Clinical Pearl: Consider Lead and Other Heavy Metal Toxicities in the Evaluation of Nonspecific Symptoms
Nonspecific complaints such as constipation, headache, fatigue, abdominal pain, myalgias, and arthralgias can be common among refugees. Given the prevalence of these complaints, and the incidence of PTSD and depression, it is often tempting after the initial screening and fruitless evaluation, to ascribe these common symptoms to somatic components of depression or PTSD and to not push the work-up yet further. Recent reports from the New York Health Department and the Center for Disease Control highlight the prevalence of high lead levels among recently arrived children and adults from Burma.
Pediatricians will be more familiar with this pediatric public health concern than their internist counterparts. It is important to note that adult lead exposure and toxicity was also common among Burmese refugees. As clinicians see new refugees the initial screening often turns up microcytic anemias. The prevalence of nutritional anemias, such as iron deficiency, and parasitic infections, such as hook worm, can readily explain the findings, as can the prevalence of asymptomatic alpha thalassemia among immigrants from Southeast Asia. Toxic exposures do not usually top the list of suspected etiologies.
We are reminded that environmental exposures in camps and in rapidly industrializing nations are common. Immigrants and refugees can be exposed to high levels of environmental and work place toxins that would be uncommon in western countries: mercury from mines, cadmium, arsenic, asbestos, silica, lead, beryllium to name only a few exposures can easily occur in the work environments in developing countries. The CDC report also identifies traditional treatments as a source of lead exposure, a source often not considered, and not limited to Burmese new arrivals. (Another recent CDC report identified a case in which the likely source of lead exposure was a traditional amulet made in Cambodia with leaded beads that was worn by the affected child.) It should go without saying that the immigrants themselves will be oblivious of these exposures.
Remember after the initial evaluations and treatment of abdominal pain, constipation, and fatigue, if persistent, an underlying toxicity should be considered. Evaluation of anemia should keep sideroblastic anemias in the differential in addition to the nutritional and parasitic burdens refugees often endure.