This is a 7-1/2 year old boy who loves to juggle.  
One day he was juggling dice and accidentally 
swallowed one of the dice.  He did not tell his mother 
until 3 days later.  She brought him to the emergency 
department where a radiograph was obtained.

View radiograph.

     Is there anything we should be concerned about?  If 
dice are inert, then it is likely that it would pass 
spontaneously in the stool after it passes into the 
stomach.
     The radiograph revealed that the die (a single dice) 
was in his stomach.  For the next 7 days, he was 
ordered to strain his stool to recover the die.  This was 
unsuccessful.  After 7 days, he was given a 
polyethylene glycol and saline cathartic to accelerate 
passage of the die.  Still... "No dice."  At this point, a 
second radiograph was taken.

View follow-up radiograph.

     This follow-up radiograph shows that the die has 
not moved much.  Although dice may seem inert, some 
dice contain lead.  This may not be immediately 
obvious.  A serum lead level was 84 mcg/dL (high) and 
his RBC's showed basophilic stippling.  He was, 
however, asymptomatic, now 11 days post ingestion.   
A gastroenterologist was then consulted for endoscopic 
retrieval but the die was then passed in his stool.

     Ten days later (21 days post ingestion) he presented 
with abdominal pain, diarrhea, and emesis.  He also 
was noted to have gingival discoloration and speckling 
at the tip of the tongue.
     He was hospitalized at this point.  His serum lead 
level was now 48 mcg/dL and his urine lead level was 
253 (nl<80).  He was thus treated with EDTA 
(ethylenediaminetetraacetic acid) chelation 
for 3 days.  He then became asymptomatic and was 
discharged home in stable condition.

Lead Poisoning (Plumbism)
     In the past 20 years, the incidence of lead poisoning 
in children has decreased, however, there are still 
significant numbers of children with toxic lead levels.
     Case detection is best done by screening 
populations at risk, including children of lead industry 
workers, the workers themselves and children living in 
homes that were painted before 1980.  The Center for 
Disease Control recommends universal screening 
beginning at age 6 months.

Risk Factors are as follows:

Exposure:
     Air/dust/water/paint
     Lead curtain weights
     Fishing weights, dice
     Retained bullets/shrapnel
     Bootleg whiskey, hair spray

Absorption:
     Through lungs if inhaled.
     Symptoms develop more quickly through GI tract.
     Toxicity is more severe in the presence of 
concomitant iron, zinc, or calcium deficiency.

Children are at higher risk:
     They absorb 50% of their exposure and retain 30%.
     Adults absorb 5-15%, and retain less than 5%.

Signs and Symptoms:
     Acute toxicity:  Anorexia, vomiting, malaise, 
convulsions, permanent brain injury and reversible renal 
injury.
     Chronic toxicity:  Weight loss, weakness, anemia, 
neurobehavioral deficit, hypertension, wristdrop and 
colic  (Most are slow in onset).

By systems:
     Neuro:  Levels > 10 mcg/dL.  Learning disability, 
decreased IQ, Mental retardation, encephalopathy, 
motor deficit, seizures, cerebral edema, hearing loss.
     GI:  Abdominal pain, nausea, vomiting, diarrhea, 
constipation, anorexia, metallic taste in mouth, ileus.
     Renal:  Tubular damage, azotemia, gout.
     Heme:  Levels > 15 mcg/dL.  Affects heme 
synthesis, hemolysis, RBC stippling, iron deficiency.
     Musculoskeletal:  Muscle and joint pain, lead lines in 
metaphysis.
     Soft tissue:  Blue black line in gum margins.
     Endocrine:  Decreased stature, decreased growth 
hormone, decreased vitamin D levels.

Treatment:
     Identification and abatement of lead exposure 
sources is first and foremost in treatment.  Ingestion of 
a known or visible lead foreign body is okay to leave 
untreated if eliminated within 2 weeks.  If not, removal 
becomes necessary.
     The San Francisco Poison Center states that lead 
absorption is only a problem when in gastric acid, 
however, this is not documented in other sources.
     Acute ingestion:  Consider ipecac within 30 minutes 
if neurologically intact.  Activated charcoal/cathartic 
and/or cleansing enema if lead is seen in the lower 
bowel.  However, activated charcoal has a limited ability 
to absorb lead and it is of questionable efficacy.  Whole 
bowel irrigation may also be beneficial.

Obtain a blood lead level (mcg/dL)
     Category I (level< 9):  Education about lead hazards 
and rescreen.
     Category IIA (level 10-14):  Education about lead 
hazards and rescreen.
     Category IIB (level 15-19):  Recheck in one month 
by venipuncture rather than capillary.  Correct Fe 
deficiency.  Treat if the level is greater than 15 for 3 
months.  Determine the source of lead exposure and 
prevent further exposure.  Correct Fe deficiency.
     Category III (level 20-44):  Same as category IIB.
     Category IV (level 45-69):  Recheck  in 48 
hours.  Correct Fe deficiency,  Chelation therapy.
     Category V: (level> 70):  Recheck now, and if 
confirmed, treat immediately (chelation).

     There are some inconsistencies in the chelation 
treatment recommendations of various sources.  These 
recommendations should be considered as guidelines.  
A toxicologist or a current version of the Poisindex 
should be consulted for treatment recommendations in 
individual cases.
     Surgical removal of bullets and shrapnel is indicated 
if they are located near synovial spaces.  Surgical 
removal of lead foreign bodies in the gut is indicated if 
not eliminated within 2 weeks.
     Chelation is indicated if the level is greater than 45 
mcg/dL even if asymptomatic.  One should first correct 
any iron deficiency.  Chelating agents include EDTA, 
BAL, D-Penicillamine, and Succimer.

     EDTA:  A provocation test can be done to determine 
the lead excretion ratio.  Give the EDTA dose, then 
collect urine for 8 hours.  Total urine lead (mcg)/Total 
CaNa2EDTA (mg) dose given.  This test is positive if 
> 0.5.  There is no need to do this if the lead level is 
greater than 40 mcg/dL.  EDTA can also be used as a 
chelator for lead removal over 5 days.
     BAL (dimercaprol)  3-5 mg/kg/dose IM every 4 hours 
over 2-10 days. 
     D-Penicillamine 10/mg/kg/dose orally x 5 days.  This 
was first used as a copper chelator in Wilson's Disease.  
This can be used long term.  It is good for levels 
between 20-35.
     Succimer (DMSA) is the first oral agent approved by 
the FDA.  Because of the oral administration route, this 
can be used for outpatient chelation therapy, 30 
mg/kg/day x 5 days.  Patients may need multiple 
courses.

Bibliography
      Lead.  In:  Poisindex Volume 84, Expires 5/31/95,  
Micromedex, Inc.
      Glotzer DE.  Management of Childhood Lead 
Poisoning:  Strategies for Chelation.  Pediatric Annals 
1994;23(11):608-615.
     Liebelt EL, Shannon MW.  Oral Chelators for 
Childhood Lead Poisoning.  Pediatric Annals 
1994;23(11):616-626.