Citation

Malherbe J, Chaba A, Birsen R, Vigneron C. BMJ Case Rep. 2023; 16(6): e254199.

Copyright

(Copyright © 2023, BMJ Publishing Group)

DOI

10.1136/bcr-2022-254199

PMID

37286233

Abstract

A man in his 50s without any significant medical history was admitted in intensive care unit (ICU) for coma following seizures. His relatives reported recent abdominal pain and hepatitis. Symptoms progressively increased within the last few weeks with asthenia associated with headache and drowsiness. Neurological examination at ICU admission revealed tetrapyramidal syndrome and comatose state requiring mechanical ventilation. Brain MRI revealed bilateral T2 fluid-attenuated inversion recovery(FLAIR) hyperintense signal involving temporal and occipital lobes consistent with posterior reversible encephalopathy syndrome (PRES) (figure 1). Cerebrospinal fluid (CSF) appeared cloudy with high protein level (2.18 g/L), without meningitis. Blood tests revealed hepatitis (serum glutamic-oxaloacetic transaminase (SGOT) 108 UI/L and serum glutamic-pyruvic transaminase (SGPT) 118 UI/L) and microcytic regenerative anaemia at 68 g/dL. Basophilic stippling in the erythroblasts were found on the peripheral red blood smear (figure 2). After ruling out the usual causes of PRES (eg, hypertension, autoimmune disorders and drugs) and considering the combination of these clinical and biological data, lead levels were measured at day 10 following ICU admission and were elevated in blood, CSF, urine and liver biopsy, respectively, at 797.9 µg/L (n<85), 24.0 µg/L (n<10), 172.0 µg/L (n<30) and 151.3 µg/g (n<3.1). The patient was treated with intravenous calcium disodium EDTA at 1000 mg/m2/day associated with oral 2,3-dimercaptosuccinic acid succimer (DMSA) at 10 mg/kg three times a day for 5 days followed after 7 days by calcium EDTA alone, resulting in a decrease of BLL at 547.0 µg/L. The patient recovered, allowing mechanical ventilation weaning 1 week after treatment initiation and hospital discharge 1 month later. The suspected lead source was herbal medicine after exhaustive research of other potential exposition. Investigations did not reveal lead intoxication among his relatives...

Language: en

Keywords

Coma and raised intracranial pressure; Haematology (incl blood transfusion)