A Case of Severe Lead Encephalopathy with Cardiac Arrest Managed During a Chelation Shortage

Abstract

Introduction: For many years, the standard of care in the USA has been to treat acute lead encephalopathy with a combination parenteral dimercaprol (BAL) and CaNa₂EDTA. We present a case of a pediatric patient with severe lead encephalopathy, complicated by cardiac arrest, who was treated with an alternative regimen when CaNa₂EDTA was unavailable.

Case report: A 24-month-old male was brought by ambulance to an emergency department (ED) with new onset seizures and sustained a cardiac arrest. An initial blood lead concentration returned at 263 mcg/dl. The hospital was unable to obtain CaNa₂EDTA due to the nationwide shortage. For this reason, the patient was chelated with BAL IM for 12 days and dimercaptosuccinic acid (DMSA) for 28 days. He received a second 5-day course of BAL due to rebounding blood lead concentrations. Eight days after cardiac arrest, he was extubated; however, despite ongoing therapy, subsequent follow-up 2 months later demonstrated persistent cognitive deficits.

Discussion: The combination of DMSA and BAL was effective in rapidly decreasing whole blood lead concentrations. Drug shortages continue to have implications for the management of poisoned patients. This case highlights how shortages of chelating agents complicate patient care.