A case of abdominal colic presented with bilateral wrist drop and anemia working in Battery factory without protection as contract labor in India.

1. Lead Poisoning in
Neurology
Dr. P.S. Deb
Sr. Consultant Neurology
SSSIHMS Bengaluru

2. History
● GS 45/M
● DOA 25th May DOD -31st May 2019
● Presenting Hx
○ Abdominal pain x 2 years, Visited several physician and undergone endoscopy and treated as
gastritis, and later Ulcerative colitis
○ Gum discoloration
○ Unable to use both hand due to weakness
● Occupation : Battery worker

3. Examination
● Pallor
● Gum discoloration black and poor
hygiene
● BP 120/80mmHg
● Bilateral wrist drop
● Abdomen no tenderness or lump
Diagnosed as Lead Poisoning

4. Investigation
● Hb 6.5gm%
● Peripheral smear: Basophilic stippling
● Blood lead level : 68.5mcg/dl
● LFT, RFT, TFT Normal
● NCV: Bilateral Radial and Median motor neuropathy

5. Treatment
● Penicillamine 500mg b.d. 3 weeks in a month x 3 months
● Ca, Mg, Zn
● Vitamins
● Follow-up
○ Pain in abdomen improved and started eating
○ Mild improvement of wrist weakness

7. Burden of lead related diseases
● 0.6% of the global burden of disease.
● 2016 lead exposure accounted for 540 000 deaths and 13.9 million years of healthy
life lost (disability-adjusted life years (DALYs)) worldwide.
● The highest burden was in low- and middle-income countries.
● 63.8% of the global burden of idiopathic developmental intellectual disability,
● 3% of the global burden of ischemic heart disease and
● 3.1% of the global burden of stroke .
Institute for Health Metrics and Evaluation (IHME)

8. Economic cost of Lead poisoning in Children

9. LEAD TOXICITY: AN OVERVIEW OF PREVALENCE IN INDIANS.
IYER S1, SENGUPTA C1, VELUMANI A1.
● George foundation St Jon's Medical college Bengaluru in 1998-99
analysed BLL of Large cities across India of 222,668 cohort.
● Sex: 121,115 M and 101,553 F
● Age : <2 to >55 years
● 1.16% had high lead level.
● Males were affected more than females

10. PREVALENCE OF ELEVATED BLOOD LEAD
LEVEL IN CHILDREN OF INDIA
VOL. 17, NO. 3, 2018 NATURE ENVIRONMENT AND POLLUTION TECHNOLOGY
● 47% of Indian children have elevated BLL (10mcg/dl),
● The low value 5mcg/dl is associated with impaired intelligence in
long term

11. Statue of Balikligol at the Cradle of Civilization
● In 1963 Professor Klaus Schmidt, in Göbeklitepe, known as the “zero point in history” in
southeastern Turkey found the oldest lead artifact about 11500 years old.
● 3000 B.C. Babylonians used soldered lead sheet to fasten bolts and construct building
Balıklıgöl Statue
Göbeklitepe City of Abraham

12. 3000-4000 B.C. Egyptian used cosmetic kohl
Egyptian miners died of lead poisoning 3000-300 B.C.
PbS – Galena

13. Lead Coins
● 2000 B.C. Chinese used to make coin
● 300 B.C. Greeks used to make coin
● Hippocrates described lead poisoning : Loss of appetite, Weight loss,
Fatigue, Pallor, Colic, Irritability and Nervous Spasm.

14. Roman used lead most extensively
● To coat water tank and join pipes (plumber)
Lead pipes, such as these discovered in Bath, England, were used for
plumbing by ancient Romans.

15. Salt of Saturn and Saturnine Gout
● By boiling acidic wine in lead-lined vessels yields a
sweet syrup due to the formation of lead acetate (Sapa).
● Lead acetate is also known as sugar of lead, salt of
Saturn,, is a white crystalline chemical compound with a
sweetish taste.
● A form of lead intoxication known as saturnine gout
takes its name from ancient Rome.
● Saturn was a demonic god, a gloomy and sluggish
figure who ate his own children.

16. LEAD POISONING AND THE FALL OF ROME
• Aristocracy and patricians made extensive use of wine and food sweetened by sapa, of lead
plumbing, and of lead-lined storage vessels
• The widespread behavioral and neurological deficiencies of the Roman Emperors were due to
lead intoxication.
• Increasing evidence that there was an epidemic of gout and rampant lead intoxication among
the patricians of ancient Rome, 1965, Gilfillan

17. First Prohibition on Wine adulteration by “Sapa”
● French and Spanish authorities issued edicts in 1427
prohibiting the addition of sapa to sweeten wine.
● in 1478, German authorities made wine adulteration a crime
punishable by death

18. Modern – Industrial Revolution
Electrical Storage batteries, solder
Fermented beverages Fortified wines, moonshine
Glass Leaded glass and art objects
Glazing Litharge, caulk
Metal reclamation Gold, silver, lead, iron, etc
Metal tubing Pipes and solder
Mining Lead release from ores
Munitions Guns and ammunition
Oil Leaded gasoline, tetraethyl lead
Paint Red and white lead pigments
Patent medicines Herbal medicines
Pottery Lead glazes and tableware
Printing Leaded types and inks
Ship and bridge repair Flakes of leaded paint
Silverware Silver and pewter objects
Smelting Atmospheric lead and slag

21. Use of Lead in India

22. Large‐scale mining for lead at Rajpura‐Dariba goes back to
circa 3000 years

23. sisarupa (lead) : Arthashastra of Chanakya

24. The Satvahanas lead coins 3C BC 2C AD
The Ikshvaku lead coins 3C AD
Hiranyaka Lead Coins . 3rd-4th C AD

25. Kohl (surma)

27. Lead in Ayurvedic Medicine

28. • The team visited 15 Indian specialty stores in the Boston area and purchased 71
cultural powders and 86 spices and food products.
• About 25% of the food items, including spices such as cardamom, fenugreek and
chili powder, contained more than 1 microgram of lead per gram of product
• About 65% of the ceremonial powders, including sindoor, contained the same
amount

31. Lead oxide in Black paste

32. 42 rivers have an extremely high concentration of neurotoxic heavy
metals
Ganga was found to be polluted with five heavy metals, namely
chromium, copper, nickel, lead and iron

33. Significant traces of lead was found
in ambient air samples near a
kerbside monitoring site set up on
Mathura Road by researchers from
the IIT-Delhi.

34. PROJECT LEAD FREE
● The National Referral Centre for Lead Poisoning in India (NRCLPI), set
up 1998 on the St. John's Medical College campus here, has embarked on
a project to prepare the "Lead Map of India"
● In April 2000, all three oil companies announced the introduction of
unleaded petrol throughout India. The government regulated that all
automobiles use unleaded petrol with immediate effect.
● Regulation on Lead contents in Household and Decorative Paints Rules, 2016
The Ministry of Environment, Forest and Climate Change (MOEFCC),an