Lead Poisoning-Associated Death from Asian Indian Folk Remedies -- Florida

In January 1984, a 9-month-old Asian Indian boy died in Florida of lead poisoning that resulted from ingestion of folk remedies. The case report follows.

The infant, born in April 1983 in Massachusetts, moved with his family to Lake County, Florida, when he was 6 months old. He was under the care of a local physician and developed normally until he was 8 months old. In December 1983, he became lethargic and less responsive and stopped crawling. Within a few weeks, the behavioral abnormalities worsened, and he refused bottle-feeding, and began to have tremors. On January 5, 1984, the infant was examined by a physician for an ear infection, and the behavioral changes were noted. On January 9, the infant had seizures at his home and was taken to the hospital emergency room. During a lumbar puncture, he became apneic and was transferred to another hospital. The lumbar puncture ruled out meningitis as the cause of his neurologic signs. A computerized tomography scan suggested a midline cerebellar mass with enlargements of the third and lateral ventricles in the brain. On January 10, he underwent an operation for decompression of the posterior fossa. During the operation, apparent necrotic tissue was excised from the cerebellum. The infant died the next day.

Postmortem examination revealed severe lead poisoning as the underlying cause of death. High concentrations of lead were found in the blood, urine, liver, and kidneys (Table 4). Lead lines were seen in radiographs of the long bones.

The source of lead could not be identified in the house or environment on examination. However, the parents disclosed that they had regularly given the baby folk remedies from India since he was 2 months old. The parents provided samples of three folk remedies for analysis by the Florida Department of Health and Rehabilitative Services. All three contained lead (Table 5). The highest concentration (1.6%) was in ghasard, a brown powder given once daily as a tonic. Reported by ML Colgrove, M Zinion, Nursing Dept, JM Atkinson, MD, Lake County Public Health Unit, Tavares, T Collins, MD, District 3, Gainesville, L Maslund, MW Clark, MD, WF Hamilton, MD, Office of the Medical Examiner, District 8, Gainesville, NP Chopra, MD, Lake County, CL Bush, Office of Laboratory Svcs, JJ Witte, MD, JJ Sacks, MD, Acting State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs; Div of Field Svcs, Epidemiology Program Office, Special Studies Br, Chronic Diseases Div, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Lead poisoning should be suspected in every infant and child with developmental problems, behavioral abnormalities, or neurologic symptoms. Signs of acute lead encephalopathy include coma, seizures, bizarre behavior, ataxia, apathy, incoordination, vomiting, alteration in consciousness, and subtle loss of recently acquired skills (1). Lead encephalopathy is a medical emergency and requires prompt diagnosis and treatment. One or more of the above signs and a blood-lead concentration of 70 ug/dl or higher are sufficient for diagnosis. Lumbar puncture is usually not required for diagnosis of acute lead encephalopathy and may pose a risk to the patient when intracranial pressure is elevated. Treatment consists of chelation with 2,3-dimercaptopropanol (BAL--British anti-lewisite) and edathamil calcium disodium (CaNa((2))-EDTA) (1).

At blood-lead concentrations of 50 ug/dl or higher, lead poisoning can produce the following symptoms: decreased play activity, lethargy, anorexia, sporadic vomiting, intermittent abdominal pain, and constipation. Children with lead poisoning should be treated on an emergency basis, since they may develop acute encephalopathy (1).

Lead-containing folk remedies have been reported as the cause of lead poisoning in Mexican-Hispanic and Hmong children (2-4). This report of lead-containing folk remedies from India raises the concern that lead may be present in folk remedies from other parts of the world. Hmong folk remedies have also been found to contain arsenic and mercury (4), and they have been suspected of causing arsenic poisoning in several adults (5). Other heavy metals, therefore, may also be present in some Indian folk remedies.

Health-care providers need to be sensitive to the cultural beliefs and practices of ethnic groups. In their native countries, these groups may have used traditional foods and remedies. Parents often give these substances to their infants and children to help their growth and development or to treat them for minor illnesses. Often, the parents acquire the substances from relatives and friends, and they do not suspect the substances may be harmful. If symptoms persist, they may give even larger amounts, inadvertently causing further illness.

Testing for lead toxicity can be done simply and relatively inexpensively by determining blood concentrations of lead and erythrocyte protoporphyrin (EP). Determining the EP level is a good screening test for lead exposure, since an elevated EP level usually indicates iron deficiency or lead toxicity (6). If lead poisoning is suspected, however, both EP and blood-lead levels should be determined without delay.

Lead poisoning can be prevented by removing the child from exposure to lead. In the United States, the most common source of lead that causes symptomatic poisoning is deteriorating lead-based paint in older houses. Other potential sources--including occupations and hobbies that result in exposure to lead; food stored in imported, glazed pottery; and folk remedies--should also be investigated. It is very important that the source or sources of lead be identified and removed from the child's environment.

Based on recommendations by CDC's Ad Hoc Advisory Committee on Childhood Lead Poisoning Prevention, CDC is revising the guidelines for lead screening in young children. The new guidelines recommend EP screening of all children between 9 months and 6 years of age. A child with an EP level of 35 ug/dl or higher should have a repeat EP test, a blood-lead test, and a hematocrit or hemoglobin test. Lead toxicity--defined as a blood-lead level of 25 ug/dl or higher, along with an EP level of 35 ug/dl or higher--requires further medical evaluation and environmental investigation to identify the source(s) of lead. These new guidelines will be distributed in the form of a CDC statement to health departments and health-care providers. More details will be included in a future issue of MMWR.

References

1. Piomelli S, Rosen JF, Chisolm JC, Graef JJ, Jr. Management of childhood lead poisoning. J Pediatr 1984;105:523-32.

2. CDC. Use of lead tetroxide as a folk remedy for gastrointestinal illness. MMWR 1981;30:546-7.

3. CDC. Lead poisoning from lead tetroxide used as a folk remedy--Colorado. MMWR 1982;30:647-8.

4. CDC. Folk remedy-associated lead poisoning in Hmong children--Minnesota. MMWR 1983;32:555-6

5. CDC. Nonfatal arsenic poisoning in three Hmong patients--Minnesota. MMWR 1984;33:347-9.

6. CDC. Preventing lead poisoning in young children: a statement by the Center for Disease Control. Atlanta, Georgia: Center for Disease Control, 1978.

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