Abstract:
INTRODUCTION:Despite greater than 60,000 nonfatal firearm injuries per year in the United States, retained shrapnel is a relatively rare cause of systemic lead toxicity with less than 100 cases reported in the medical literature since 1867. While intra-articular retained shrapnel as a cause of lead toxicity is well-described, extra-articular fragments are less well known to cause symptomatic disease. CASE REPORT:A 31-year-old man initially presented with abdominal pain, constipation, jaundice, and elevated liver transaminases approximately 3 weeks after suffering a left lower extremity injury during athletic activity. The patient was found to have steatohepatitis after extensive inpatient and outpatient gastroenterological workup to include upper and lower endoscopy, liver ultrasound, and biopsy of the liver to confirm the diagnosis. Imaging was incidentally notable for retained gunshot in the left flank and large shell fragment containing seroma in the left thigh. The patient was initially discharged with improved pain, but later presented to a primary care clinic with weight loss and continued pain. This was followed by a subsequent progression to diffuse weakness, ultimately resulting in an inability to ambulate. The patient was readmitted to a tertiary care medical center, 3 months after the initial presentation. Physical exam was then notable for 70-lb weight loss from initial admission and diffuse peripheral weakness with global muscle atrophy. Following a broad differential workup, he was found to have a blood lead level of 129 μg/dL, and hemoglobin of 7.7 g/dL with basophilic stippling on peripheral smear. The patient was transferred to the intensive care unit for chelation therapy with dimercaprol and calcium ethylenediaminetetraacetic acid. Lead levels initially decreased, but rose when patient was transitioned to oral therapy with succimer. Surgery was consulted for removal of multiple retained fragments, which were analyzed by the Joint Pathology Center and found to contain lead. The patient's motor function gradually improved on oral chelation and he was discharged to a subacute rehabilitation facility. CONCLUSION:This complex case describes a rare cause for a relatively common clinical presentation, jaundice and hepatitis, and reinforces the importance of longitudinal follow up and reassessment of a patient with an unknown illness and worsening clinical condition. Diagnosis of systemic lead toxicity is challenging because of its protean clinical manifestations, and relative rarity with the advent of strict environmental lead controls and decrease in lead-based paint and industrial products. Furthermore, extra-articular lead remains a rare cause of systemic toxicity, and the surgical standard of care has been to not remove these fragments in gunshot victims. This case adds to a small amount of evidence that lead screening may be of value in selected patients with extra-articular retained shrapnel, especially those with seroma and osteophyte formation in the wound.
journal_name
Mil Medjournal_title
Military medicineauthors
Grasso IA,Blattner MR,Short T,Downs JWdoi
10.7205/MILMED-D-16-00231subject
Has Abstractpub_date
2017-03-01 00:00:00pages
e1843-e1848issue
3eissn
0026-4075issn
1930-613Xjournal_volume
182pub_type
杂志文章abstract:INTRODUCTION:Nearly 10% of all combat injuries during the most recent conflicts in Iraq and Afghanistan involve thoracic trauma. The long-term outcomes of these combat-related injuries with respect to lung function have not been fully evaluated. Limited research in civilian polytrauma patients have shown significant ob...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usaa165
更新日期:2020-12-30 00:00:00
abstract::An investigation was conducted to determine if testing machine crosshead speed influenced shear bond strength (SBS) or the failure mode of composite bonded to enamel and dentin. Composite cylinders were bonded to 50 enamel and 50 dentin surfaces and thermocycled. Groups of 10 samples were debonded at speeds of 0.1, 0....
