To the Editor: As a consequence of strict regulations, leadintoxication has not occurred in Germany in recent decades.Recently, during a period of 3 to 4 months, 29 patients (16to 33 years of age) were admitted to four different hospitalsin the greater Leipzig area (population, approximately 650,000)with classic signs and symptoms of lead intoxication. Twentyof these patients were admitted to our hospital (UniversityHospital Leipzig), 16 on an emergency basis (Table 1). The patientspresented with abdominal cramps, nausea, anemia of varying severity,and fatigue. Most patients had basophilic stippling and a "Burton'sline," and some had neurologic symptoms. In other hospitals,one patient had severe encephalopathy with hallucinations andperipheral neuropathy with permanent extensor palsy in the forearm,and another patient underwent exploratory laparoscopy.1
Table 1. Clinical and Laboratory Characteristics of 16 Patients with Lead Intoxication.
The diagnosis was quickly established, and chelation therapywas effective, but despite great efforts by health authoritiesand police, the source of lead could not be identified. After8 weeks, we detected a common pattern: the patients were young,were unemployed or were students, had a history of smoking,and had body piercings. On questioning, all the patients eventuallyconceded that they were regular users of marijuana smoked in"joint" form or with the use of a water pipe. We recovered eitherhalf-used packages or aliquots of "home supplies" of marijuanafrom three patients, and we identified elemental lead by meansof atomic absorptiometry and 9-tetrahydrocannabinol by meansof high-pressure liquid chromatography. One package containedobvious lead particles (Figure 1); this strongly indicated thatthe lead was deliberately added to the package rather than inadvertentlyincorporated into the marijuana plants from contaminated soil.At this point, we involved the police, and a full criminal investigationwas begun. Health authorities immediately started an anonymousscreening program for marijuana users. After 2 weeks, 145 personshad used this service. A total of 95 of these persons had bloodlead levels that required treatment (>25 µg per deciliter),and some of these persons had dangerous levels of lead (>80µg per deciliter).
In this 10 ($15.39) bag, which was obtained from a patient, the plant material had been mostly consumed. The small grayish metal particles were identified as elemental lead. They can be easily distinguished from marijuana leaves both in the original package (Panel A) and under the magnifying lens (Panel B).
The current working hypothesis of the police is that becauseof its high specific gravity and inconspicuous grayish color,lead was used to increase the weight of street marijuana soldby the gram and thereby to maximize profits among dealers. Inthe material that was obtained, the lead content on averagewas 10% by weight, which translates into a profit increase ofapproximately 1,000 ($1,500.00) per kilogram of marijuana. Leadparticles smoked in a joint, which can have a core temperatureof 1200°C,2 are very effectively absorbed in the respiratorytract. The medical community, including pediatricians,3 shouldconsider adulterated marijuana as a potential source of leadintoxication.
Franziska Busse, M.D. Leyla Omidi, M.D. Alexander Leichtle, M.D. University Hospital Leipzig D-04103 Leipzig, Germany
Michael Windgassen, M.D. Dialysis Center Grimma 04668 Grimma, Germany
Eyleen Kluge, M.D. Michael Stumvoll, M.D. University Hospital Leipzig D-04103 Leipzig, Germany michael.stumvoll{at}medizin.uni-leipzig.de
References
Garcia RC, Snodgrass WR. Lead toxicity and chelation therapy. Am J Health Syst Pharm 2007;64:45-53. [Free Full Text]
Baker RR. Temperature distribution inside a burning cigarette. Nature 1974;247:405-406. [CrossRef]
Needleman HL, Schell A, Bellinger D, Leviton A, Allred EN. The long-term effects of exposure to low doses of lead in childhood: an 11-year follow-up report. N Engl J Med 1990;322:83-88. [Abstract]
9-tetrahydrocannabinol by means of high-pressure liquid chromatography. One package contained obvious lead particles (Figure 1); this strongly indicated that the lead was deliberately added to the package rather than inadvertently incorporated into the marijuana plants from contaminated soil. At this point, we involved the police, and a full criminal investigation was begun. Health authorities immediately started an anonymous screening program for marijuana users. After 2 weeks, 145 persons had used this service. A total of 95 of these persons had blood lead levels that required treatment (>25 µg per deciliter), and some of these persons had dangerous levels of lead (>80 µg per deciliter). 
1,000 ($1,500.00) per kilogram of marijuana. Lead particles smoked in a joint, which can have a core temperature of 1200°C,2 are very effectively absorbed in the respiratory tract. The medical community, including pediatricians,3 should consider adulterated marijuana as a potential source of lead intoxication. 
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