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Lead Poisoning Due to Adulterated Marijuana in Leipzig

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Official websites use. Share sensitive information only on official, secure websites. Stumvoll medizin. Between August and December , a mass poisoning due to adulterated marijuana was uncovered in the area of Leipzig, Germany. Retrospective reports of patients with lead poisoning who were treated at Leipzig University Hospital. Analysis of data from the local health office, where marijuana consumers could have their blood lead concentration determined. At Leipzig University Hospital, 35 patients 7 female; age Five hundred ninety-seven marijuana consumers men, women; age Among them, Drug consumption should be considered in otherwise unexplained anemia and abdominal colic. Several hundred people suffered lead poisoning presumably resulting from the desire of drug dealers to maximize profits. The reasons include the strict legal regulations on chemicals, the environment, and the workplace, and particularly the fact that all old lead pipes for domestic water have been replaced. Common sources of lead intoxication these days include lead-based paints in old houses, uncontrolled recycling procedures, car batteries, cosmetics, or toys 1 — 3. In the new German states, lead intoxications due to antiquated lead pipes were seen before reunification. In Leipzig, a series of lead intoxications occurred at the end of that were due to a hitherto unknown source of exposure: marijuana that had been adulterated with lead. Several people had to be treated for acute lead intoxication in the hospitals around the Leipzig area 4. The state attorney is bringing a case for dangerous bodily harm against persons unknown, and the European police authority Europol was consulted. The authors report about the patients who were treated at Leipzig University Hospital and about the results of a screening program initiated by the local health office, in whose context marijuana consumers were able to have the lead concentrations in their blood measured. The authors analyzed retrospectively the data of the patients with lead poisoning who had been treated at Leipzig University Hospital and data from the health office. They performed a literature search in Medline, using the search terms 'lead and poisoning,' 'intoxication,' 'therapy,' 'exposure,' cannabis,' 'marijuana,' 'drugs. From August to February , 35 patients including 7 women were treated for lead poisoning at Leipzig University Hospital. All patients were marijuana users. Five patients additionally reported using alcohol or further drugs, such as cocaine, amphetamines, or heroin. All patients were young adults or teenagers Atomic absorption spectrometry was used, and elementary lead was found in one specimen. The average number of joints consumed per week in the cohort was 7. The blood lead concentrations did not correlate with the amount consumed. This is presumably due particularly to the different degrees of contamination of the marijuana. It was not possible to determine the lead concentration per gram of marijuana as purchasing the drug is a punishable offence. Almost half the patients presented initially to the accident and emergency department. The following symptoms of lead intoxication were noted:. Figure 1 shows the therapeutic scheme used in the patients at Leipzig University Hospital. The local health office offered anonymous blood testing for lead to marijuana users until end-August Each test cost 22 euros; participants had to pay for themselves. Altogether specimens were examined men, women; age The oldest user was 56 years old and the youngest 15 years. The health office had no reports of fatalities due to lead intoxication or of pregnancies in women with raised lead concentrations. This size is reached in lead fumes during the burning of a cigarette or joint, at temperatures above degrees centigrade e5, e6. Metallic lead is slowly absorbed through the gastrointestinal tract and the skin, whereas tetraethyl lead antiknock agent is lipophilic and rapidly enters through the skin. If metallic lead or barely soluble lead salts are taken in only once, a toxic effect will be noticeable only in high concentrations. However, even tiny quantities, taken in over time, build up concentrations in the body and are excreted only very slowly. This proportion can be exchanged rapidly. Within days the lead concentrates in organs such as the liver, kidneys, brain, lungs and the spleen, in the aorta, teeth, and the skeleton 6. Its half-life in blood is 30 days 5. Lead stored in the bones is eliminated with a terminal half-life of up to 37 years 5 , 7. Because of the redistribution