alan m. ducatman, md, msc west virginia university school of medicine
DESCRIPTION
Alan M. Ducatman, MD, MSc West Virginia University School of Medicine. 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. - PowerPoint PPT PresentationTRANSCRIPT
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Alan M. Ducatman, MD, MSc West Virginia University
School of Medicine
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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.
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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.
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Historic Production of Lead
1. 3500 BC-1450 AD: Mostly mined as a byproduct of silver extraction, and mostly converted to… SMOKE.
2. 1450-1750 AD: Byproduct of copper smelting.
3. Industrial Revolution: Byproduct of coal and combustion. Taller stacks spread pollution. Peak emissions 1970-80 (400,000 tons/yr).
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Historic Production of Lead
Lead in paints (never permitted in some alert countries). Banned 1978 in the U.S.
Automobile (1923 - depends on country)
Emission byproduct of leaded gasoline.
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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 1994-1998.
% with elevated BLLSGeometric Mean >10 >15 >20 μg/dL
1994 2.7 10.5 3.9 1.91996 8.6 3.2 1.51998 2.0 7.6 2.7 1.2
Approximate # of children tested= 1.2 million yearlyFrom: MMWR 2000;49:1133-1137
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Childhood Risk Factors for Elevated BLLs (>10μg/dl)
Pre-1946 HousingNon-Hispanic Black 21.9%Mexican American 13.0%White 5.6%
Low Income 16.4%High Income 0.9%
NHANES III, and CDC Recommendations for BL Screening of YoungChildren (Dec. 2000)
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Lead- It’s Everywhere
USES OF Pb
Storage batteries Automobile radiators
Cable Brass and bronze Production
Radiation shielding Construction
Galvanizing Ammunition
Annealing Printing
Plating
Paint Plastics
Soldering Television electronics
Glass Petroleum
Insecticides
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Sources of Lead- Air
Uncontaminated Contaminated
1-2 μg/m3 4-16 μg/m3
Near Smelter
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SOURCES OF LEAD- Water
Uncontaminated
Standards vary Internationally.
In U.S. <15 μg/L 99% of water supplies
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SOURCES OF LEAD- Food
Uncontaminated
Mixed Diet 9.43 μg/kg/day
Bottled Baby Food 3.5 μg/LContaminated
Older Canned Baby Food 202 μg/L
Bone Meal 60-190 μg/g_______________________________________________
Compare this to a paint chip 100,000 μg/g or morePaint Chip 100,000 μg/g or more
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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.
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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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SOURCES OF LEAD- Soil
Uncontaminated
Remote area 2-200 µg/g
Contaminated
Urban residential mean 585 µg/g
City parks 194 - 3,357 µg/g
Near smelter mean 7,600 µg/g
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SOURCES OF LEAD-House Dust
Uncontaminated- New inner-city home
Floor Surface- 2-24 µg/sq ft
Contaminated- Old inner-city home
Floor Surface- 33-486 µg/sq ft
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How does lead enter the body?
1. RespiratoryBreathing in dust that contain lead. Lead is absorbed and distributed to other parts of the body via the bloodstream.
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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).
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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.
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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
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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 1998:147:1162-1174
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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”.
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Lead Compartments BONE BLOOD SOFT TISSUE10 Days 27 Days 30-40 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)
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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.
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What Does Lead Do?
Lead inhibits certain types of enzymes,Particularly enzymes dependant uponsulfhydryl groups.
Organ systems affected include:Neurologic Endocrine (including BP)Reproductive MusculoskeletalBlood RenalGI
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Microcytic Anemiawith Basophilic Stippling
Larger area is a thick thick smear to demonstrate the frequency of basophilic stippling
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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.
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CNS Symptoms in Adults
Early Later Chronic
Irritability Ataxia Hearing Loss
Impaired Judgment
Hallucinations Diminished Judgment
Depression Seizure ↓ Memory
↓ Dexterity Death ↓Cognition
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Peripheral Neuropathy in Lead Poisoning
Distal Symmetric Axonal Polyneuropathy:
Wrist Drop
Foot Pain
Joint Pain
Dexterity
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Cognitive Performance Deficits* in Lead- Exposed Children
Deficits:Psychomotor performanceAuditory and language processingSustained attention & concentrationMeasured outcomes: Less likely to graduate High SchoolMore likely to be convicted of felonies
*Deficits consistent across cultures and controlled for SES
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Lead Poisoned Children as Young Adults
A 20-year follow up by ATSDR of 917 leadpoisoned children (mean 50 ug/dl) measuredlead bone storage by tibial KXRF.Diminished were:1. Sural nerve sensory and peroneal motor evoked response
amplitude.Vibro-tactile thresholds: Fingers and toesStanding coordination
2. Hand-eye coordination in several types of test performance (Trails B, Symbol Digit, Learning Error).
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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 12-14 weeks gestation
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Lead Outcomes in ChildrenExposed in Utero
High Dose Lower Dose
Spontaneous Abortion Low Birth WeightStillbirth Neuropsychologic
ProblemsAdditional risk from breast milk
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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
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Lead & Bones
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Lead & Hypertension
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Lead and the KidneyAcute 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.
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Other Organ Systems Affected by Lead
Hearing (8th nerve damage)
Gout
GI- Anorexia, colic
Endocrine- Vitamin D Metabolism
Genotoxicity
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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!
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Key Presenting Symptoms
Mild Moderate Severe
Fatigue Paresthesia Paralysis
Irritability Myalgia Colic
Arthralgia
Headache
Tremor
GI Distress
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Physical Findings
Early Chronic
Wrist Drop Transverse Nail Lines
Distal Sensation Blue-Black Gum Lines
Proprioception
Vibration Sense
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Detecting Lead Poisoning in Young Children
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CDC“Preventing Lead Poisoning in Young Children”
Oct- 1991
Initial Test (12 months)
Surveillance Strategy
<10 µg/dl 10-14 µg/dl
Repeat at 24 months Retest in 1-3 months
>15 µg/dl Individual Case Management
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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 µg/dl (repeated) or 60 µg/dl once.
Repeat testing: Monthly, depending on lead level
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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.
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The Key to “Treatment”of Lead Poisoning
Remove from exposure, or otherwise preventexposure.
Workplace Home Substitution MoveEngineering Identify and AbatePersonal ProtectionWork PracticesJob Placement
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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.
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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 300-450 mg/m²/d x 3 daysIn childrenSocial Danger:Lowering blood level by oral chelation is not a substitute forworkplace hygiene!!
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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.
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Helpful Web Sites
• ATSDR http://www.atsdr.cdc.gov/HEC/CSEM/lead/index.html
• ATSDR Toxicological Profiles http://www.atsdr.cdc.gov/toxpro2.html• ATSDR ToxFAQs ™ http://www.atsdr.cdc.gov/toxfaq.html• CDC-NCEH http://www.cdc.gov/nceh/lead/lead.htm• NIOSH http://www.cdc.gov/niosh/leadpg.html