This is a 7-1/2 year old boy who loves to juggle.
One day he was juggling dice and accidentally
swallowed one of the dice.  He did not tell his mother
until 3 days later.  She brought him to the emergency
department where a radiograph was obtained.
View radiograph.

     Is there anything we should be concerned about?  If
dice are inert, then it is likely that it would pass
spontaneously in the stool after it passes into the
stomach.
     The radiograph revealed that the die (a single dice)
was in his stomach.  For the next 7 days, he was
ordered to strain his stool to recover the die.  This was
unsuccessful.  After 7 days, he was given a
polyethylene glycol and saline cathartic to accelerate
passage of the die.  Still... "No dice."  At this point, a
second radiograph was taken.
View follow-up radiograph.

     This follow-up radiograph shows that the die has
not moved much.  Although dice may seem inert, some
dice contain lead.  This may not be immediately
obvious.  A serum lead level was 84 mcg/dL (high) and
his RBC's showed basophilic stippling.  He was,
however, asymptomatic, now 11 days post ingestion.
A gastroenterologist was then consulted for endoscopic
retrieval but the die was then passed in his stool.
     Ten days later (21 days post ingestion) he presented
with abdominal pain, diarrhea, and emesis.  He also
was noted to have gingival discoloration and speckling
at the tip of the tongue.
     He was hospitalized at this point.  His serum lead
level was now 48 mcg/dL and his urine lead level was
253 (nl<80).  He was thus treated with EDTA
(ethylenediaminetetraacetic acid) chelation
for 3 days.  He then became asymptomatic and was
discharged home in stable condition.
Lead Poisoning (Plumbism)
     In the past 20 years, the incidence of lead poisoning
in children has decreased, however, there are still
significant numbers of children with toxic lead levels.
     Case detection is best done by screening
populations at risk, including children of lead industry
workers, the workers themselves and children living in
homes that were painted before 1980.  The Center for
Disease Control recommends universal screening
beginning at age 6 months.
Risk Factors are as follows:
Exposure:
     Air/dust/water/paint
     Lead curtain weights
     Fishing weights, dice
     Retained bullets/shrapnel
     Bootleg whiskey, hair spray
Absorption:
     Through lungs if inhaled.
     Symptoms develop more quickly through GI tract.
     Toxicity is more severe in the presence of
concomitant iron, zinc, or calcium deficiency.
Children are at higher risk:
     They absorb 50% of their exposure and retain 30%.
     Adults absorb 5-15%, and retain less than 5%.
Signs and Symptoms:
     Acute toxicity:  Anorexia, vomiting, malaise,
convulsions, permanent brain injury and reversible renal
injury.
     Chronic toxicity:  Weight loss, weakness, anemia,
neurobehavioral deficit, hypertension, wristdrop and
colic  (Most are slow in onset).
By systems:
     Neuro:  Levels > 10 mcg/dL.  Learning disability,
decreased IQ, Mental retardation, encephalopathy,
motor deficit, seizures, cerebral edema, hearing loss.
     GI:  Abdominal pain, nausea, vomiting, diarrhea,
constipation, anorexia, metallic taste in mouth, ileus.
     Renal:  Tubular damage, azotemia, gout.
     Heme:  Levels > 15 mcg/dL.  Affects heme
synthesis, hemolysis, RBC stippling, iron deficiency.
     Musculoskeletal:  Muscle and joint pain, lead lines in
metaphysis.
     Soft tissue:  Blue black line in gum margins.
     Endocrine:  Decreased stature, decreased growth
hormone, decreased vitamin D levels.
Treatment:
     Identification and abatement of lead exposure
sources is first and foremost in treatment.  Ingestion of
a known or visible lead foreign body is okay to leave
untreated if eliminated within 2 weeks.  If not, removal
becomes necessary.
     The San Francisco Poison Center states that lead
absorption is only a problem when in gastric acid,
however, this is not documented in other sources.
     Acute ingestion:  Consider ipecac within 30 minutes
if neurologically intact.  Activated charcoal/cathartic
and/or cleansing enema if lead is seen in the lower
bowel.  However, activated charcoal has a limited ability
to absorb lead and it is of questionable efficacy.  Whole
bowel irrigation may also be beneficial.
Obtain a blood lead level (mcg/dL)
     Category I (level< 9):  Education about lead hazards
and rescreen.
     Category IIA (level 10-14):  Education about lead
hazards and rescreen.
     Category IIB (level 15-19):  Recheck in one month
by venipuncture rather than capillary.  Correct Fe
deficiency.  Treat if the level is greater than 15 for 3
months.  Determine the source of lead exposure and
prevent further exposure.  Correct Fe deficiency.
     Category III (level 20-44):  Same as category IIB.
     Category IV (level 45-69):  Recheck  in 48
hours.  Correct Fe deficiency,  Chelation therapy.
     Category V: (level> 70):  Recheck now, and if
confirmed, treat immediately (chelation).
     There are some inconsistencies in the chelation
treatment recommendations of various sources.  These
recommendations should be considered as guidelines.
A toxicologist or a current version of the Poisindex
should be consulted for treatment recommendations in
individual cases.
     Surgical removal of bullets and shrapnel is indicated
if they are located near synovial spaces.  Surgical
removal of lead foreign bodies in the gut is indicated if
not eliminated within 2 weeks.
     Chelation is indicated if the level is greater than 45
mcg/dL even if asymptomatic.  One should first correct
any iron deficiency.  Chelating agents include EDTA,
BAL, D-Penicillamine, and Succimer.
     EDTA:  A provocation test can be done to determine
the lead excretion ratio.  Give the EDTA dose, then
collect urine for 8 hours.  Total urine lead (mcg)/Total
CaNa2EDTA (mg) dose given.  This test is positive if
> 0.5.  There is no need to do this if the lead level is
greater than 40 mcg/dL.  EDTA can also be used as a
chelator for lead removal over 5 days.
     BAL (dimercaprol)  3-5 mg/kg/dose IM every 4 hours
over 2-10 days.
     D-Penicillamine 10/mg/kg/dose orally x 5 days.  This
was first used as a copper chelator in Wilson's Disease.
This can be used long term.  It is good for levels
between 20-35.
     Succimer (DMSA) is the first oral agent approved by
the FDA.  Because of the oral administration route, this
can be used for outpatient chelation therapy, 30
mg/kg/day x 5 days.  Patients may need multiple
courses.
Bibliography
      Lead.  In:  Poisindex Volume 84, Expires 5/31/95,
Micromedex, Inc.
      Glotzer DE.  Management of Childhood Lead
Poisoning:  Strategies for Chelation.  Pediatric Annals
1994;23(11):608-615.
     Liebelt EL, Shannon MW.  Oral Chelators for
Childhood Lead Poisoning.  Pediatric Annals
1994;23(11):616-626.
 

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