Cholestasis and seizure due to lead toxicity: a case report

Adult Lead Poisoning Caused by Contaminated Opium: A Two-Year Longitudinal Follow-Up Study

Background:

A major episode of lead poisoning caused by lead-adulterated opium occurred in Iran in 2016. Patients were removed from exposure and treated with chelating agents. A subset of those patients was evaluated in this follow-up study to evaluate treatment efficacy in relation to patient outcome.

Methods:

Between March 2016 and December 2017, thirty-five male cases of lead poisoning due to ingestion of lead-adulterated opium were followed for two years. There are three patient groups: 1) those who abstained from opium use; 2) those who continued to use potentially contaminated opium; and 3) those who abstained from opium and were placed on maintenance therapy. Maintenance therapy included: methadone and opium tincture, offered by the Opioid Maintenance Therapy (OMT) clinics. Amongst the three patient groups Blood Lead Levels (BLL), complete blood count, and kidney and liver function tests were compared.

Findings:

The results of BLL, hemoglobin, hematocrit, and aspartate aminotransferase were significantly different between the admission time and follow-up. Of the three patient groups, no difference was detected in these measures.

Conclusions:

Treatment of lead poisoning combined with OMT proved an effective method to prevent recurrent lead poisoning.

Abdominal pain related to adulterated opium: An emerging issue in drug addicts

Lead may contaminate opium, heroin and illicit opiates and is particularly observed in Iran. Lead, a natural heavy metal is able to interfere with several organ functions after ingestion or inhalation. Lead poisoning manifestations are non-specific and thus lead poisoning remains difficult to diagnose. Among the manifestations, abdominal pain is almost the most frequent symptom causing patients to seek medical care. In patients with a history of opium addiction presenting with moderate-to-severe abdominal pain, lack of diagnosis of lead toxicity may thus result in time-consuming and unnecessary medical work-ups that can end up in invasive surgery. This paper aims to briefly review abdominal pain as an emergency issue and the leading symptom of lead poisoning that brings most of the patients to healthcare facilities. All published adult cases and case series of opium addicts admitted with abdominal pain due to lead-adulterated opium consumption have been reviewed. A trend of increasing numbers of lead poisoning cases has recently emerged among opium addicts in Iran. Due to the non-specific manifestations and hazardous effects, psychiatrists and emergency physicians should consider lead poisoning in patients with a past or present history of opium addiction referred for acute abdominal pain, particularly in case of colicky abdominal pain.

Lead Poisoning in Opium Abuser in Iran: A Systematic Review

Substance abuse and its consequences are major health hazards in the world. Opium addiction is a common form of substance abuse in Iran. Adulteration of illegal substances in the process of production and distribution of the drug in black market with many types of materials have been reported. One of the main goals of the adulteration of illegal substances is cutting of the substance for deal and increase of the weight for more benefit. However, adding of adulterating agents to illegal drugs could be considered as a cause of nonspecific and rare toxicity during substance abuse. Although the presence of lead in street-level heroin, marijuana, and amphetamines has been reported from some countries previously, recently, several reports suggested lead poisoning in Iranian opium addicts. Adulteration of opium with lead is a new source of lead poisoning in Iran in which the opium abuse is frequent and it could be a new health problem in the future. In this regard, evaluation of blood lead level would be important for early diagnosis of lead poisoning in opium addicts.

Clinical Aspects of Opium Adulterated with Lead in Iran: A Review

Adulteration of drugs with poisonous substances during production or consumption has caused numerous health problems. Among contaminants that have the potential of producing poisonous effects are the heavy metals lead, arsenic and thallium that make up an important group of toxic substances. The emergence of these new health problems related to opioid abuse has precipitated this MiniReview on the status of the most hazardous and common opioid adulterants. In fact, adulterated opium is a major public health problem and can threaten the health of users. In this study, we searched for information on opium, opiates, lead poisoning, toxicity, intoxication, Iran and heavy metals in the TUMS Digital Library, PubMed, Scopus, EMBASE and Google Scholar bibliographical databases. This MiniReview primarily included articles on lead poisoning, signs and symptoms, and management in opioid-dependent individuals. Exclusion criteria were articles dealing with animal studies, specific paediatric studies, adulterants other than heavy metals and substances other than opioids. Adulterated opium is one of the new sources of exposure to lead and has precipitated an increase in lead-poisoned cases owing to the widespread use of opium. The toxicology of lead and general guidelines on diagnosis and treatment of lead poisoning is briefly reviewed. The symptoms of lead toxicity mimic several diseases often leading to unnecessary diagnostic methods, misdiagnoses and even surgery. Finally, owing to the fact that lead toxicity shows non-specific signs and symptoms, screening for this disease, by taking blood samples and assessing blood lead levels in high-risk people, should be given an utmost priority. It is recommended that screening tests are adopted and applied for any drug-abusing patient with non-specific subacute signs and symptoms like abdominal pain, constipation and anaemia.

