Case Diagnosis: Lead Toxicity from Retained Bullet Fragments in a Patient with Chronic Spinal Cord Injury (SCI)

Case Description: 38-year-old male with chronic SCI from a gunshot wound sustained 8 years ago. He has a retained bullet fragment (RBF) at the left T10-T11 neural foramen. He developed severe left-sided abdominal pain and trunk spasms 9 months post-injury. Patient had extensive gastrointestinal evaluation with different providers.  Pain management strategies include medications for neuropathic pain, trigger point and botox injections. CT myelogram showed RBF at the left T11 pedicle and severe left T10-T11 neural foraminal narrowing. Patient was initially referred to surgery for RBF removal, but surgeon did not recommend surgery. Given progression of abdominal pain, a blood lead level was obtained. Patient had significantly elevated levels at 63 mcg/dl (normal: < 5). Medical toxicologist recommended removal of RBF as no other source was identified. Patient underwent surgery. Post-op patient reported a brief period of improvement in symptoms. Serial monitoring show gradual decrease of lead levels, with latest at 44.6 mcg/dl.

Discussions: Symptoms of lead toxicity can be difficult to identify in patients with chronic SCI as they can be variable and are often overlooked as part of sequelae following their injury. Routine monitoring of lead levels is not a common practice in chronic SCI care. A high index of suspicion is warranted in individuals with history of RBF presenting with worsening abdominal pain, nausea, or with encephalopathy or peripheral neuropathy. Removal of the bullet does not guarantee resolution of symptoms.

Conclusions: Lead toxicity should be part of the differential diagnosis in SCI patients with RBF.