Michael J. Kosnett

Recommendations for medical management of adult lead exposure

Research conducted in recent years has increased public health concern about the toxicity of lead at low dose and has supported a reappraisal of the levels of lead exposure that may be safely tolerated in the workplace. In this article, which appears as part of a mini-monograph on adult lead exposure, we summarize a body of published literature that establishes the potential for hypertension, effects on renal function, cognitive dysfunction, and adverse female reproductive outcome in adults with whole-blood lead concentrations < 40 μg/dL. Based on this literature, and our collective experience in evaluating lead-exposed adults, we recommend that individuals be removed from occupational lead exposure if a single blood lead concentration exceeds 30 μg/dL or if two successive blood lead concentrations measured over a 4-week interval are ≥ 20 μg/dL. Removal of individuals from lead exposure should be considered to avoid long-term risk to health if exposure control measures over an extended period do not decrease blood lead concentrations to < 10 μg/dL or if selected medical conditions exist that would increase the risk of continued exposure. Recommended medical surveillance for all lead-exposed workers should include quarterly blood lead measurements for individuals with blood lead concentrations between 10 and 19 μg/dL, and semiannual blood lead measurements when sustained blood lead concentrations are < 10 μg/dL. It is advisable for pregnant women to avoid occupational or avocational lead exposure that would result in blood lead concentrations > 5 μg/dL. Chelation may have an adjunctive role in the medical management of highly exposed adults with symptomatic lead intoxication but is not recommended for asymptomatic individuals with low blood lead concentrations.

Arsenic-Induced Skin Lesions among Atacameno People in Northern Chile despite Good Nutrition and Centuries of Exposure

It has been suggested that the indigenous Atacameño people in Northern Chile might be protected from the health effects of arsenic in drinking water because of many centuries of exposure. Here we report on the first intensive investigation of arsenic-induced skin lesions in this population. We selected 11 families (44 participants) from the village of Chiu Chiu, which is supplied with water containing between 750 and 800 microg/L inorganic arsenic. For comparison, 8 families (31 participants) were also selected from a village where the water contains approximately 10 microg/L inorganic arsenic. After being transported to the nearest city for blind assessment, participants were examined by four physicians with experience in studying arsenic-induced lesions. Four of the six men from the exposed village, who had been drinking the contaminated water for more than 20 years, were diagnosed with skin lesions due to arsenic, but none of the women had definite lesions. A 13-year-old girl had definite skin pigmentation changes due to arsenic, and a 19-year-old boy had both pigmentation changes and keratoses on the palms of his hands and the soles of his feet. Family interviews identified a wide range of fruits and vegetables consumed daily by the affected participants, as well as the weekly intake of red meat and chicken. However, the prevalence of skin lesions among men and children in the small population studied was similar to that reported with corresponding arsenic drinking water concentrations in both Taiwan and West Bengal, India--populations in which extensive malnutrition has been thought to increase susceptibility.

Health Risks from Lead-Based Ammunition in the Environment

Lead is one of the most studied toxicants, and overwhelming scientific evidence demonstrates that lead is toxic to several physiological systems in vertebrates, including the nervous, renal, cardiovascular, reproductive, immune, and hematologic systems (Health Risks from Lead-Based Ammunition in the Environment—A Consensus Statement of Scientists 2013). Furthermore, there is no level of lead exposure in children known to be without adverse effects [Centers for Disease Control and Prevention (CDC) 2012a, 2012b]. In light of this evidence, there is an urgent need to end a major source of lead for animals and humans: spent lead bullets and shotgun pellets. Notably, production of lead-based ammunition in the United States accounted for > 69,000 metric tons consumed in 2012; this is second only to the amount of lead used to manufacture storage batteries (U.S. Geological Survey 2013). However, there are few regulations regarding the release of lead into the environment through discharge of lead-based ammunition. For other major categories of lead consumption, such as lead batteries and sheet lead/lead pipes, environmental discharge and disposal are regulated. Therefore, lead-based ammunition is likely the greatest largely unregulated source of lead that is knowingly discharged into the environment in the United States. In contrast, the release or distribution of other major sources of environmental lead contamination (e.g., leaded gasoline, lead-based paint, lead solder) have been substantially regulated and reduced since the mid-1970s (Health Risks from Lead-Based Ammunition in the Environment—A Consensus Statement of Scientists 2013). There is a national discussion—polarized at times—of the health risks posed to humans and wildlife from the discharge of lead-based ammunition. To inform this discussion, a group of 30 nationally and internationally recognized scientists with expertise regarding lead and environmental health recently collaborated to create an evidence-based consensus statement (Health Risks from Lead-Based Ammunition in the Environment—A Consensus Statement of Scientists 2013) supporting the reduction and eventual elimination of lead released to the environment through the discharge of lead-based ammunition. The discharge of lead bullets and shotgun pellets into the environment poses significant health risks to humans and wildlife. The best available scientific evidence demonstrates that the discharge of lead-based ammunition substantially increases environmental lead levels, especially in areas with higher shooting activity (U.S. Environmetal Protection Agency 2012) and that the discharge of lead-based ammunition poses risks of elevated lead exposure to gun users (National Research Council 2012). When lead-containing bullets are used to shoot wildlife, they can fragment into hundreds of small pieces, many of which are small enough to be easily ingested by scavenging animals or to be retained in meat prepared for human consumption (Hunt et al. 2009; Knott et al. 2010; Pauli and Burkirk 2007). Consequently, lead-based ammunition may be a significant source of lead exposure in humans that regularly ingest wild game (Hanning et al. 2003; Johansen et al. 2006; Levesque et al. 2003; Tsuji et al. 2008). In addition, lead pellets and fragments have been reported in gastrointestinal tracts of hunters who consume meat from animals shot with lead-based ammunition (Carey 1977; Reddy 1985). The use of lead pellets in shotgun shells for hunting waterfowl posed a serious threat to wetland birds, and secondarily to bald eagles, in the United States, leading to the U.S. Fish and Wildlife Service’s 1991 nationwide regulations requiring use of nontoxic shotgun pellets for hunting waterfowl (Anderson 1992). However, lead poisoning from ingestion of spent lead-based ammunition fragments continues to pose a particularly serious health threat for scavenging species. These lead-containing fragments remain the principal source of lead exposure to endangered California condors and continue to prevent the successful recovery of these birds in the wild (Church et al. 2006; Finkelstein et al. 2012; Green et al. 2008; Parish et al. 2009; Rideout et al. 2012; Woods et al. 2007). Other wildlife species, such as golden eagles, bald eagles, ravens, turkey vultures, and pumas, are also exposed to the fragments of spent lead ammunition (Burco et al. 2012; Clark and Scheuhammer 2003; Craighead and Bedrosian 2008; Cruz-Martinez et al. 2012; Fisher et al. 2006; Kelly and Johnson 2011; Stauber et al. 2010; Wayland and Bollinger 1999). No rational deliberation about the use of lead-based ammunition can ignore the overwhelming evidence for the toxic effects of lead, or that the discharge of lead bullets and shot into the environment poses significant risks of lead exposure to humans and wildlife. Given the availability of non-lead ammunition for shooting and hunting (Thomas 2013), the use of lead-based ammunition that introduces lead into the environment can be reduced and eventually eliminated. This seems to be a reasonable and equitable action to protect the health of humans and wildlife.

