To the Editor: Cox and Pesola (Dec. 29 online issue)1 describelead-shot accumulation in the cecal appendix of an Alaskan native,which was probably caused by the ingestion of shotgun-culledwaterfowl. Their description did not mention the potential forlead absorption and systemic toxicity. Blood lead levels almosttwice those of controls may be found after sequestration ofjust one or two shot pellets in the appendix2; a toxic levelof lead (67.4 µg per deciliter) was reported after theretention of 29 pellets.3 The authors' comment that shot inthe appendix is commonly seen in Alaskan natives suggests animportant public health concern. Presentations of adult leadpoisoning (plumbism) range from nonspecific symptoms to acuteencephalopathy. Children absorb lead more readily than do adults,which can result in reduced IQ; the fetus is particularly susceptible.Interventions include screening, medical management, publichealth education, and promotion of the use of steel shot insteadof lead. Within the indigenous community, reduced lead levelswould confer substantial health benefits.
Leo J. Schep, Ph.D. John S. Fountain, M.B., Ch.B. National Poisons Centre Dunedin 9001, New Zealand john.fountain{at}otago.ac.nz
Madsen HH, Skjodt T, Jorgensen PJ, Grandjean P. Blood lead levels in patients with lead shot retained in the appendix. Acta Radiol 1988;29:745-746. [Medline]
Durlach V, Lisovoski F, Gross A, Ostermann G, Leutenegger M. Appendicectomy in an unusual case of lead poisoning. Lancet 1986;1:687-688. [Medline]
The authors reply: In 1991, the United States instituted a nationwideban on lead shot for waterfowl hunting, owing in part to theconcern regarding lead toxicity from this practice. Unfortunately,the ban does not extend to all hunting; thus, there is a riskto hunters and others who inadvertently eat lead from theircatch.1 Countries such as Denmark and the Netherlands have acomplete ban on lead for hunting; alternatives to lead shotinclude bismuth, steel, tin, and tungsten. Therefore, a solutionto lead ingestion and potential toxicity problems is present.
As Schep and Fountain suggest, it is reasonable to screen forlead when shot is found in the appendix during radiography.If an elevated lead level is found, appropriate action shouldbe taken. We did not know the blood lead level in the patientin our report, since she had been sent for radiography someyears earlier. In the future, all such testing will includea suggestion to obtain a lead level in similar clinical situations.
William M. Cox, M.D. Norton Sound Regional Hospital Nome, AK 99762
Gene R. Pesola, M.D., M.P.H. Mailman School of Public Health New York, NY 10032
References
Gustavsson P, Gerhardsson L. Intoxication from an accidentally ingested lead shot retained in the gastrointestinal tract. Environ Health Perspect 2005;113:491-493. [Medline]
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