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Severe lead poisoning in a 6-month-old infant
L E T T E R S TO T H E E D I T O R Clinical notes
"Clinical Notes" represent clinical and/or laboratory experiences which can be presented in 200 to 400 words, 3 or 4 references, and, if contributory, one illustration or short table. "Clinical Notes" are subject to the same critical peer review and editing as papers published in other sections of the JOURNAL.
Severe lead poisoning in a 6-month-old infant To the Editor: Despite numerous reports of lead poisoning from the ingestion of liquids stored in improperly fired, glazed ceramic containers, such poisonings continue to occur. 14 The case reported here is significant because the infant was less than 6 months old, from a middle-class family, and the presence of subdural effusions obscured the central nervous system signs of lead poisoning. CASE REPORT Patient S. P., a 4-month-old Caucasian female, was referred to us in March, 1974, for evaluation of three seizures, preceded by two weeks of listlessness and poor feeding. Birth had been by cesarean Section, necessitated by a breech presentation, but the infant had developed normally. Physical examination was unremarkable except for irritability and poor head control. Laboratory evalu, ation, including complete blood count, blood urea nitrogen, calcium, phosphorus, SGOT, SGPT, alkaline phosphatase, iron, total protein, and urinary amino acid screen was normal, except for a hemoglobin of 8.4 gm and 15% reticulocytes. Roentgenogram of the skull and trans-illumination were normal. Cerebrospinal fluid contained 330 RBC/mm 3, 16 WBC/mm 3, and a protein content of 111 mg/dl. Electroencephalog}'am showed focal slowing and rare sharp waves in the left postero-lateral area. The infant was started on anticonvulsant therapy without a specific diagnosis having been established and seemed to improve. She was readmitted two months later because of recurrent anemia (hemoglobin 7.9 gm, 3.9% reticulocytes) and two weeks of irritability and listlessness. Examination was normal except for lethargy. Repeat lumbar puncture showed a pressure of 200 m m H20 and a cerebrospinal fluid' protein of 240 mg/dl. Subdural taps revealed fluid bilaterally with protein values of 270 and 520 mg/dl on the left and right sides, respectively. Bilateral trephine procedures revealed a large subarachnoid space on the right side and a subdural hygroma under pressure on the left. Although anemia is common with subdural effusions, a striking basophilic stippling of the red blood cel!s was noted and remained unexplained. Free erythrocyte protoporphyrin
810
TheJournalof P E D I A T R I C S Vol. 86, No. 5, pp. 810-821
Fig. 1. Heavy growth arrest lines in wrists. was elevated (1,174 /zg/dl RBC; normal 30-220), and blood lead level and urinary coproprophyrins were 80 /~g/dl and " 4 + , " respectively. Skeletal roentgenograms showed heavy densities at the ends of the long bones (Fig. 1), It was ascertained that the infant had been given fruit juice stored in an earthenware pitcher. This pitcher was found to contain lead in the glaze that was readily leached out by 4% acetic acid as well as by fruit juice. COMMENT As of December, 1974, the infant has received six courses of EDTA, the first three in conjunction with BAL. Although her development is progressing at near normal levels, she still has blood lead levels of 60/xg/dl and free erythrocyte protoporphyrin of 600 /xg/dl RBC and continues under close observation. The etiology of the subdural fluid has not been established.
Volume 86 Number 5
Letters to the Editor
This has not been reported with lead poisoning, but the possibility that it may be secondary to the increased cerebrospinal fluid protein and pressure cannot be completely ruled out, particularly in such a young infant. Anneliese L. Sitarz, M.D. Department o f Pediatrics Babies Hospital, The Children's Medical and Surgical Center 3975 Broadway New York, N. Y. 10032
REFERENCES 1. Browder AA: Lead poisoning from glazes, Ann Intern Med 76:665, 1972. 2. Klein M, Namer R, Harpur E, and Corbin R: Earthenware containers as a source of fatal lead poisoning (case study and public health considerations), N Engl J Med 283:669, 1970. 3. Clarke KGA: Lead-glazed earthenware, Lancet 2:662, 1972. 4. Block JL: The accident that saved five lives, Good Housekeeping 169:60, 1969.
Hydrocele following placement of a ventriculoperitoneal shunt To the Editor: The ventriculoperitoneal shunt is now widely used in the treatment of hydrocephalus. Since the introduction of the Raimondi peritoneal catheter, there has been considerable reduction in the incidence of distal obstruction. Serious systemic complications of infection and cardiac damage are avoided when this shunt is employed in preference to the ventriculoatrial procedure. ~ Although a variety of complications have been well documented, 2,3 there has been little attention given in the literatureto the association with hydrocele illustrated in the following two cases.