MASSIVE HUMAN INGESTION OF ORPIMENT (ARSENIC TRISULFIDE)

BACKGROUND Because the toxicity of arsenic is well known, arsenic-containing compounds have frequently been ingested for suicidal purposes. We report a case of attempted suicide by massive ingestion of arsenic trisulfide, an arsenic mineral of low solubility, which resulted in minimal symptoms. CASE REPORT An asymptomatic 57-year-old man presented to an Emergency Department 13h after his reported ingestion of approximately 84g of arsenic contained in a mineral specimen of orpiment (arsenic trisulfide) that had been crushed and mixed with an alcoholic beverage and food. His only symptom before presentation was nausea. Physical examination was unremarkable, and diagnostic tests included a normal electrolyte panel, a normal serum lactate, and a normal electrocardiogram. An abdominal radiograph revealed hyper-dense material scattered throughout the large intestine. As per the recommendations of the regional poison center, the patient was managed with whole bowel irrigation with a polyethylene glycol solution, maintenance intravenous hydration, and observation on a telemetry unit. Chelation was not performed. A spot urine specimen collected 12h after admission contained 1490μg of total arsenic per liter (background range<50μg per liter). The patient remained asymptomatic throughout his hospital course. Follow-up studies revealed a diminution in both intra-abdominal radiopacities and urine arsenic concentration. X-ray diffraction analysis of the specimen confirmed its identity as arsenic trisulfide. CONCLUSIONS Our experience demonstrates that massive ingestion of a poorly soluble inorganic arsenic compound can be successfully managed with gastrointestinal decontamination alone without chelation, provided that the patient remains asymptomatic during close clinical monitoring.

Fatal cesium chloride toxicity after alternative cancer treatment.

BACKGROUND Cesium chloride (CsCl) is sold as a treatment for several types of cancers. The purported mechanism of action is alkalinization of relatively acidic neoplastic cells. The efficacy of CsCl has not been demonstrated in controlled experiments. Oral and intravenous CsCl use has been associated with seizures, cardiotoxicity, syncope, and death. Although intratumoral treatment with various antineoplastic agents is described, no cases of intratumoral cancer treatment with CsCl have been found in the medical literature. The case described here appears to be of the first reported patient with CsCl toxicity secondary to subcutaneous exposure after attempted intratumoral injection. CASE DETAILS A 61-year-old woman presented in cardiac arrest 20 hours after injecting 9 mL of an oral CsCl preparation around a mass in her breast. She had been taking the CsCl orally for approximately 1 year to treat her breast mass. The patient had a headache and nausea for several hours after injection and then experienced ventricular tachycardia arrest at home. She received advanced cardiac life support care and multiple antiarrhythmic medications and underwent electrical cardioversion early in the course of the arrest. After stabilization, her electrocardiogram revealed QT interval prolongation to >700 milliseconds. Upon discovery of her CsCl exposure, she was treated with Prussian blue. Her initial whole blood cesium level was 100,000 μg/L (reference range <10 μg/L). Her QT prolongation resolved after several days, but she experienced no meaningful postarrest neurologic recovery and died at home less than a week after exposure. DISCUSSION CsCl is sold as an alternative treatment for cancer. There is no demonstrable efficacy, and clear evidence shows life-threatening toxicity. Reported here is a case of fatal CsCl toxicity after attempted intratumoral injection.