kinetics, the time of exposure cannot be determined with certainty. Organic lead alkyl compounds are dealkylated via hepatic cytochrome P—dependent mono-oxygenases, a process during which highly neurotoxic metabolites are formed 6. Lead has a high affinity to sulfhydryl groups and interacts with different enzyme systems and intracellular calcium channels. The result is disruption of heme synthesis, neuronal and renal damage, and osteoblast dysfunction. Lead poisoning typically manifests with acute abdominal colic, anemia, renal tubulopathy, peripheral neuropathy, or encephalopathy 2. In small children, a risk of intellectual developmental deficits is present 6 , 8. The box summarizes the symptoms and signs of lead poisoning. Owing to the ineffective heme synthesis, raised concentrations of porphyrins can be shown in urine. A possible differential diagnosis is porphyria, which is also accompanied by abdominal colic. The maturation of the erythrocyte lines is inhibited as a result of the inhibited activity of pyrimidine 5'-nucleotidase, which eventually causes normocytic hypochromic anemia with a shortened survival time of the erythrocytes, especially because of hemolysis, and reticulocytosis 9. The typical basophile stippling of the erythrocytes is the result of sedimentation of denatured ribosomal DNA and of mitochondrial fragments 8 , 10 figure 2. Lead competes for binding sites for cations such as calcium, zinc, or iron. Some of the toxic effects can be explained with its ability to substitute calcium. This influences mitochondrial function inhibition of cell breathing and neuronal signal transmission. The result: an increased release of neurotransmitters. Conspicuous behaviors in lead intoxication or porphyria may be caused by this. Depending on the extent and duration of exposure, lead can interfere with all systems of the central and peripheral nervous system. It has a toxic effect on immature astrocytes and, among others, invades the astroglia and neurons via voltage dependent calcium channels. Lead also affects myelin formation, which is essential for an intact blood-brain barrier e7. An increased permeability for proteins such as albumin results in edema with raised intracranial pressure and encephalopathy. Toddlers are particularly at risk of permanent damage, owing to immaturity of synaptogenesis, cell migration, or glial cell growth 6. Early symptoms of lead intoxication include irritability, headache, and impaired concentration. Subsequent symptoms include memory loss and cognitive impairments and disturbed fine motor control. In children, conspicuous behaviors—impulsiveness, attention deficit, reduced play activity, and loss in IQ—have been described The peripheral neuropathy mostly manifests as a weakness in the extensor muscle in the upper limb, which in serious cases may present as the classic 'drop hand. Lead-induced nephropathy manifests as proximal tubular damage, glomerular sclerosis, or interstitial fibrosis, and even renal failure. The extent of lead exposure does not correlate with the extent of nephrotoxic damage, which results in an increase in renal retention parameters in lowered glomerular filtration rate GFR , proteinuria, aminoaciduria, glycosuria, or transport defects for organic anions 12 , e8. The vitamin D hypovitaminosis caused by renal insufficiency is increased by the lead related inhibition of the transformation of OH vitamin D into active 1,OH vitamin D e9. In women, lead is mobilized from the skeletal stores to an increased degree during pregnancy and breast feeding by means of hormonal remodeling processes. Lead penetrates the placental barrier. Fetotoxic effects result in premature births or miscarriages, malformation, developmental delays, and neurocognitive deficits, as a result of the effects on immature neuronal structures 13 , In men, lead intoxication can result in hypospermia, teratospermia, or infertility 6. The typical signs of lead poisoning include abdominal colic and analgesic-resistant abdominal pain, whose pathogenesis can be explained with effects on the visceral muscles from lead competing with calcium on the ion channels 6. Meta-analyses have shown a statistical association between the degree of lead intoxication in the blood and the risk of hypertension 15 , 16 , e The relative risk of cardiovascular mortality was 1. The International Agency for Research on Cancer classified anorganic lead compounds as likely to be carcinogenic in e Data from epidemiological studies and meta-analyses have assessed the relative risk for tumor development for high grade exposure in the workplace at 1. Especially stomach and lung cancers and tumors of the deferent urinary tract seemed more common than in the