An unusual source of lead poisoning in a family

A two-year-old boy was hospitalized for anemia with loss of appetite, nausea, vomiting, and abdominal pain for one week. Due to an exhaustive but unremarkable laboratory and imaging evaluation for anemia and the patient’s nonspecific symptoms, a comprehensive review of his medical history was conducted, lead toxicity was accordingly considered. The patient was native to the Tibetan Autonomous Prefecture, China. He lived with his parents (mother, 28 years of age; father, 37 years of age), sibling (1month of age), uncles (uncle1, 43 years of age; uncle 2, 28 years of age), and grandfather (57 years of age). The entire family, except the patient’s sibling, had a daily intake of “ManjusriZenghuiGanlu Pills” (Figure 1), which were manufactured at a local temple. No packaging information indicated the metal content of the pills. Bone marrow biopsy and peripheral blood spears showed extensive basophilic stippling characteristic of lead poisoning (Figure 2). Testing of the pill by inductively coupled plasma spectrometry showed a lead concentration of 223 g/kg (22% lead). His blood lead level (BLL) was 965lg/L (reference 1–100 lg/L), and his urine lead level was 238.6 lg/L (reference 0–70 lg/L). All family members had elevated BLL (Figure 3). The lead concentration corresponded with frequency of pill consumption. For the one-month-old sibling, breast milk was the only source of food. The patient underwent lead chelation therapy by intravenous infusion of dimercaptosuccinic acid (600mg/d) for 19 days with multivitamins supplement during hospitalization, and oral dimercaptosuccinic acid (400mg/d) after discharge. We continued to follow-up the patient for six months, recording his blood concentrations of lead (Figure 3). Rebound in his blood lead may be related to the mobilization and redistribution of bone lead. Moreover, the patient’s family members were advised to stop taking the pills, and his mother was also advised to terminate breastfeeding. Besides, his family received lead chelation therapy by intravenous infusion of CaNa2EDTA (mother and uncle 2, 1 g/d; sibling, 400mg/d) for five days during hospitalization, and oral dimercaptosuccinic acid (mother and uncle 2, 1500mg/d) after discharge. Through further inquiry, we learned that people in this region customarily took these pills. Hundreds of local people who took the pills showed elevated BLL. More than one hundred people in the same village had BLL exceeding 450ug/L. Lead poisoning in children is serious with permanent damages. Elevated blood lead concentration may be correlated with autism spectrum disorder, cognitive dysfunction, and intellectual impairment [1,2]. Lead exhibits high milk-toplasma ratios, so maternal lead exposure is a key source of lead poisoning in breast-feeding infants [3]. In recent years, lead poisoning from ingestion of traditional folk medicine and cultural products has been increasingly reported [4–6]. Consecration is a daily blessing performed in Buddhist ceremonies. Devotees ingest religious consecration pills from these ceremonies daily without any prior knowledge as to their production date or ingredients. Convincing the religious leaders and followers that these pills may cause harm would require sensitization toward cultural beliefs and traditions.