2 3 ) ( ) ( ) (

2  3 )  (          )  (        )  (

2

3 ) ( ) ( ) ( ( ) ( ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) (

)) ) ( ( ) ) ( ) ( 4 Lead in Jewelry 5

6 . . . . . .

. - . ( ( . ) . . ( . . . C . . 7

. . ( ( . . . . . . . . 8

( / ) . No blood level of lead is considered safe. 10 g/dL as the level of concern . . . . Lead poisoning is said to be the most common environmental illness of children in the United States.

9 RBC - (

) . (hippocampus, ).cerebellum, cerebral cortex, medulla . . 10

. . GFR RPF . . . . . . 11 :

. . . ( )OH, SH,NH2 . . . ( . .

. . ( 12 13 14

. . . . ( 15 . .

. ( . Neurotoxicity 16 The neurotoxicity of lead involves multiple targets, including cerebrovascular endothelium, mitochondria, neural cell adhesion molecules, neurotransmitter and second-messenger function,regulation of apoptosis, and myelin formation.

. . Alzheimer disease . . . ICP . . . ( . ) (

. . IQ ( 4.6 7.4) CT scan of the brain reveals diffuse cerebral edema and loss of gray-white matter differentiation on day 1 of hospitalization of a 3 year-old boy. He had presented with a brief prodrome of vomiting and altered mental status followed by status epilepticus, characteristic of acute lead encephalopathy. His blood lead concentration was 220 g/dL. 17 Magnetic resonance image of the brain reveals cortical atrophy and multiple areas of cerebral infarction in the same patient 18

Encephalopathy 19 characterized by pernicious vomiting and apathy, bizarre behavior, loss of recently acquired developmental skills, ataxia, incoordination, seizures, altered sensorium, or

coma. (cerebral edema and increased ICP ) Physical examination may reveal papilledema, oculomotor or facial nerve palsy, diminished deep tendon reflexes, or other evidence of increased ICP. 20 Encephalopathy usually occurs in children ages 15 to 30 months; is associated with BLLs above 100 g/dL, although it is reported with BLLs as low as 70 g/dL; and tends to occur more commonly in summer months

Mortality caused by encephalopathy was 65% in the prechelation era, decreasing to below 5% with the advent of effective chelation. The incidence of permanent neurologic sequelae, includingmental retardation, seizure disorder, blindness, and hemiparesis, is 25% to 30% in patients who develop encephalopathic symptoms before the onset of chelation

21 BLL>150 g/dL seizures )75% of cases(, obtundation, confusion, focal motor disturbances, papilledema, headaches, and optic neuritis Hematologic Toxicity 22

heme . . RBC . pyrimidine-5-nucleotidase RNA . basophilic stippling PBS

. This peripheral smear of blood examined under high-power microscopy demonstrates the classic basophilic stippling associated with lead poisoning. The patients blood lead concentration was over 100 g/dL. 23 Nephrotoxicity 24 ) Aminoaciduria, Glycosuria, Phosphaturia( . interstitial fibrosis

( ) Renal adenocarcinoma ()Saturnine gout , . . g/dL 5 ( . . .

Cardiotoxicity 25 . ( ) . . The association is particularly strong for adult men ages 40 to 59 years, with an approximate 1.5 to 3.0 mm Hg increase in systolic pressure for every doubling of BLL beginning at 7 g/dL.

Reproductive Toxicity 26 Impairment of both male and female reproductive function , Reduction in libido Gametotoxic effects chromosomal abnormalities, infertility Testicular endocrine hypofunction

Women experience an increase in the incidence of stillbirth, spontaneous abortions, pregnancy induced hypertension and prematurity.( reproductive effects occur at relatively low levels of exposure) Endocrine Toxicity 27 - .

syndrome of inappropriate excretion of (antidiuretic hormone )SIADH Skeletal Toxicity 28 .

Bands of increased metaphyseal density on radiographs of long bones )lead lines( in young children with heavy lead exposure represent increased calcium deposition These lines represent periods of growth arrest, not lead toxicity . other metals )arsenic , bismuth, and mercury(, healing rickets, and recovery from scurvy Radiograph of the wrist and knee reveals increased bands of calcification )lead lines( 29

Gastrointestinal Toxicity 30 Constipation Anorexia, nausea, vomiting colicky abdominal pain spasmodic contraction of intestinal wall smooth muscle . . . . . .

