title: Severe Systemic Lead Toxicity Resulting From Extra-Articular Retained Shrapnel Presenting as Jaundice and Hepatitis: A Case Report and Review of the Literature.
abstract: Despite greater than 60,000 nonfatal firearm injuries per year in the United States, retained shrapnel is a relatively rare cause of systemic lead toxicity with less than 100 cases reported in the medical literature since 1867. While intra-articular retained shrapnel as a cause of lead toxicity is well-described, extra-articular fragments are less well known to cause symptomatic disease.
  
  
  
  A 31-year-old man initially presented with abdominal pain, constipation, jaundice, and elevated liver transaminases approximately 3 weeks after suffering a left lower extremity injury during athletic activity. The patient was found to have steatohepatitis after extensive inpatient and outpatient gastroenterological workup to include upper and lower endoscopy, liver ultrasound, and biopsy of the liver to confirm the diagnosis. Imaging was incidentally notable for retained gunshot in the left flank and large shell fragment containing seroma in the left thigh. The patient was initially discharged with improved pain, but later presented to a primary care clinic with weight loss and continued pain. This was followed by a subsequent progression to diffuse weakness, ultimately resulting in an inability to ambulate. The patient was readmitted to a tertiary care medical center, 3 months after the initial presentation. Physical exam was then notable for 70-lb weight loss from initial admission and diffuse peripheral weakness with global muscle atrophy. Following a broad differential workup, he was found to have a blood lead level of 129 μg/dL, and hemoglobin of 7.7 g/dL with basophilic stippling on peripheral smear. The patient was transferred to the intensive care unit for chelation therapy with dimercaprol and calcium ethylenediaminetetraacetic acid. Lead levels initially decreased, but rose when patient was transitioned to oral therapy with succimer. Surgery was consulted for removal of multiple retained fragments, which were analyzed by the Joint Pathology Center and found to contain lead. The patient's motor function gradually improved on oral chelation and he was discharged to a subacute rehabilitation facility.
  
  
  
  This complex case describes a rare cause for a relatively common clinical presentation, jaundice and hepatitis, and reinforces the importance of longitudinal follow up and reassessment of a patient with an unknown illness and worsening clinical condition. Diagnosis of systemic lead toxicity is challenging because of its protean clinical manifestations, and relative rarity with the advent of strict environmental lead controls and decrease in lead-based paint and industrial products. Furthermore, extra-articular lead remains a rare cause of systemic toxicity, and the surgical standard of care has been to not remove these fragments in gunshot victims. This case adds to a small amount of evidence that lead screening may be of value in selected patients with extra-articular retained shrapnel, especially those with seroma and osteophyte formation in the wound.
authors.affiliation: Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building 19, Bethesda, MD 20899.
authors.forename: Ian A
authors.initials: IA
authors.lastname: Grasso
authors.affiliation: Department of Neurology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building 19, Bethesda, MD 20899.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Blattner
authors.affiliation: F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
authors.forename: Tyler
authors.initials: T
authors.lastname: Short
authors.affiliation: Department of Preventive Medicine and Public Health, Blanchfield Army Community Hospital, 2576 23rd Street, Fort Campbell, KY 42223.
authors.forename: John W
authors.initials: JW
authors.lastname: Downs
mesh_terms: D015746:Abdominal Pain / Q000209:etiology; D000328:Adult; D002614:Chelating Agents / Q000494:pharmacology / Q000627:therapeutic use; D015913:Chelation Therapy / Q000379:methods; D003248:Constipation / Q000209:etiology; D004112:Dimercaprol / Q000494:pharmacology / Q000627:therapeutic use; D005547:Foreign Bodies / Q000150:complications*; D006505:Hepatitis / Q000209:etiology; D006801:Humans; D007565:Jaundice / Q000209:etiology; D007854:Lead / Q000633:toxicity*; D007855:Lead Poisoning / Q000175:diagnosis / Q000209:etiology*; D008297:Male; D014948:Wounds, Gunshot / Q000150:complications* / Q000601:surgery
chemical_list: D002614:Chelating Agents; D004112:Dimercaprol; D007854:Lead