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.