Children )typically nonspecific( 31 Temperamental lability, irritability, behavioral changes, Hyperactivity or decreased activity Loss of developmental milestones, language delay, Abdominal pain, loss of appetite, vomiting, constipation, Headache, ataxia, somnolence, Lethargy, seizures, stupor, coma

The presence of fever does not rule out the diagnosis, Lead line on gingival border 32 Wrist drop in adult with lead poisoning and renal failure 33 Clinical Manifestations of Lead Poisoning in Children 34

Clinical Manifestations of Lead Poisoning in Adults 35 36 37 DIAGNOSTIC TESTING Clinical Diagnosis in Symptomatic Patients 38

comprehensive medical history: environmental, occupational, or recreational sources of exposure, history of pica or acute unintentional, ingestions, foreign bodies, history of irondeficiency anemia , deteriorated paint Children: Adults: persistent vomiting, lethargy, irritability, clumsiness, or loss of recently acquired developmental skills; afebrile seizures; or evidence of

child abuse or neglect gunshot wounds with retained bullets, occupational exposure 39 Lead encephalopathy can be strongly considered with positive supportive laboratory findings such as anemia, basophilic stippling, elevated erythrocyte protoporphyrin )especially >250 g/dL(, and abnormal urinalysis.

radiologic findings of dense metaphyseal lead lines at wrists or knees, or evidence of recent pica for ingested foreign bodies or lead paint particles on abdominal radiographs. 40 41 . . 42 ( ( . ( (PBS) basophilic stippling

elevated erythrocyte protoporphyrin ()especially >250 g/dl abnormal urinalysis radiologic findings of dense metaphyseal lead lines at wrists or knees The BLL is typically determined by atomic absorption spectrophotometry.

43 : DT zone test . )

. . BLL Blood Lead Level: Electroencephalography )EEG( may be normal or may show nonspecific findings. Provocative chelation test: )CaNa

2 (EDTA ( 44 )Baseline CT Scan (, Routine serum chemistries, BUN/Cr, LFT, CBC, Ca, U/ A, BLL BLL . ( . BLL . ( .

. 45 Acute CNS infection )bacterial meningitis or )herpetic encephalitis LP ICP . CT (> )mL 1. . carpal tunnel syndrome, Guillain - Barr syndrome, sickle cell crisis, acute appendicitis, renal colic, infectious encephalitis.

Children are often initially considered to have viral gastroenteritis Differential Diagnoses 46 Acute Anemia

Chronic Anemia Confusional States and Acute Memory Disorders Constipation in Emergency Medicine Depression and Suicide

Diabetic Neuropathy Emergent Management of Guillain-Barre Syndrome Epileptic and Epileptiform Encephalopathies

Frontal Lobe Syndromes Gout and Pseudogout Heavy Metal Toxicity Mercury Toxicity

Organic Solvent Neurotoxicity Radial Mononeuropathy . . 47

/. . . . : . PEG . ( ) .

48 . . . Any BLL higher than 10 g/dL is considered positive and consequential. Patients with BLLs between 10 and 20 g/dL require removal from the exposure, repeated testing, and follow-up.

. 49 ( ( . . ) . . ( ) BLL . . . . . .

. . . . . 50 . BLL . ( . - .

CaNa2EDTA . BAL succimer . ( ) . . .. some clinicians suggest that adults with severe lead poisoning may be successfully treated with CaNa2EDTA alone in doses of 2 to 4 g/d by continuous IV infusion.

and 51 and and and or 52 D-Penicillamine 53

( . ) . . ( - : - PO

- : . PO . . . . . . . ( . 54 : : ( . . . . . . ( . . . .

: . . . . (SUCCIMER )DMSA 55

. ( BAL CaNa2EDTA. . . . . D-Penicillamine . : . . :

. . . 56 ..... ( ( ) 2/3 1/3 ..... . . ( . ) HCO3<30 PH<7.50 ( PH 12 ( PH <8 >7.5 ) . 500 ( . )

. . 57 ) mg/kg 4( 200

10-5 IM . 250 ( ( . . ) ( ) . . . 58 . . . (> 15 ) . .

WBI ( PPI . . ..

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