- Acute (days to weeks) vs chronic (months)
- Sxs are nonspecific: abd pain (“lead colic”), neuropsychiatric sxs, peripheral neuropathies, sxs of anemia
- See microcytic anemia with basophilic stippling on smear. In adults, can also see hemolysis.
- If Pb>100 à admit for IV chelation with EDTA. Can improve sxs (such as lead colic)
- Watch for side effects! hypoglycemia, hypocalcemia –> arrhythmias
- When sxs improve, can discharge with po chelation
- If Pb<100 à po chelation with succimer, removal from exposure
- Pt will need to be on chelation therapy for a long time, as it takes months for lead levels to come down (half life of lead is decades in the bones!)
- R/o other heavy metal toxicities! Work with local poison control/environmental health
Peripheral eosinophilia ddx
- Parasitic infections
- Endocrine – adrenal insufficiency!
- Malignancy (esp leukemias and lymphomas)
- Allergic diseases (atopy)
- Clinical manifestations – nonspecific, including fatigue, anorexia, n/v. On labs, can see peripheral eosinophilia!
- Think about primary vs secondary.
- Primary: see electrolyte abnormalities (hypoNa, hyperK, hyperCa – from mineralocorticoid effects), hyperpigmentation.
- Secondary: no electrolyte abnormalities or hyperpigmentation
- Workup: beautiful diagram from clevelandclinicmeded.com!
- Primary AI: Addison’s disease (most common in US), TB, bilateral adrenal hemorrhage, drugs
- Secondary AI: withdrawal of steroids is most common! Others include pituitary lesions/surgery, drugs
- Tertiary AI: from inadequate secretion of CRH
- Advanced learning: Nonclassic (late onset) 21-hydroxylase deficiency (CAH) = often confused with PCOS!
- Often see acne, hirsutism, oligo/amenorrhea! To dx this, check an AM 17-hydroxyprogesterone level.
- Super advanced pathophys: low 21-hydroxylase enzyme activity à decreased cortisol production à increased ACTH secretion à increased androgen secretion, such as DHEA and 17ohydroxyprogesterone