journal_title:Military medicine
pub_type: 杂志文章
doi:
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abstract::This article presents the results of a survey distributed to military women within and outside the continental United States (CONUS and OCONUS) who had received prenatal care and delivered at one of six Army, Navy, or Air Force military facilities. This comparative descriptive study was undertaken to determine from th...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:2001-05-01 00:00:00
abstract::During Operation Desert Storm, in February 1991, Iraqi troops began burning Kuwaiti oil wells. Almost immediately there was concern about possible adverse health effects in U.S. personnel exposed to crude oil combustion products. Combustions products were predicted from the known composition of Kuwaiti crude oil. Moni...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/milmed-d-11-00079
更新日期:2011-07-01 00:00:00
abstract::This study determined the perception by 951 U.S. Army soldiers of positive and negative consequences of a peacekeeping deployment to Bosnia. Seventy-seven percent reported some positive consequences, 63% reported a negative consequence, and 47% reported both. Written comments were also provided. Of the 951 soldiers, 4...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/milmed.170.10.815
更新日期:2005-10-01 00:00:00
abstract::This retrospective study examined spinal-related hospitalizations of U.S. Army soldiers deployed to Afghanistan and Iraq. Spinal cord injuries (SCI) and vertebral column injuries (VCI) were identified using International Classification of Disease, 9th Revision, Clinical Modification diagnosis codes. In our study, spin...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/MILMED-D-14-00061
更新日期:2015-02-01 00:00:00
abstract:INTRODUCTION:Obtaining vascular access is of paramount importance in trauma care. When peripheral venous access is indicated but cannot be obtained, the intraosseous route represents an alternative. The Bone Injection Gun (BIG) is the device used for intraosseous access by the Israeli Defense Force (IDF). The purpose o...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/MILMED-D-14-00013
更新日期:2014-11-01 00:00:00
abstract:OBJECTIVES:Given the burden of multiple chronic conditions (MCCs) in the Veterans Affairs (VA) Health Care System, understanding perspectives of Veterans with MCC is essential to evaluate chronic care and ensure that care and quality improvement efforts align with patient needs. The purpose of this study was to use the...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/MILMED-D-15-00207
更新日期:2016-05-01 00:00:00
abstract::In June 1998, six unexpected anterior cruciate ligament (ACL) ruptures within 12 months were detected by routine injury surveillance in a cohort of Australian Army recruits. Local investigation, reported separately as a Case Report in this issue, suggested the cause to be an excessive coefficient of friction between r...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:2002-04-01 00:00:00
abstract::This study compared the effects of a higher protein supplement manufactured from milk vs. a commercially available higher carbohydrate supplement on serum markers of muscle damage, anaerobic exercise, choice reaction time, and body composition during 2 weekends of vigorous hikes with simulated mountain skirmishes. Thi...
journal_title:Military medicine
pub_type: 杂志文章,随机对照试验
doi:10.7205/milmed-d-11-00396
更新日期:2012-06-01 00:00:00
abstract::Over 20 yr have elapsed since the end of the First Gulf War, yet approximately one-third of the veterans exhibit Gulf War Illness (GWI) symptoms, particularly depression and memory impairments. Exposure to organophosphate (OP) compounds is implicated for GWI development. The role of calcium (Ca2+) signaling in learnin...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usx148
更新日期:2018-03-01 00:00:00
abstract::The increasing incidence of malignant melanoma challenges physicians to find innovative ways to preserve function and appearance in affected areas that require partial resection. We carefully planned the resection of a malignant lesion between the third and fourth toes of a 77-year-old man with the aid of computer tec...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:2001-08-01 00:00:00
abstract::The study determines the extent to which payment thresholds for reporting malpractice claims to the National Practitioner Data Bank identifies substandard health care delivery in the Department of Defense. Relevant data were available on 2,291 of 2,576 medical malpractice claims reported to the closed medical malpract...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:1997-04-01 00:00:00
abstract::This article describes, from the perspective of Project HOPE volunteers, the precedent-setting, military-civilian partnership in staffing the USNS Mercy as part of the rapid response of the United States to the overwhelming devastation and loss of life resulting from the tsunami off the coast of Indonesia. The article...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/milmed.171.1s.34
更新日期:2006-10-01 00:00:00
abstract:OBJECTIVE:This article addresses the design of a robust autopilot for the delivery of intravenous anesthesia drugs. METHODS:A mathematical framework that expresses the pharmacological variability of a patient population into uncertainty bounds is proposed. These bounds can be effectively used to tune the parameters of...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/MILMED-D-14-00380
更新日期:2015-03-01 00:00:00
abstract::A young man evaluated for a testis tumor was found to have Burkitt's lymphoma. The presentation of Burkitt's lymphoma in the United States as a testis mass is unusual. The rapid proliferation and metastatic potential of the tumor mandates prompt evaluation and the early initiation of systemic chemotherapy. ...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:1994-04-01 00:00:00
abstract:INTRODUCTION:Tinnitus is an auditory problem frequently reported by military personnel and is currently responsible for 1 billion dollars annually in disability compensation. Recent military conflicts in Iraq and Afghanistan saw high levels of combat exposure coupled with a surge in blast weaponry, both of which can ad...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usaa103
更新日期:2020-09-18 00:00:00
abstract:OBJECTIVE:To assess whether race is a significant factor in the ability of prostate-specific antigen velocity (PSAV) for predicting high-grade prostate cancer (HGPC). METHODS:Records of men who underwent prostate biopsy between January 2003 and December 2007 were retrospectively reviewed to collect demographic data, s...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/MILMED-D-13-00332
更新日期:2014-03-01 00:00:00
abstract:OBJECTIVE:The purpose of this study is to report the device lessons learned from an emergency tourniquet program and, in particular, to emphasize analysis of discarded devices recovered after clinical use. METHODS:Discarded tourniquet devices were analyzed after use in emergency care of war casualties to determine wea...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/milmed-d-11-00114
更新日期:2011-10-01 00:00:00
abstract:INTRODUCTION:The most common cause of preventable death on the battlefield is significant blood loss, eventually causing decrease in tissue oxygen delivery. Pulse oximeters (POs) are widely used by the Israeli Defense Forces to obtain fast and noninvasive information about peripheral oxygen saturation (SpO2). However, ...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usaa314
更新日期:2021-01-25 00:00:00
abstract:OBJECTIVES:To evaluate a managed care demonstration project in CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), the insurance program covering physical and mental health care services for the dependents of active duty military personnel, military retirees, and the retirees' dependents. The demon...
