Lead Shot in the Appendix
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《新英格兰医药杂志》
To the Editor: Cox and Pesola (Dec. 29 online issue)1 describe lead-shot accumulation in the cecal appendix of an Alaskan native, which was probably caused by the ingestion of shotgun-culled waterfowl. Their description did not mention the potential for lead absorption and systemic toxicity. Blood lead levels almost twice those of controls may be found after sequestration of just one or two shot pellets in the appendix2; a toxic level of lead (67.4 μg per deciliter) was reported after the retention of 29 pellets.3 The authors' comment that shot in the appendix is commonly seen in Alaskan natives suggests an important public health concern. Presentations of adult lead poisoning (plumbism) range from nonspecific symptoms to acute encephalopathy. Children absorb lead more readily than do adults, which can result in reduced IQ; the fetus is particularly susceptible. Interventions include screening, medical management, public health education, and promotion of the use of steel shot instead of lead. Within the indigenous community, reduced lead levels would confer substantial health benefits.
Leo J. Schep, Ph.D.
John S. Fountain, M.B., Ch.B.
National Poisons Centre
Dunedin 9001, New Zealand
john.fountain@otago.ac.nz
References
Cox WM, Pesola GR. Buckshot ingestion. N Engl J Med 2005; 353:e23 (Web only). (Available at http://www.nejm.org/cgi/content/full/353/26/e23.)
Madsen HH, Skjodt T, Jorgensen PJ, Grandjean P. Blood lead levels in patients with lead shot retained in the appendix. Acta Radiol 1988;29:745-746.
Durlach V, Lisovoski F, Gross A, Ostermann G, Leutenegger M. Appendicectomy in an unusual case of lead poisoning. Lancet 1986;1:687-688.
The authors reply: In 1991, the United States instituted a nationwide ban on lead shot for waterfowl hunting, owing in part to the concern regarding lead toxicity from this practice. Unfortunately, the ban does not extend to all hunting; thus, there is a risk to hunters and others who inadvertently eat lead from their catch.1 Countries such as Denmark and the Netherlands have a complete ban on lead for hunting; alternatives to lead shot include bismuth, steel, tin, and tungsten. Therefore, a solution to lead ingestion and potential toxicity problems is present.
As Schep and Fountain suggest, it is reasonable to screen for lead when shot is found in the appendix during radiography. If an elevated lead level is found, appropriate action should be taken. We did not know the blood lead level in the patient in our report, since she had been sent for radiography some years earlier. In the future, all such testing will include a suggestion to obtain a lead level in similar clinical situations.
William M. Cox, M.D.
Norton Sound Regional Hospital
Nome, AK 99762
Gene R. Pesola, M.D., M.P.H.
Mailman School of Public Health
New York, NY 10032
References
Gustavsson P, Gerhardsson L. Intoxication from an accidentally ingested lead shot retained in the gastrointestinal tract. Environ Health Perspect 2005;113:491-493.
Leo J. Schep, Ph.D.
John S. Fountain, M.B., Ch.B.
National Poisons Centre
Dunedin 9001, New Zealand
john.fountain@otago.ac.nz
References
Cox WM, Pesola GR. Buckshot ingestion. N Engl J Med 2005; 353:e23 (Web only). (Available at http://www.nejm.org/cgi/content/full/353/26/e23.)
Madsen HH, Skjodt T, Jorgensen PJ, Grandjean P. Blood lead levels in patients with lead shot retained in the appendix. Acta Radiol 1988;29:745-746.
Durlach V, Lisovoski F, Gross A, Ostermann G, Leutenegger M. Appendicectomy in an unusual case of lead poisoning. Lancet 1986;1:687-688.
The authors reply: In 1991, the United States instituted a nationwide ban on lead shot for waterfowl hunting, owing in part to the concern regarding lead toxicity from this practice. Unfortunately, the ban does not extend to all hunting; thus, there is a risk to hunters and others who inadvertently eat lead from their catch.1 Countries such as Denmark and the Netherlands have a complete ban on lead for hunting; alternatives to lead shot include bismuth, steel, tin, and tungsten. Therefore, a solution to lead ingestion and potential toxicity problems is present.
As Schep and Fountain suggest, it is reasonable to screen for lead when shot is found in the appendix during radiography. If an elevated lead level is found, appropriate action should be taken. We did not know the blood lead level in the patient in our report, since she had been sent for radiography some years earlier. In the future, all such testing will include a suggestion to obtain a lead level in similar clinical situations.
William M. Cox, M.D.
Norton Sound Regional Hospital
Nome, AK 99762
Gene R. Pesola, M.D., M.P.H.
Mailman School of Public Health
New York, NY 10032
References
Gustavsson P, Gerhardsson L. Intoxication from an accidentally ingested lead shot retained in the gastrointestinal tract. Environ Health Perspect 2005;113:491-493.