Medical Mystery of the Week

 You have recieved your COVID19 immunizations but are still practicing telemedicine due to the recent surge in delta COVID19 cases.
       Your are shown a picture of a 65-year-old man but are not given any history or physical findings. You are, however, provided a picture of a Wright-Giemsa stain of his peripheral blood (see below).

DIAGNOSIS: Lead poisoning (plumbism) leading to bilateral radial nerve palsies and anemia with basophilic stippling of erythrocytes.
      Heavy metals (lead, mercury, chromium, cadmium and arsenic) disrupt cellular growth, proliferation, differentiation, damage-repair, and apoptosis by increasing ROS generation, by weakening antioxidant defenses and enzyme inactivation, and by inducing oxidative stress.  Exposure can occur via inhalation, ingestion, and/or skin absorption.

      Sources of lead are myriad and include lead paint, batteries, and lead plumbing (hence the term "plumbism").
      Lead toxicity is defined by having a blood level of ≥ 10ug/dl. Clinical manifestations may be neurologic (e.g., mononeuritis multiplex, particularly of the radial nerve), gastrointestinal (abdominal cramping, GI hemorrhage), pulmonary (cough, chest discomfort, dyspnea), renal (kidney failure), cardiac (myocardopathy, ischemic heart disease), hematologic (anemia), immunological (increased production of IFN-γ), and/or mucocutaneous pigmentation(see picture of a lead [Burton's] line below). Children are particularly susceptible to the toxic effects of lead.
      Chelating agents (e.g., ethylenediaminetetraacetic acid (EDTA) are used in the treatment of heavy metal intoxications.

Mucosal lead (Burton's) line.