More fun with abdominal pain

Kathy Garcia AM Report February 15, 2012

HPI
2 year old previously healthy Somali girl Chief Complaint: abdominal pain HPI: 2-3 weeks of intermittent abdominal pain, poor appetite, and vomiting Progressive limitation of diet from regular table foods to essentially only milk Drinks >5 glasses of whole milk daily, sometimes juice Denies feeling hungry and if pushed to eat other foods will vomit Vomiting only associated with eating Intermittent episodic abdominal pain, sometimes associated with eating, but not always Recently has been seen eating non-food items (dirt, paper, paint chips, wood)

HPI continued
ROS: + constipation PMH: healthy, no hospitalizations/surgeries Had 2yr WCC yesterday Imms: UTD Meds: no medicines, herbal supplements Family Hx: family members healthy Social Hx: lives in a house with parents, 2 brothers. Family originally from Somalia but pt born in US.

Physical Exam
T 37. HR 112. RR 22. BP 101/60 SaO2 98% on Room Air. WEIGHT - 11.3 Kg, (8%ile) HEIGHT - 85 cm (6%ile) , BMI 15.6 (40%ile) GENERAL: NAD, lying comfortably on bed, cooperative with examination HEENT: normocephalic, atraumatic, PERRL, moist mucus membranes, tonsils without exudate, no pharyngeal erythema or lesions CV: normal rate, rhythm, and S1/S2, without murmur or gallop. Pulses appropriate. Capillary refill time 2 seconds LUNGS: clear to auscultation bilaterally, good air flow, no retractions ABDOMEN: soft, non-tender, non-distended with active bowel sounds and no masses or hepatosplenomegaly EXTREMITIES: all extremities warm and well perfused NEUROLOGIC: awake and alert, grossly normal strength, normal tone SKIN: no rashes, mottling, jaundice, or unusual birthmarks

DIFFERENTIAL DIAGNOSIS?

Work-Up
CBC: WBC 6.1, Hct 34, Plt 366
MCV 55, 4+ microcytosis

TIBC: 441 (NL), Iron 64 (NL), Retic count 0.4% ZPP: 388 (NL < 69) Lead: 72.9 Vitamin D: 22 KUB: normal

LEAD
Has been used since 4000 BC Lead poisoning has been recognized nearly that long poudre de la succession Plumbism from use of lead (Pb) as inexpensive pipe material

Lead Exposure
Can be inhaled or ingested Used in paint in US until 1978 In gasoline until 1995 Common sources: water (pre-1988 plumbing), food (soil along major roads), herbal remedies, glazed pottery, imported jewelry and toys Pica: paint, soil, buckshot, fishing weights

Lead Toxicity
Neurologic: irritability, decreased activity, hearing loss, peripheral neuropathy, developmental delay (particularly language), behavioral disturbance, seizures
Lead encephalopathy: acute, persistent vomiting, AMS, ataxia, seizures, coma, cerebral edema

Hematologic: decreased heme synthesis Renal: lead nephropathy (chronic interstitial nephritis) GI: lead colic sporadic vomiting, intermittent abdominal pain, constipation Endocrine: decreased Vitamin D, delayed puberty, decreased growth

Diagnosis
Blood lead level >10mcg/dL on venous blood sample Physical Exam: neurologic abnormalities, Burton lines Lab: basophilic stippling, elevated ZPP

Evaluation
Repeat venous lead level (takes 1-2 days) ZPP (only elevated if lead level >30) CBC, retic count, iron studies KUB if history of pica or ingestion of lead containing items

Management
Notify Health Department Severe (BLL >70 or symptoms of encephalopathy) -> IV chelation
Dimercaprol: aka BAL

Moderate (BLL 45-69) -> oral chelation

Succimer: aka DMSA

Mild (BLL <44)

Education, nutrition, stop exposures, recheck in 1 month

Don t Be Like These Guys