Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management

Lead intoxication (plumbism) from retained bullets has rarely been reported but may be fatal if unrecognized. Bullets lodged within joint spaces or pseudocysts are more likely to develop this complication, although patients with retained missiles in other locations may also be at risk. Subtle findings such as the occurrence of unexplained anemia, abdominal colic, nephropathy, or neurologic deterioration in patients with retained missiles may suggest consideration of plumbism. An intercurrent metabolic stress such as infection, endocrinopathy, or alcoholism may be a precipitating factor. Among the various diagnostic studies available, mass spectrometric stable isotope dilution analysis may be the most reliable. It is important to employ chelation therapy prior to any operative intervention. This will reduce the mobilization of lead from bone during or following the surgical procedure.