Case presentation
A 40-year-old man was transferred to our center at Abu Ali Sina
Hospital, Shiraz, Iran, to be evaluated for severe bone pain and
abdominal pain for a month with worsening since 1 week ago. The bone
pain was mostly limited to lower extremities and the abdominal pain was
severe with colicky pattern and radiation to both scrotums. It was
accompanied by nausea, vomiting and constipation. The patient was also
complaining of severe weight loss (15 kg during a month). He was a fast
food employee with history of excessive alcohol intake over 3 years,
with no periods of abstinence. He was drinking 1-2 liters of homemade
alcohol (using traditional container for distillation) daily until few
days prior to admission. Additionally, he reported a history of on and
off synthetic marijuana abuse till 3 days prior to admission. His past
medical history was not significant and he was not taking any
medication. His physical examination was significant for high blood
pressure (180/100 mmHg), tachycardia (108/min) and low grade fever
(37.9°C) with abdominal and both scrotal tenderness.
Laboratory investigations at presentation showed moderate microcytic and
hemolytic anemia in addition to significantly elevated liver enzymes.
Abdominopelvic sonography and CT scan showed biliary sludge and small
liver hemangioma, respectively. Other laboratory and imaging
investigations (color doppler sonography of mesenteric artery and vein,
upper gastrointestinal endoscopy, colonoscopy) were unremarkable. He
underwent cholecystectomy with the impression of acute cholecystitis and
the microscopic pathologic diagnosis was just chronic cholecystitis
without cholelithiasis. Due to the presence of unexplained anemia and
severe bone pain, bone marrow study was done for him to rule out of
leukemia, which was in favor of myelodysplastic syndrome (MDS) with 10%
ring sideroblasts (Figure 1). Cytogenetic study was normal. Complete
blood count (CBC) test with peripheral blood smear (PBS) checking
(according to our policy in the hematology laboratory) was done for the
patient several times at presentation and during hospitalization. Blood
film examinations revealed mild to moderate anemia, microcytic
hypochromic red blood cells with, anisocytosis, polychromasia and also
frequent coarse basophilic stippling of the red cells (Figure2 A, B);
the last one was missed at the first PBS review. Regarding the presence
of ring sideroblasts in the bone marrow report, the possibility of lead
poisoning was considered and surprisingly the blood lead level was
markedly raised (151 µg/dL; reference range was 10 µg/dL). Since there
was no occupational exposure, the traditional distillation dish (made of
copper and lead) was traced as the possible source of the lead.