Clinical Information

Lead is a heavy metal naturally found in the environment that can be an acute and chronic toxin. Lead can enter the environment through releases from mining lead and other metals, and from factories that make or use lead, lead alloys, or lead compounds. Lead is released into the air during burning coal, oil, or waste. Before the use of leaded gasoline in motor vehicles was banned (January 1, 1996), most of the lead released into the United States environment came from vehicle exhaust.

Lead was banned from household paints in 1978 but is still found in paint produced for nondomestic use and in artistic pigments. Ceramic products available from noncommercial suppliers (such as local artists) often contain significant amounts of lead that can be leached from the ceramic by weak acids, such as vinegar and fruit juices. Lead is commonly found in soil especially near roadways, older houses, old orchards, mining areas, industrial sites, near power plants, incinerators, landfills, and hazardous waste sites. Recent data has shown that inexpensive cosmetic jewelry pieces sold to the general public may contain high levels of lead, which can be transferred to the skin through routine handling. However, not much lead can get into your body through your skin.

People may be exposed to lead by eating food or drinking water that contains lead. Drinking (tap) water in houses containing lead pipes may contain lead, especially if the water is acidic or "soft". Foods may contain small amounts of lead. Leafy fresh vegetables grown in lead-containing soils may have lead-containing dust on them. Lead may also enter foods if they are put into improperly glazed pottery or ceramic dishes and from leaded-crystal glassware. However, since lead solder is no longer used in cans, very little lead is typically found in food.

The typical diet in the United States contributes 1 to 3 mcg of lead per day, of which 1% to 10% is absorbed; children may absorb as much as 50% of the dietary intake, and the fraction of lead absorbed is enhanced by nutritional deficiency. The majority of the daily intake is excreted in the stool after direct passage through the gastrointestinal tract. While a significant fraction of the absorbed lead is incorporated into bone (approximately 94% adults; approximately 73% children) and erythrocytes, lead ultimately distributes among all tissues with lipid-dense tissues, such as the central nervous system, being particularly sensitive to organic forms of lead. All absorbed lead is ultimately excreted in the bile or urine. Soft-tissue turnover of lead occurs within approximately 120 days.

Other alternative sources of lead include moonshine distilled in lead pipes, some traditional home medicines, non-Western cosmetics (eg, surma and kohl), and some types of hair colorants, cosmetics, and dyes.

Lead expresses its toxicity by several mechanisms:

1. It avidly inhibits aminolevulinic acid dehydratase and ferrochelatase, 2 of the enzymes involved in the synthesis of heme. In the end, this inhibition causes decreased hemoglobin synthesis resulting in anemia.

2. Lead is also an electrophile that avidly forms covalent bonds with the sulfhydryl group of cysteine in proteins. Thus, proteins in all tissues exposed to lead will have lead bound to them. The most common sites affected are epithelial cells of the gastrointestinal tract and epithelial cells of the proximal tubule of the kidney.

Avoidance of exposure to lead is the treatment of choice. However, chelation therapy is available to treat severe disease and may be necessary especially in children if the blood lead is higher than 25 mcg/dL. The standard chelating agents currently in use are dimercaprol (British Anti-Lewisite), CaNa2-EDTA (or EDTA), penicillamine, and 2,3-dimercaptosuccinic acid (DMSA; succimer).