A 31-year-old woman felt epigastric discomfort without any obvious cause, along with glutted, nausea and vomit on December 28, 2018. She went to hospital two days later and treated with acid-inhibitory drug. However, there was no improvement with the patient. She underwent a gastroscopy showing chronic gastritis on January 4, 2019 and taken omeprazole and domperidone. There was also no remission. On January 7, 2019, she felt tolerable abdominal pain without any treatment. Then she felt abdominal pain intensified along with anus stopping exhaust and defecate on the next day. The patient went to the emergency room and taken a series of examinations. Blood routine examination showed leukocyte 7.4*10^9/L, neutrophil 80%, hemoglobin 94g/L. Routine urine test showed urine protein (++), ketone body (+), and occult blood (-). Other examinations such as blood electrolytes, abdominal elevation film, and color Doppler ultrasound of liver, bile, pancreas, spleen, and urinary system were normal. The patient felt better after treated by analgesia.
The next day, severe abdominal pain attacked the patient again. On examination, the urine pregnancy experiment was negative and the abdominal computerized tomography (CT) scan was also normal. The abdomen was soft, and there was tenderness in hypogastrium without rebound pain and muscle tension. She was treated by enema and anti-infection with no anesis. A repeat blood routine examination showed leukocyte 9.9*10^9/L, neutrophil 84.2%, hemoglobin 102g/L. Liver function showed abnormal liver function (alanine transaminase [ALT] 401U/L, aspartate transaminase [AST] 77 U/L, total bilirubin [TB] 30.8umol/L, direct bilirubin [DB] 2.6 umol/L, indirect bilirubin [IB] 28.2 umol/L, glutamyl transpeptidase [GGT] 138 U/L). Routine urine test and gynecological sonography provided no positive result. As the patient's symptoms could not be improved and cause was unclear, she presented to the emergency department at our hospital on January 11, 2019.
When in our hospital, her abdominal pain was worse with anus stopping exhaust defecate. On examination, the vital signs were normal. The blood routine examination showed leukocyte 14.8*10^9/L, neutrophil 88.1%, hemoglobin 100g/L. The abdominal CT scan revealed intestinal obstruction and small amount of pelvic effusion (Figure 1A-C). The electrocardiography was sinus rhythm. A diagnosis of acute intestinal obstruction was made, and she was dealt with ambrosia, anti-inflammation, acid-inhibitory, spasmolysis, and analgesia. That evening, the abdominal pain was recurrent and markedly increased, and the peregoric, such as dezocine or tramadol hydrochloride could remit briefly. Later, imageological examination of superior mesenteric blood vessels reconstruction was made, which showed no abnormal change in the blood vessels. The emergency department also could not get a definitive diagnosis, and the patient was transferred to colorectal surgery.
On examination, the temperature was 37.2 C, the blood pressure was 131/83mmHg, the pulse was 71/min, and breathe was 20/min. There was pressing pain in the hypogastrium and the bowel sound was weak; the remainder of the examination was normal. The primary diagnosis was intestinal obstruction and the patient was treated with fast, anti-infection, acid-inhibitory, inhibition of enzyme, spasmolysis, and nutrition support. Magnesium sulfate and racolamine hydrochloride could relieve the abdominal pain, while the dezocine could not.
On January 13, 2019, A repeat blood routine examination showed leukocyte 12.1*109/L, neutrophil 83.9%, hemoglobin 94g/L. Liver function showed abnormal liver function (ALT 181.2 U/L, AST 32 U/L, TB 23.3umol/L, DB 9.6 umol/L, GGT 138 U/L). The infectious disease indicators were all normal. Repeated severe abdominal pain attacked the patient today and magnesium sulfate helped her momentarily. The patient defecated today. Then she was treated with enema and taken for an electronic colonoscopy with nothing unusual.
Up to now, the course of the disease continued for 16 days without a definite diagnosis. The common causes of acute abdominal diseases, such as gastrointestinal perforation, acute cholecystitis, acute pancreatitis, gynecological disease, and urologic diseases were all excluded. A series of test results mentioned above showed anemia and abnormal liver function. So we should consider the rare cause of abdominal pains, such as Porphyria, abdominal epilepsy, herpes zoster, heavy metal poisoning, and so on. We have made the physical examination carefully and found no herpes, so the herpes zoster was excluded. The electroencephalogram was normal and the abdominal epilepsy was not considered. Then, we took the patient's urine and place it in the sun for an hour without color change. So the Porphyria was also excluded. Blood levels of heavy metals were detected and the lead was 463.17 microg/L, which was very high (normal value was less than 100 microg/L). Therefore, the diagnosis of lead poisoning was made.
The patient was treated with intravenous drip of calcium sodium edentate. The frequency of abdominal pain decreased gradually. She felt pain once a day on January 15 and 16. Later, she felt comfortable and resumed eating. Test results indicated an improvement in liver function. A week later, the blood level of lead dropped to 443.79 microg/L. According to the treatment guidelines, she should continue to receive intravenous drip of calcium sodium edentate.
In addition, we have also paid attention to the source of lead poisoning. Combing the common causes of lead poisoning and living habit of the patient, we focused on a set of cosmetics without trademark (Figure 1D). She have used the cosmetics for more than half a year and got a very good whitening effect. We test the lead content of this cosmetic and found that the lead concentration was 65.3mg/kg, which was higher than the national safety standard significantly. Therefore, we thought this set of cosmetics was the cause of lead poisoning. She stopped using this set of cosmetics immediately.