Ans. a. Lead poisoning (Ref: Parikh 6/e p9.22; Reddy 33/e p544, 31st/e p506-508)The most likely diagnosis in a young male who presented with abdominal pain for the past 2 years with complains of weakness in his hands and hemoblobin level of 8 gm/dL is lead poisoning.Lead poisoningMetallic lead and all its salts are poisonous.Principal toxic salts of Lead* Lead acetateQ (Saturn salt or sugar of lead)* Lead carbonateQ (safeda)* Lead chromateQ* Lead tetra oxide (red lead, vermillion, sindur)* Lead mono oxide (litharge)* Lead sulphide (Least toxic)At cellular level lead interacts with sulfhydryl groups and interferes in action of enzymes essential for heme synthesis, thus for hemoglobin and cytochrome production. It causes hemolysisQ.Fatal dose:Lead acetate: 20 gm; Lead carbonate: 40 gmFatal period: 1-2 daysSigns and symptoms of Lead PoisoningAcute PoisoningChronic Lead Poisoning (Plumbism, saturnism)* Astringent or metallic taste* Dry throat and thirst* Abdominal painQ, nausea and vomiting, sometimes diarrhea.* Peripheral circulatory collapseQ* Headache, weakness, insomnia, paresthesia, depression, coma and death.* Cerebellar ataxia is common in children in acute lead poisoningQ* Facial pallor Earliest and most consistent signQ* Weakness* Punctate basophilic or basophilic stipplingQ* Lead line (Burtonian lines in gums)Q* Colic (Dry belly ache)Q and constipation is late symptomQ* Sterility in males and females.* Wrist drop and foot dropQ* Vasoconstriction leads to hypertension and arteriolar degenerationQ* Lead encephalopathyQDiagnosis:Porphyrinuria (mainly due to coproporphyrin III inhibition)Stood testsUrine tests* >200 punctate basophilia stippling cells /mm3 is diagnosticQ* Zinc protoporphyrin and free erythrocyte protoporphyrin > 50mg/100mlQ* Increased lead and aminolaevulinic acid (>25mg/100ml)Q* Increased coproporphyrin (CPU) levels. In nonexposed person it is <150mg /literQ* Aminolaevulinic acid > 5mg* Presence of 0.25mg lead/liter is diagnosticQX-ray: Radiopaque matter in GI tract (ingested < 48 hours): Radio-opaque bands /lines at metaphysis of long bones in childrenQTreatment:Gastric lavage with 1% solution of sodium or magnesium sulphateQChelating agent: BAL, DMSAMost effective antidote: Calcium Disodium VersenateQIntravenous calcium chloride causes deposition of lead in skeleton from bloodQ.Peritoneal or hemodialysis.Symptomatic treatmentChronic Lead Poisoning presents with "New-A B C D E F"New* Neuropathy (leading to weakness, wrist drop) and NephropathyQ (Late feature)A* Anemia with punctate basophilia (i.e. basophilic stippling)Q (Early feature)B* Burtonian or blue stippled lead line on gumsQC* Colic (abdominal pain) and ConstipationQD* Dry belly ache i.e. diarrhea is very rareQ* Dyspepsia. Drop of wrist etc due to neuropathyQE* EncephalopathyQ, EosinophiliaF* Facial pallorQ (earliest sign)