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Pellets in the Appendix

An 8-year-old hyperactive boy was admitted to the hospital after having been found to have elevated blood lead levels, ranging from 17.4 to 27.4 μg per deciliter (reference range, <10) over a period of 2 years. An abdominal radiograph revealed large numbers of small, hyperdense foci in the right lower quadrant.

Pellets in the Appendix
A follow-up radiograph of the patient revealed that pellets were still present in the gastrointestinal tract, in either the cecum or the appendix.

After identifying foreign objects inside what looked like the boy’s stomach, doctors flushed his digestive system out but the objects remained unchanged.

Doctors then found over 50 lead pellets trapped inside the boy’s appendix with no explanation for how the pellets got there from the digestive tract.

The high amounts of lead trapped inside the boy’s body led to symptoms of lead poisoning, including uncharacteristic hyperactivity and lead concentrations of over 5 times more than normal.

The entire family reported that they regularly ate geese that were killed with lead pellets from a shotgun, and the children reported that they had been eating the pellets as part of a game to make them disappear. The patient and his siblings underwent bowel washout.

Pellets in the Appendix
Family discovers unusual source behind boy’s lead poisoning.

Laparoscopic appendectomy was performed. The appendix weighed 27.5 g (normal weight, 4 to 5 g), measured 55 mm in length, and had an average external diameter of 7 mm with a wall thickness of 2 mm.

Pellets in the Appendix
A total of 57 lead pellets were recovered from the lumen.

Microscopical examination of the appendix showed minor changes with a focus of submucosal calcification and fibrosis. No acute inflammation was observed.

Primary Reference

  1. Ibrahim Zardawi, Eranga Siriweera. Pellets in the Appendix. August 8, 2013. N Engl J Med 2013; 369:e7 DOI: 10.1056/NEJMicm1214754

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