Moffitt AM Report Pearls 6/15: Lead poisoning, peripheral eosinophilia, and adrenal insufficiency!

Lead poisoning

  • 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

  1. Parasitic infections
  2. Endocrine – adrenal insufficiency!
  3. Malignancy (esp leukemias and lymphomas)
  4. Drugs
  5. Allergic diseases (atopy)


Adrenal insufficiency

  • 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!
  • Adrenal insufficiency
    • 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


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