Question
A 2yr old child is brought to the ED for altered mental status, vomiting, and lethargy. The parents states that this has been occurring since they moved into their grandmother’s home 2 months ago. Vitals signs are within normal limits and CBC reveals a hemoglobin – 10.1 mg/dL, mean corpuscular volume (MCV) – 71 fL/cell, and mean cell hemoglobin concentration (MCHC) – 29.1 g/dL. Peripheral smear and abdominal xray are below.
- What is the most likely diagnosis?
- What is the next diagnostic step?
- What is the first step in the management of this patient?
Answer
- The peripheral smear reveals stippling and granules in the basophils and the abdominal radiograph shows hyperlucent flecks throughout the colon. These findings with the history of living in a older home leads to the most likely diagnosis of lead intoxication from eating the chipped paint.
- The next diagnostic step for lead intoxication is to send a blood lead level for confirmation, as well as a serum erythrocyte protoporphyrin. Given his AMS, he should also have a non-contrasted head CT.
- Management of children with lead intoxication is directed by the lead levels. First and foremost, you should contact your regional poison center for guidance by a pediatric toxicologist. For our patient, he is symptomatic and management includes fluid administration, possible whole bowel irrigation (though lead is not absorbed in the colon), and chelation therapy with succimer and calcium disodium edetate.
Reference
- Centers for Disease Control and Prevention. Managing elevated blood lead levels among young children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA, Centers for Disease Control and Prevention, 2002. http://www.cdc.gov.ezproxy.uthsc.edu/nceh/lead/CaseManagement/caseManage_main.htm.
- Osterhoudt KC, Burns-Ewald M, Shannon M, Henretig FM. Toxicologic emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006.
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