History:

A six-year-old male presented with new onset status epilepticus unresponsive to standard treatments including benzodiazepines, levetiracetam, propofol, ketamine and barbiturates in the PICU. The patient had a past medical history of presumed autism with non-verbal communication issues and pica. He had migrated to the UK from Nigeria six months prior to admission. 

Investigations:

EEGs conducted on admission were consistent with sub-convulsive status epilepticus, with asynchronous seizure activity between hemispheres. There were occasional sporadic shoulder or head jerks, potentially occurring post bursts of paroxysmal EEG activity.

He had extensive grey matter abnormalities on MRI (image to be presented). His whole-genome-sequencing test for an underlying seizure disorder was negative.

Blood tests revealed hypochromic microcytic anaemia with basophilic stippling on the blood film. Blood lead concentrations were 50 times higher than the upper limit of normal. 

Abdominal x-ray showed metal fragment ingestion, consistent with lead exposure, and long bone x-rays highlighted distinct metaphyseal bands (images to be presented), emphasising the impact of lead poisoning. 

Public health England investigated the cause and found evidence of lead in the paint in the patient’s flat which he had been ingesting. 

Treatment:

Following intravenous chelation therapy and oral dimercaptosuccinic acid he improved dramatically and returned to baseline. A follow-up EEG on day four of admission, showed only occasional epileptiform discharges with an almost normal EEG background. 

Summary and Relevance:

This is a novel case of lead poisoning in the UK and exemplifies the ongoing health risks from lead exposure, especially in pre-1987 residences. The child's inadvertent ingestion of paint flakes highlights the persistent risk through pica behaviour, necessitating increased awareness and preventive measures. Additionally, the case reveals neurophysiological complexities of status epilepticus in lead poisoning, stressing the importance of early diagnosis and intervention. Insights gleaned from this case can guide management strategies for similar cases, emphasising the urgency of accurate intervention in patients with lead exposure-induced neurological complications.