Tuesday, December 25, 2007


In 2nd week of December recently, I examined one patient, 25 years old foreign worker, who was brought to our hospital's Accident & Emergency (A&E) Department around 9:00 a.m. for having severe abdominal pain associated with vomiting after taking food.
 2 week earlier, he came to our A&E with  the same problem and was treated as outpatient as a case of acute gastritis. His symptoms was relieved after given treatment.
This time, his symptoms were really severe, described as crampy abdomen and generalised body weakness. Clinical examination however showed his abdomen was soft but the bowel sound was hyperactive. Vital signs was stable. *Later examination also found he has bluish discoloration line of his gum (Burton's line) which is the sign of plumbum poisoning.(See photo on the top).
Due to severity of his symptoms , he was advised for admission.
He came with a company driver  where he works for 2 years. The company main business is battery manufacturing.
Initially I suspected the patient has Acute Gasteroenteritis (AGE) but later included Acute Lead Poisoning as the diagnosis after obtained his occupational history. His blood was sent for Lead/Plumbum level as well as full blood investigations.
Mean while  he was investigated for other causes of acute abdomen including abdominal xray(AXR) and abdomen ultrasound(AUS) and blood amylase as ordered by Physician in-charge. AXR & AUS were suggestive of subacute abdominal obstruction, however his blood amylase was normal. His Full blood counts and picture showed a feature of iron defieciency anaemia.
5 days later, his blood lead result was ready with a reading of 212 microgram/dL which is more than 5 times of normal limit as allowed by  Factories & Machinery Act(FMA) 1967 (Lead Regulations 1984) and USECHH 2000 Regulation under OSHA 1994 ( less than 40 microgram/dL).
This case is very misleading and show the importance of occupational history in history taking of the patient to get a clue to diagnose  acute lead poisoning, otherwise the diagnosis can be missed or delayed.

No comments: