Continuing our monthly series, Dr Hannah Rosa asked readers to suggest what was causing abdominal pain in this young man. Did you get the answer? All is revealed below.
Your next patient during your morning surgery is a 29-year-old male patient, who is booked in to see you with a 2-week history of abdominal pain. Before calling him in you note that he hasn’t been to see anyone at the surgery for many years, and other than mild childhood asthma, he has no other conditions listed.
You notice he walks in with ease, seems well enough in himself and appears to have come directly from work, as he is wearing dusty, paint-splattered overalls.
Further questioning reveals that he has been getting crampy abdominal pains, across his whole abdomen, for the last two weeks, and they seem to be getting worse. He has also been experiencing nausea, but no vomiting and his appetite hasn’t been too bad. He has not had loose stools, if anything he has been slightly constipated. He has not had any PR bleeding, no melaena and no slimy stools.
He hasn’t lost any weight, but he has been feeling increasingly tired, with mild headaches, which have prompted him to go to bed earlier in the evenings. He hasn’t had a fever and no one else in his family has been unwell. He doesn’t recall eating anything out of the ordinary and he hasn’t been abroad recently. He has no genitourinary symptoms.
He doesn’t take any medication and hasn’t bought any over-the-counter treatments. He smokes tobacco (10 cigarettes a day) and drinks around 12 units of alcohol a week. There are no relevant conditions that run in his family.
On examination his pulse, blood pressure and temperature are all normal, but he does look slightly pale, and his conjunctiva are paler than expected. He has slight generalised abdominal tenderness, but abdominal examination is otherwise normal. Urine dipstick is also normal.
As he pulls his overalls back on, he asks you whether stress might be causing his symptoms. He explains he is a painter and decorator working to a tight deadline in the renovation of an old Victorian stately home. He has been ‘working all hours’ stripping and sanding paint off the walls, with the paint being around 20 layers thick in places. ‘I’m worried I’m not going to get it done in time, so I’ve been cutting a few corners’, he says.
You doubt that his symptoms are stress-related and have an inkling there may be something unusual going on here. Given his previous rare attendances, the abdominal tenderness and pallor, you feel that there are enough factors to warrant advising him to attend A&E today, as he may need urgent treatment.
When you later review his discharge letter you see that you were right.
What was the cause of his symptoms? What urgent treatment did he need?
Answer
In A&E, this patient had a series of blood tests taken, including a FBC which revealed a normocytic anaemia (Hb 101g/L) and a blood film which showed basophilic stippling. His U&Es and LFTs were normal.
Given his symptoms, and the concerns related to his occupation mentioned in my referral, his blood lead level was also checked. This was found to be raised at 55.3μg/dL (above 10μg/L indicates potential lead poisoning). Hospital staff consulted Toxbase.org, which advises that ‘chelation therapy should be considered in non-encephalopathic adults with a blood lead concentration greater than or equal to 50μg/dL (2.4μmol/L)’.
He was therefore diagnosed with acute lead poisoning, which had been caused by occupational exposure when removing old Victorian leaded paint from the walls, without wearing his respirator. He was given urgent chelation therapy, and subsequently advised to adjust his working practices to ensure use of appropriate safety equipment.
Symptoms of lead poisoning can include lethargy, anorexia, abdominal cramps, arthralgia and headaches. It can also cause anaemia and in severe cases convulsions, encephalopathy and renal failure.
This case highlights the importance of taking a good occupational history, particularly in situations where the patient presents with a confusing picture involving non-specific symptoms.
Dr Hannah Rosa is a GP in the North East of England
