A 3-year-old male was brought to the emergency department (ED) by his mother, who reported the sudden onset of a rash (hives) covering his entire body, with no rash on his palms and soles. No other complaints were noted. The child’s skin appeared warm and dry. A review of systems revealed no abnormal findings. Vitals were within normal limits, with a pulse of 129, respiratory rate of 25, and oxygen saturation of 98 percent. On physical examination, the child was non-toxic, well-nourished, alert, awake, and not in acute distress. The child was diagnosed with hives and discharged to home with symptomatic management.

The next day, the patient’s mother was called to come to the emergency department with the patient due to abnormal labs. The patient had an abnormal lead screening test at age 2 and was advised to receive a comprehensive lead screening evaluation, which he did approximately one year later, shortly prior to this ED visit. Incidentally, the day after ED visit number one, the mother was called by the child’s pediatrician advising her to bring him for evaluation of lead poisoning. The initial laboratory results were abnormal, with a lead level of 56.9 μg/dL, hemoglobin of 6.4 g/dL, hematocrit of 23.9 percent, mean corpuscular volume of 53 fL, mean corpuscular hemoglobin of 14 pg, mean corpuscular hemoglobin concentration of 26.4 g/dL, and red cell distribution width of 20.84 percent.

FIGURE 1: Abdominal X-ray showing particulate radiopaque foreign bodies involving the stool. (Click to enlarge.)

A peripheral smear revealed mild anisocytosis, ovalocytes, hypochromia, microcytosis, and poikilocytosis. Blood type and screen, COVID-19 tests, and ECG were all within normal limits. An abdominal X-ray revealed particulate radiopaque foreign bodies involving the stool. The mother revealed a history of elevated blood lead levels when the child was two years old, indicating a previous exposure. The family had since relocated to a lead-safe environment. In the emergency department, consultations were made with the regional poison-control center and the regional lead center. A decision was made to transfer the patient to a tertiary center with inpatient pediatric capabilities. The patient was subsequently transferred to another medical center for treatment of anemia and lead chelation.

Discussion

Lead poisoning is a serious health concern. It can present in acute and chronic forms. It can occur due to accidental ingestion or occupational or environmental exposure.¹ Children are particularly vulnerable.² According to the latest definitions from the Centers for Disease Control and Prevention, blood lead concentrations equal to or exceeding 5 μg/dL are classified as elevated levels in both adults and children.^3-5 Exposure to lead in humans can occur through a range of sources, encompassing lead-based paints, leaded gasoline, lead-containing pipes, lead smelting, coal combustion, and occupational activities like battery recycling.⁶ Lead poisoning primarily occurs through two main routes: ingestion and inhalation. Ingestion is more prevalent among children due to their inclination to put objects in their mouths, whereas inhalation is a more common route of exposure in occupationally exposed adults.⁷ The human body can store lead in specific tissues, including bones, teeth, hair, and nails, where it forms tight bonds and appears to be relatively inert, posing less immediate harm as it is less available to affect other bodily tissues.⁸ Interestingly, in children, approximately 70 percent of the absorbed lead accumulates in their bones, whereas in adults, a higher proportion, around 94 percent, is deposited there. This difference in lead distribution may contribute to the more pronounced clinical effects of lead poisoning in young children.⁹ Lead exerts its toxic effects by interfering with various organ functions, primarily targeting the nervous system and hematopoietic system, as well as impairing liver and kidney functions.³