Lead poisoning among opium users in Iran: an emerging health hazard

Background

Lead (Pb) poisoning among people using opium has been an increasing problem in Iran. The present study highlights the clinical effects of lead toxicity associated with opium use in Iran, Kerman province.

Methods

Between January 2016 and June 2016, patients with signs and symptoms of Pb poisoning were questioned to assess whether they had a history of opium dependency. In total, 249 patients were enrolled onto this cross-sectional study, all were opium dependent. Para-clinical data including blood lead level (BLL), demographic information, user preferences, and symptoms were obtained.

Results

The patients used either opium (83.9%), refined opium (6.4%) or a combination of both (9.7%) via ingestion (71.9%), smoking (8.4%) or a combination of both (19.7%). The overall median BLL was 80.0 μg/dL [IQR: 51.7–119.0]. The median BLL did not differ significantly between opium and refined opium users. Further, BLL was not significantly affected by the type of substance, route of use, duration of use, or daily quantity consumed. Common symptoms included abdominal pain (86.9%), constipation (75.8%), anorexia (71.5%) and nausea (54.7%). Linear regression analysis showed log of BLL was significantly associated with abdominal pain, myalgia and anorexia.

Conclusions

The study unravelled an increase in opium-related Pb poisoning in the Kerman province. Raised awareness of this emerging Pb source and investigation of its aetiology is recommended. Pb poisoning should be considered among the primary differential diagnosis of opium users with gastrointestinal symptoms.

Severe Abdominal Pain Caused by Lead Toxicity without Response to Oral Chelators: A Case Report

A 19-year-old woman was referred to the Emergency Surgery Department with severe abdominal pain, icterus, and anemia. The patient’s clinical and paraclinical findings in addition to her occupational and social history, convinced us to assay blood lead level (BLL), which was 41/5 μg/dL. Therefore toxicology consult was performed to treat lead toxicity.

Recheck of the BLL showed the level as 53/7 μg/dL. So oral chelator with succimer was started. Despite consumption of oral chelator, there was no response and the pain continued. Because our repeated evaluations were negative, we decided to re-treat lead poisoning by intravenous and intramuscular chelators. Dimercaprol (BAL) + calcium EDTA was started, and after 5 days, the pain relieved dramatically and the patient was discharged.

We recommend more liberal lead poisoning therapy in symptomatic patients, and also suggest parenteral chelator therapy, which is more potent, instead of oral chelators in patients with severe symptoms.

Comparison of serum and urine lead levels in opium addicts with healthy control group

CONTEXT

Lead-contaminated opium is one of the new sources of lead exposure in our region. As far as the literature review is concerned, there are limited comparative studies about comparison of blood lead level (BLL) in addict patients with healthy controls.

OBJECTIVE

We aimed to compare BLL and urine lead level (ULL) between opium addicts with the healthy control group.

MATERIALS AND METHODS

Forty opium addict subjects (mean age: 43 ± 10 years) as the patient group and 40 healthy subjects (mean age: 41 ± 9 years) as the control group participated. Three milliliter of whole blood and urine was obtained from both groups and lead level was assessed using atomic absorption spectrophotometry.

RESULTS

The mean value of BLL in patient group was 7.14 ± 1.41 mcg/dL and that in the healthy control group was 5.42 ± 1.46 mcg/dL. The mean value of ULL was 2.62 ± 0.83 mcg/dL in the patient group and 2.50 ± 0.76 mcg/dL in the healthy control group.BLL was different in the two groups (p < 0.001), but ULL was not (p = 0.5). There was a significant correlation between BLL with duration of opium addiction in the patient group (r = -0.403, p = 0.01). BLL and ULL were significantly correlated in controls (r = 0.436, p = 0.005) and not in patients.

DISCUSSION AND CONCLUSION

It was observed that the BLL in opium addicts was significantly higher than that in the healthy control group. This can be due to use of adulterated opium with lead. Therefore, screening of blood lead concentration is helpful for opium-addict patients especially with nonspecific symptoms.