High Lead Levels From Old Bullet Fragments

Bullets and bullet fragments are not always removed if they don’t threaten the injured person’s life. But “retained” bullet fragments (RBFs) can lead to nonspecific symptoms of lead toxicity years later, such as, fatigue, abdominal pain, and memory loss.

Routine testing of adults with RBFs is infrequent, the CDC says. Usually, testing for blood levels of lead is done to monitor occupational exposure. But the number of people with RBFs who have toxic blood lead levels (BLLs) may be higher than thought. At BLLs ≥ 10 µg/dL, hypertension, kidney dysfunction, possible subclinical neurocognitive deficits, and adverse reproductive outcomes have been documented.

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CDC researchers analyzed data from 41 states for 145,811 adults with elevated BLLs from all causes, reported by the Adult Blood Lead Epidemiology and Surveillance program from 2003 to 2012. Of those reported cases, 349 had levels ≥ 80 µg/dL. RBF-associated cases accounted for 0.3% of adults with elevated BLLs, but 4.9% of adults with BLLs ≥ 80 µg/dL. The maximum recorded RBF-associated BLL was 306 µg/dL. Further, RBF-associated cases were “overrepresented” among people with BLLs ≥ 80 µg/dL: 3.7%, compared with 0.2% of people without RBF-related elevated lead levels.

As of 2004, the researchers say, < 100 cases of lead toxicity caused by RBFs had been reported in the medical literature. They advise asking any patient who has elevated BLLs with an unknown lead exposure source about RBFs. A low index of suspicion could delay diagnosis or even contribute to an incorrect diagnosis.

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Moreover, BLLs can fluctuate in people with RBFs, they note. A patient with a low BLL at the time of testing can have an increase in BLL and become symptomatic when RBFs migrate, such as into a joint space. The CDC researchers suggest baseline and intermittent BLL tests for people with a history of RBFs.