control group Lead poisoning can be diagnosed from the development of a lead seam along the gingivodental margin figure 3. The dark blue—purplish black seam results from a reaction of the lead with sulfur ions that are formed by bacteria in the oral cavity and that form deposits as lead sulfide along the dental-gingival margin 20 , A lead seam does not correlate with the amount of lead in the blood, but is a reliable indicator for longer term exposure to lead. The whole blood concentration is the most commonly used biomarker for lead exposure, but only acute exposure from the preceding 35 days can be measured. Because lead is eliminated to variable extents through urine and the redistribution kinetics described earlier, lead measurement in urine is a qualitative measurement and does not provide valid information on the exposure quantity. Sufficient diuresis needs to be established, which may necessitate giving diuretics where required. Chelators bind lead reversibly and remove it from the organism via renal excretion of water-soluble complexes. Because of the redistribution of lead from the organ stores into the blood, repeat measurements may be required after 4 weeks, potentially followed by a repeated therapeutic cycle Succimer has to be imported, which may delay the start of therapy. Calcium EDTA and penicillamine are effective chelators; however, penicillamine has a problematic side effect spectrum. Antioxidants, such as vitamin C, can have a synergistic effect with chelator treatment In tetraethyl lead antiknock agent , chelator therapy is almost completely ineffective. Medical charcoal is the treatment of choice in this setting. The options for symptomatic treatment of abdominal cramps are limited because these symptoms do not respond well to relaxants or analgesics. In patients with pronounced anemia, transfusion may become necessary. No randomized controlled trials have been conducted for lead intoxication. The therapy should follow the suggestions made by the specialist societies A formal reference value—a threshold level of lead in the blood from which therapy is indicated—does not exist. The authors proceeded according to the scheme shown in figure 1 in their own inpatients. The cases of lead intoxication in young adults described in this article give reason to include the misuse of marijuana or other recreational drugs among possible causes of anemia and abdominal colic. Lead-tainted marijuana has thus far not been described as a source of exposure 4 , but case reports exist about adulterations of opium, heroin, methamphetamines, or cocaine with lead compounds e12 — e In the US state of Oregon, a case was reported in of mass intoxication with lead adulterated amphetamines e22 that bore similarities to the recent Leipzig incident. The origin and purpose of the lead in marijuana in the Leipzig scenario has not been criminalistically explained and is not known to the public. Because of its high specific weight According to oral communications from the drug advisory center and the health office, no lead-tainted marijuana is now available. It is of note that a relatively high proportion of users 6. This raises the suspicion that drug misuse starts early, in the teenage years. A targeted education campaign about drug consumption and prevention should be started for young teenagers. Treatment can effectively be administered by using a chelator—under the condition that the patient henceforth abstains from misusing recreational drugs. However, it needs to be clarified in advance whether health insurers will cover the—not insubstantial—costs. Particular thanks are due to Ms S. Lein, addiction officer of the City of Leipzig; Dr. Renal Center in Grimma; Dr. Ruf, St Georg Hospital in Leipzig; the police force of the City of Leipzig; and all doctors and patients who participated in the investigation and treatment. The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors. As a library, NLM provides access to scientific literature. Dtsch Arztebl Int. Find articles by Franziska P Busse. Georg Martin Fiedler , Dr. Find articles by Georg Martin Fiedler. Alexander Leichtle , Dr. Find articles by Alexander Leichtle. Helmut Hentschel , Dr. Find articles by Helmut Hentschel. Michael Stumvoll , Prof. Find articles by Michael Stumvoll. PMC Copyright notice. See letter ' Correspondence letter to the editor : Incorrectly Cited ' in volume on page See letter ' Correspondence letter to the editor : Indicative of Intoxication ' in volume on page See letter ' Correspondence reply : In Reply ' in volume on page Open in a new tab. Conflict of interest statement The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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