Severe lead toxicity attributed to bullet fragments retained in soft tissue

Abstract

A man aged 30 years presented to an emergency department with a 1 month history of severe abdominal pain, jaundice, constipation, lower extremity weakness and weight loss. A peripheral blood smear was performed that showed basophilic stippling of erythrocytes prompting a blood lead level (BLL) evaluation. The patient had a BLL of >200 µg/dL. Retained bullet fragments were identified in the left lower extremity from a previous gunshot wound 10 years prior. Lead from the excised bullet fragment was consistent with the patient's blood lead by isotope ratio analysis. This case is a rare example of a severely elevated BLL attributed to bullet fragments in soft tissue. Bullets retained in soft tissue are not often considered a risk factor for a markedly elevated BLL because they become encapsulated within the tissue over time.

Gunshot Wounds: Ballistics, Pathology, and Treatment Recommendations, with a Focus on Retained Bullets

“…Injuries which result in retained bullet fragments carry a small but identifiable risk for plumbism or lead toxicity, defined as blood lead ≥10 μg/dL, which have been reported to occur within 2 days to 40 years of GSW. 148,195,196 Unfortunately, lead toxicity can be difficult to predict and diagnose. 197,198 Symptoms including headache, fatigue, nausea, abdominal discomfort, anemia, kidney failure, encephalopathy, and neuropathy typically only occur at serum lead levels of >24 μg/ dL.…”

“…199 Plumbism may lead to neurotoxicity, cognitive dysfunction, peripheral neuropathy, anemia, chronic fatigue, emesis and nausea, decreased fertility, abnormal menstrual cycles, abdominal colic, and renal disease. 196,202,208 Even in asymptomatic adults, long-term exposure of low amounts of lead, may still bring about lasting consequences in renal, cardiovascular, cognitive function. 199 While only 0.3% of US adults with elevated blood lead levels can be attributed to retained bullet fragments, high levels ≥80 μ/dL are more likely to occur in these persons.…”

Gunshot-Related Injuries to the Foot & Ankle: Review Article

“…Similar to the hand, projectiles may be located where they can cause discomfort or mechanical problems, such as the sole or the dorsum of the foot, and should be removed. Additionally, it is recommended to remove bullets when they are in a joint due to the potential mechanical trauma with subsequent arthritis and loss of function, and bullet lead toxicity can damage the cartilage 14,46,50 (Figure 3).…”

How Decomposition and Processing Affect Metallic Particles From a Bullet in Gunshot Defects

“…Bullets and bullet fragments may be embedded and retained in the hard and soft tissues of the bullet tract (Weiss et al, 2017). Hollow-point (HP) bullets expand upon impact with a target as a result of their open tips.…”

“…This may also result in a decreased frequency of embedding in the target and a greater rate of entrance-exit defects. Bullet fragmentation and retainment have been studied at length (Fackler, 1986;Langley et al, 2018;Weiss et al, 2017); however, the samples were not exposed to environmental and taphonomic processes when analyzed, which could significantly influence the radiographic detection of bullets and metallic fragments.…”