1 figure omitted
Although ingestion of dust from lead-based paint is the most common
source of lead exposure among children in the United States,1 lead
also can be present in unsuspected objects. Ingestion of these objects can
result in elevated blood lead levels (BLLs). This report describes an investigation
by the Deschutes County Health Department and the Oregon Department of Human
Services of lead poisoning in a boy who swallowed a medallion pendant from
a neckace sold in a toy vending machine. The investigation resulted in a nationwide
recall in September 2003 of the implicated toy necklace. Clinicians and caregivers
should consider lead poisoning in any child who ingests, or puts in his mouth,
a metal object. Cases of lead poisoning should be reported immediately to
public health authorities to prevent other children from being exposed to
the same sources of lead.
In July 2003, a boy aged 4 years was taken to a physician in Oregon
after several days of abdominal cramping, vomiting, and diarrhea without fever.
His symptoms resolved until 1-2 weeks later when he had another bout of vomiting
and abdominal pain. He was returned to his physician, and his condition was
diagnosed as probable viral syndrome and anemia of undetermined etiology.
Two days later he was brought to the emergency department with worsening
symptoms, including constipation and inability to eat or sleep because of
his abdominal pain. An abdominal radiograph showed a metallic object in the
stomach with no evidence of obstruction; repeat laboratory studies showed
a persistent normocytic anemia. Initially, the object was believed likely
to pass on its own; however, on the next day, an abdominal computerized tomography
showed the object more superiorly located. Endoscopy was performed, resulting
in retrieval of a medallion pendant (along with a quarter) from the boy's
Three days later, the boy returned with edema of the left cheek and
gingiva, suggesting either a dental abscess or excessive biting of the cheek.
Concern that the cheek bite might have been caused by a seizure prompted testing
of his BLL, which was 123 µg/dL (CDC's level of concern = ≥10 µg/dL).
The boy was admitted to the pediatric intensive care unit for intravenous
chelation therapy. No evidence of encephalopathy was found; a sleep electroencephalogram
was normal. The boy was treated with dimercaprol (i.e., BAL) followed by calcium
disodium versenate (i.e., EDTA), and his BLL decreased to 57 µg/dL.
He was switched to oral succimer (i.e., DMSA), but received a repeat course
of EDTA when his BLL increased to 69 µg/dL. After three courses of succimer,
his BLL was <40 µg/dL. The boy's zinc protoporphyrin level peaked
at 556 mM/M (normal: 25-65 mM/M). Peripheral blood smear showed basophilic
stippling. Subsequently, neurodevelopmental, cognitive, and speech therapy
evaluations of the boy all showed appropriate development.
An environmental investigation of the boy's home, which was built in
1996, did not reveal any additional sources of lead exposure. A sibling, aged
6 years, had a BLL of <5 µg/dL.
The medallion retrieved from the boy's stomach was reportedly purchased
from a toy vending machine in Oregon, approximately 3 weeks before it was
retrieved. The state environmental quality lab found the medallion's contents
to be 38.8% lead (388,000 mg/kg), 3.6% antimony, and 0.5% tin. Similar medallions
purchased from toy vending machines in other areas of Oregon were found to
have similar high proportions of lead (44% and 37%). These medallions are
round, measuring approximately 7/8 of an inch in diameter, gray in color,
with a symbol on one side (Figure). State health officials notified the U.S.
Consumer Product Safety Commission; a national voluntary recall* was announced
on September 10, 2003, of approximately 1.4 million of the metal toy necklaces.
A distributor of the medallions reported that they had been manufactured in
India and distributed throughout the United States. Oregon health officials
cautioned that more of the medallions might still be sold in vending machines
in the state.2
JL VanArsdale, MD, BZ Horowitz, MD, Oregon Health and Science Univ,
Portland; TA Merritt, MD, St. Charles Medical Center, Central Oregon Pediatric
Associates; DW Peddycord, E Severson, KM Moore, NJ Pusel, Deschutes County
Health Dept, Bend; RD Leiker, MS, BR Zeal, MJ Scott, Oregon Childhood Lead
Poisoning Prevention Program; MA Kohn, MD, Oregon Dept of Human Svcs, Health
WL Pickner, Oregon Childhood Lead Poisoning Prevention Program, Oregon
Dept of Human Svcs, Health Svcs; Deschutes County Health Dept, Bend; A Jaffe,
MD, Oregon Health and Science Univ, Portland, Oregon. MW Shannon, MD, Children's
Hospital, Boston, Massachusetts.
*Available at http://www.cpsc.gov/cpscpub/prerel/prhtml03/03178.html.
Brief Report: Lead Poisoning From Ingestion of a Toy Necklace—Oregon, 2003. JAMA. 2004;292(4):430. doi:10.1001/jama.292.4.430