 3.After several weeks, most lead moves into bones and teeth (and some into hair). About 94% of adults total lead burden is in bones and teeth Only about 73% for children 4. Lead in bones and teeth equilibrates over time and circumstance with other “compartments”.

27 Lead Compartments BONE  BLOOD  SOFT TISSUE 10 Days 27 Days Days   TEETH URINE BILE, HAIR, SWEAT, NAIL Figure 2.5 A simple three-compartment model for absorption, retention, and elimination of lead in humans. Quantitative estimates apply to adult males. Source: derived from Rabinowitz et al. (1975)

28 How Does Lead Get Out of the Body Kidneys- urine Bowels- stool Glands-sweat Breast- breast milk Hair, nails, teeth (very slow turnover) It takes >10 years to turn over one half the body’s stored lead. Bone source slowly leaches into the blood.

29 What Does Lead Do? Lead inhibits certain types of enzymes, Particularly enzymes dependant upon sulfhydryl groups. Organ systems affected include: NeurologicEndocrine (including BP) ReproductiveMusculoskeletal BloodRenal GI

30 Microcytic Anemia with Basophilic Stippling Larger area is a thick thick smear to demonstrate the frequency of basophilic stippling

31 Alternative tests to blood lead Erythrocyte protoporphyrin and zinc protoporphyrin tend to become elevated as lead-induced hemoglobin salvage increases. These tests are neither sensitive nor specific for detecting lead exposure. They have limited usefulness in the diagnosis, surveillance, or treatment of lead exposure and lead poisoning.

32 CNS Symptoms in Adults EarlyLaterChronic IrritabilityAtaxiaHearing Loss Impaired Judgment HallucinationsDiminished Judgment DepressionSeizure↓ Memory ↓ DexterityDeath↓Cognition

33 Peripheral Neuropathy in Lead Poisoning Distal Symmetric Axonal Polyneuropathy: Wrist Drop Foot Pain Joint Pain  Dexterity

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35 Cognitive Performance Deficits * in Lead- Exposed Children Deficits: Psychomotor performance Auditory and language processing Sustained attention & concentration Measured outcomes: Less likely to graduate High School More likely to be convicted of felonies *Deficits consistent across cultures and controlled for SES

36 Lead Poisoned Children as Young Adults A 20-year follow up by ATSDR of 917 lead poisoned children (mean 50 ug/dl) measured lead bone storage by tibial KXRF. Diminished were: 1. Sural nerve sensory and peroneal motor evoked response amplitude. Vibro-tactile thresholds: Fingers and toes Standing coordination 2. Hand-eye coordination in several types of test performance (Trails B, Symbol Digit, Learning Error).

37 Lead Exposure in utero Lead crosses the placenta in plasma. Pregnancy (and lactation) causes lead release from bone stores into plasma Plasma lead is about 1% of circulating blood lead. Epidemiologic effects on CNS have been documented. Peak transfer is at weeks gestation

38 Lead Outcomes in Children Exposed in Utero High DoseLower Dose Spontaneous AbortionLow Birth Weight StillbirthNeuropsychologic Problems Additional risk from breast milk

39 Lead and Adult Reproduction Reproductive Females - Miscarriage, still birth - Inability to conceive Males - Decreased libido - Decreased fecundity - Sperm abnormalities: counts, abnormal forms Dose response relationship

40 Lead & Bones

41 Lead & Hypertension

42 Lead and the Kidney Acute and Chronic Disease 1.Lead nephropathy (Fanconi syndrome) is characterized by aminoacidura, glucosuria, phosphaturia with hypophosphatemia, and deceased uric acid excretion. 2.Chronic kidney disease may also arise, sometimes associated with gout.

43 Other Organ Systems Affected by Lead Hearing (8 th nerve damage) Gout GI- Anorexia, colic Endocrine- Vitamin D Metabolism Genotoxicity

44 Key Aspects of the Clinical History * Home environment (or environment where a child visits) Home remodeling (occupational histories: all family members) Hobbies, making glazed ceramics, fishing sinkers Unusual medications, cosmetics For children, the vast majority of sources will be paint. For adults, it will be occupation. For adults and children, home remodeling is an issue Occupational Histories All family members *The exposure history provides the key to successful Rx!

45 Key Presenting Symptoms MildModerateSevere FatigueParesthesiaParalysis IrritabilityMyalgiaColic Arthralgia Headache Tremor GI Distress

46 Physical Findings EarlyChronic Wrist DropTransverse Nail Lines Distal SensationBlue-Black Gum Lines Proprioception Vibration Sense

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48 Detecting Lead Poisoning in Young Children

49 CDC “Preventing Lead Poisoning in Young Children” Oct Initial Test (12 months) Surveillance Strategy <10 µg/dl10-14 µg/dl Repeat at 24 monthsRetest in 1-3 months >15 µg/dlIndividual Case Management

50 Medical Surveillance for Adult Workers When: Exposure above “action level” >30 days/yr What: Triggers periodic exams and biologic monitoring (including blood level) Removal threshold: 50 µ g/dl (repeated) or 60 µ g/dl once. Repeat testing: Monthly, depending on lead level

51 Adult Return to Work Lead poisoned workers can return to the workplace when blood lead is <40 µg/dl. Symptomatic workers can remain out of the workplace at lower levels. Workers whose blood lead is near 40 µg/dl are most likely to be able to remain in the workplace if they can perform modified duty without lead exposure.

52 The Key to “Treatment” of Lead Poisoning Remove from exposure, or otherwise prevent exposure. WorkplaceHome SubstitutionMove EngineeringIdentify and Abate Personal Protection Work Practices Job Placement

53 Chelation Therapy For symptoms, or physical findings. May prevent dread acute consequences- seizure No longer believed to protect CNS in asymptomatic children Must be considered in light of possible complications- kidney damage and arrhythmia. Will cause increased lead absorption if exposure persists.

54 Choice of Chelation Agents Outpatient: Succimer 1050 mg/m²x 7 days 700 mg/m²x14-19 days Inpatient: CaNa² -EDTA 1000 –1500 mg/m²/dx 5 days Encephalopathy Add: BAL mg/m²/d x 3 days In children Social Danger: Lowering blood level by oral chelation is not a substitute for workplace hygiene!!

55 Prevention of Lead Poisoning Prevention of lead poisoning is a superior public health measure; medical treatment alone is disappointing. The key to treatment is cessation of exposure, and the public health need is to consider and find other possible victims.

56 Helpful Web Sites ATSDR ml ml ATSDR Toxicological Profiles ATSDR ToxFAQs ™ CDC-NCEH NIOSH


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