routine pediatric evaluation swelling of the right scrotum was noted without evidence of inguinal bulge. Abdominal films confirmed the shunt tip in the right scrotum and uncompli~;ated surgical repair and shunt repositioning followed. At 8 months of age the child continues to do well. DISCUSSION Hydrocele as a complication of peritoneal shunts has been cited as an infrequent finding in one rePorted earlier series. 4 Since many of these previous shunts were soon obstructed and were generally quickly replaced by other types of procedures, it is not surprising that this complication was met infrequently in the past. Recently a 16% incidence of clinical inguinal hernia has been noted to occur on the average within seven months after the initial ventriculoperitoneal shunt procedure. 5 Thus, itcan be expected that the presence of hydrocele will now be commonly found. This should not be a basis for special concern by the pediatrician nor a contraindication of this type of shunt procedure. Rather, this finding suggests that particular attention should be given to subtle signs of hernia or increasing hydrocele formation both before and especially after peritoneal shunting. In particular, the inguinal and scrotal areas should be regularly observed by all those responsible for evaluating peritoneal shunt functioning. Alfred L. Scherzer, Ed.D., M.D. Associate Professor o f Pediatrics Department o f Pediatrics Cornell University Medical Center 525 E. 68th St. New York, N. Y. 10021
REFERENCES 1.
2. 3.
4. 5.
CASE R E P O R T S Patient C. H., a 3-month-old male, had a low lumbosacral meningomyelocele sac repaired shortly after birth. A ventriculoperitoneal shunt was placed at 13 days using a Raimondi lowpressure peritoneal catheter. The course was uneventful until large bilateral hydroceles were noted during an orthopedic evaluation when a roentgenogram revealed the catheter tip in the left scrotum. On surgical exploration there were bilateral communicating hydroceles with the shunt tubing in the left scrotum and bilateral inguinal hernias. The peritoneal catheter was repositioned in the abdomen and the hernias repaired. The subsequent course to the age of 2 years has been benign. Patient W. M., a 2-month-old male, had a similar history with closure of the meningomyelocele sac at seven hours and placement of a ventriculoperit0neal shunt at the age of 35 days. On
811
Little J, Rhoton A, and Mellinger J: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children, Mayo Clin Proc 47:396, 1972. Ames R: Ventriculoperitoneal shunts in the management of hydrocephalus, J Neurosurg 27:525, 1967. Weiss S, and Raskind R: Twenty-two cases of hydrocephalus treated with a silastic ventriculoperitoneal shunt, Int Surg 51:13, 1969. Murtagh F, and Lehman R: Peritoneal shunts in the management of hydrocephalus, JAMA 202:1010, 1967. Grosfeld J, et ah Intra-abdominal complications following ventriculoperitoneal shunt procedures, Pediatrics 54:791, 1974.
Supraventricular tachycardia in an infant associated with a rhinoviral infection To the Editor." We have recently seen a 4-week-old boy who developed supraventricular tachycardia in association with virologic and
"Clinical Notes" represent clinical and/or laboratory experiences which can be presented in 200 to 400 words, 3 or 4 references, and, if contributory, one illustration or short table. "Clinical Notes" are subject to the same critical peer review and editing as papers published in other sections of the JOURNAL.
Severe lead poisoning in a 6-month-old infant To the Editor: Despite numerous reports of lead poisoning from the ingestion of liquids stored in improperly fired, glazed ceramic containers, such poisonings continue to occur. 14 The case reported here is significant because the infant was less than 6 months old, from a middle-class family, and the presence of subdural effusions obscured the central nervous system signs of lead poisoning. CASE REPORT Patient S. P., a 4-month-old Caucasian female, was referred to us in March, 1974, for evaluation of three seizures, preceded by two weeks of listlessness and poor feeding. Birth had been by cesarean Section, necessitated by a breech presentation, but the infant had developed normally. Physical examination was unremarkable except for irritability and poor head control. Laboratory evalu, ation, including complete blood count, blood urea nitrogen, calcium, phosphorus, SGOT, SGPT, alkaline phosphatase, iron, total protein, and urinary amino acid screen was normal, except for a hemoglobin of 8.4 gm and 15% reticulocytes. Roentgenogram of the skull and trans-illumination were normal. Cerebrospinal fluid contained 330 RBC/mm 3, 16 WBC/mm 3, and a protein content of 111 mg/dl. Electroencephalog}'am showed focal slowing and rare sharp waves in the left postero-lateral area. The infant was started on anticonvulsant therapy without a specific diagnosis having been established and seemed to improve. She was readmitted two months later because of recurrent anemia (hemoglobin 7.9 gm, 3.9% reticulocytes) and two weeks of irritability and listlessness. Examination was normal except for lethargy. Repeat lumbar puncture showed a pressure of 200 m m H20 and a cerebrospinal fluid' protein of 240 mg/dl. Subdural taps revealed fluid bilaterally with protein values of 270 and 520 mg/dl on the left and right sides, respectively. Bilateral trephine procedures revealed a large subarachnoid space on the right side and a subdural hygroma under pressure on the left. Although anemia is common with subdural effusions, a striking basophilic stippling of the red blood cel!s was noted and remained unexplained. Free erythrocyte protoporphyrin
810
TheJournalof P E D I A T R I C S Vol. 86, No. 5, pp. 810-821
Fig. 1. Heavy growth arrest lines in wrists. was elevated (1,174 /zg/dl RBC; normal 30-220), and blood lead level and urinary coproprophyrins were 80 /~g/dl and " 4 + , " respectively. Skeletal roentgenograms showed heavy densities at the ends of the long bones (Fig. 1), It was ascertained that the infant had been given fruit juice stored in an earthenware pitcher. This pitcher was found to contain lead in the glaze that was readily leached out by 4% acetic acid as well as by fruit juice. COMMENT As of December, 1974, the infant has received six courses of EDTA, the first three in conjunction with BAL. Although her development is progressing at near normal levels, she still has blood lead levels of 60/xg/dl and free erythrocyte protoporphyrin of 600 /xg/dl RBC and continues under close observation. The etiology of the subdural fluid has not been established.