journal_title:Military medicine
pub_type: 临床试验,杂志文章
doi:
更新日期:2000-05-01 00:00:00
abstract::The radiopacity of intermediate restorative materials should be sufficient to enable the clinician to distinguish the material from normal and decalcified tooth structure. The purpose of this study was to determine the relative radiopacities of intermediate restorative materials, including a newly introduced high-visc...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:2000-04-01 00:00:00
abstract::A case of primary squamous cell carcinoma of the thyroid is presented. Squamous epithelium is normally not present in the thyroid gland, and this tumor is exceedingly rare. Proper workup is described, including the differentiation from metastatic disease. The case reported is of a 64-year-old woman who presented with ...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:2003-02-01 00:00:00
abstract::The federal initiative for electronic health record (EHR) interoperability began in 2000 and set the stage for the establishment of the 2004 Executive Order for EHR interoperability by 2014. This article discusses the chronology from the 2001 e-Government Consolidated Health Informatics (CHI) initiative through the cu...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/milmed-d-03-9708
更新日期:2009-05-01 00:00:00
abstract::A 26-year-old suspected Iraqi insurgent is brought to a Troop Medical Clinic in Baghdad, Iraq, with curious marks on his body. On questioning, he describes productive cough, subjective fever, drenching night sweats, and unintentional weight loss. This case shows a condition with which Western physicians are generally ...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.7205/MILMED-D-12-00219
更新日期:2013-07-01 00:00:00
abstract:INTRODUCTION:Medical error is the third leading cause of death in the United States, contributing to suboptimal care, serious patient injury, and mortality among beneficiaries in the Military Health System. Recent media reports have scrutinized the safety and quality of military healthcare, including surgical complicat...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usz330
更新日期:2020-03-02 00:00:00
abstract::The National Academies of Sciences, Engineering, and Medicine Report on Zero Preventable Deaths highlighted the need for a military and civilian partnership to take lessons learned from the wars in Iraq and Afghanistan and incorporate them into a national learning trauma care system. One of the specific objectives in ...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usy149
更新日期:2018-09-01 00:00:00
abstract::Mindfulness meditation training has been shown to reduce stress and improve short-term memory for military personnel. However, no studies have investigated the effects of in-person and virtual world (VW) mindfulness training on Post-Traumatic Stress Disorder (PTSD) or Attention Deficit Hyperactivity Disorder (ADHD) sy...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usx227
更新日期:2018-03-01 00:00:00
abstract::This case report examines a vesiculopustular reaction which occurred in a young Marine 9 d after receiving the smallpox vaccination. Review of the CDC guidelines, ACAM2000 package insert, and literature surrounding the smallpox vaccine reveals several well-established adverse cutaneous reactions associated with vaccin...
journal_title:Military medicine
pub_type: 杂志文章
doi:10.1093/milmed/usx133
更新日期:2018-09-01 00:00:00
abstract:OBJECTIVE:To describe the demographic characteristics and postwar health status of U.S. Gulf War veterans who participated in the Department of Veterans Affairs health examination registry program. DESIGN:Case records of 52,835 veterans who participated in a standardized health examination program were reviewed. SETT...
journal_title:Military medicine
pub_type: 杂志文章
doi:
更新日期:1999-05-01 00:00:00