Volume 86 Number 5
Letters to the Editor
This has not been reported with lead poisoning, but the possibility that it may be secondary to the increased cerebrospinal fluid protein and pressure cannot be completely ruled out, particularly in such a young infant. Anneliese L. Sitarz, M.D. Department o f Pediatrics Babies Hospital, The Children's Medical and Surgical Center 3975 Broadway New York, N. Y. 10032
REFERENCES 1. Browder AA: Lead poisoning from glazes, Ann Intern Med 76:665, 1972. 2. Klein M, Namer R, Harpur E, and Corbin R: Earthenware containers as a source of fatal lead poisoning (case study and public health considerations), N Engl J Med 283:669, 1970. 3. Clarke KGA: Lead-glazed earthenware, Lancet 2:662, 1972. 4. Block JL: The accident that saved five lives, Good Housekeeping 169:60, 1969.
Hydrocele following placement of a ventriculoperitoneal shunt To the Editor: The ventriculoperitoneal shunt is now widely used in the treatment of hydrocephalus. Since the introduction of the Raimondi peritoneal catheter, there has been considerable reduction in the incidence of distal obstruction. Serious systemic complications of infection and cardiac damage are avoided when this shunt is employed in preference to the ventriculoatrial procedure. ~ Although a variety of complications have been well documented, 2,3 there has been little attention given in the literatureto the association with hydrocele illustrated in the following two cases.
routine pediatric evaluation swelling of the right scrotum was noted without evidence of inguinal bulge. Abdominal films confirmed the shunt tip in the right scrotum and uncompli~;ated surgical repair and shunt repositioning followed. At 8 months of age the child continues to do well. DISCUSSION Hydrocele as a complication of peritoneal shunts has been cited as an infrequent finding in one rePorted earlier series. 4 Since many of these previous shunts were soon obstructed and were generally quickly replaced by other types of procedures, it is not surprising that this complication was met infrequently in the past. Recently a 16% incidence of clinical inguinal hernia has been noted to occur on the average within seven months after the initial ventriculoperitoneal shunt procedure. 5 Thus, itcan be expected that the presence of hydrocele will now be commonly found. This should not be a basis for special concern by the pediatrician nor a contraindication of this type of shunt procedure. Rather, this finding suggests that particular attention should be given to subtle signs of hernia or increasing hydrocele formation both before and especially after peritoneal shunting. In particular, the inguinal and scrotal areas should be regularly observed by all those responsible for evaluating peritoneal shunt functioning. Alfred L. Scherzer, Ed.D., M.D. Associate Professor o f Pediatrics Department o f Pediatrics Cornell University Medical Center 525 E. 68th St. New York, N. Y. 10021
REFERENCES 1.
2. 3.
4. 5.
CASE R E P O R T S Patient C. H., a 3-month-old male, had a low lumbosacral meningomyelocele sac repaired shortly after birth. A ventriculoperitoneal shunt was placed at 13 days using a Raimondi lowpressure peritoneal catheter. The course was uneventful until large bilateral hydroceles were noted during an orthopedic evaluation when a roentgenogram revealed the catheter tip in the left scrotum. On surgical exploration there were bilateral communicating hydroceles with the shunt tubing in the left scrotum and bilateral inguinal hernias. The peritoneal catheter was repositioned in the abdomen and the hernias repaired. The subsequent course to the age of 2 years has been benign. Patient W. M., a 2-month-old male, had a similar history with closure of the meningomyelocele sac at seven hours and placement of a ventriculoperit0neal shunt at the age of 35 days. On
811
Little J, Rhoton A, and Mellinger J: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children, Mayo Clin Proc 47:396, 1972. Ames R: Ventriculoperitoneal shunts in the management of hydrocephalus, J Neurosurg 27:525, 1967. Weiss S, and Raskind R: Twenty-two cases of hydrocephalus treated with a silastic ventriculoperitoneal shunt, Int Surg 51:13, 1969. Murtagh F, and Lehman R: Peritoneal shunts in the management of hydrocephalus, JAMA 202:1010, 1967. Grosfeld J, et ah Intra-abdominal complications following ventriculoperitoneal shunt procedures, Pediatrics 54:791, 1974.
Supraventricular tachycardia in an infant associated with a rhinoviral infection To the Editor." We have recently seen a 4-week-old boy who developed supraventricular tachycardia in association with virologic and