Clinical context

A 50-year-old female with weight loss and microcytic anaemia

At a glance

Stain	MGG

About Lead Poisoning

This patient has lead poisoning. Lead inhibits haem synthesis, causing retention of ribosomal RNA within red cells. This presents in the blood films as a microcytosis and prominent basophillic stippling (#1, #2, #3). Lead poisoning and iron deficiency are the only two causes of a fluctuant microcytosis - i.e. if a patient had a normal FBC, and now is microcytic. Haemoglobinopathies and thalassaemia patients will always be microcytic (B12 deficiency aside!).

In the bone marrow, we may see ring sideroblasts.

Clinically, patient often present with abdominal colic, peripheral neuropathy, encephalopathy and a blue gum line. Treatment is by removing the source and chelating the lead with DMSA or EDTA.

Morphological features

Prominent Basophilic Stippling

Microcytosis

If you are presented with this film - and you have no idea what it is - remember to establish the basics. This is a normal lymphocyte, and the red cells here are really quite microcytic. They should be roughly the same size. Microcytosis should make you think haemoglobinopathy, iron deficiency or lead poisoning. There are no real features of hbopathy (doesn't exclude alpha thal, I know), and it doesn't look like iron deficiency. Easy!

Basophillic Stippling

This is prominent basophilic stippling. This is suggestive of dyserythropoiesis - in the absence of features of beta thal, and in conjunction with microcytosis, this is suggestive of lead poisoning.

Basophillic Stippling

This is prominent basophilic stippling. This is suggestive of dyserythropoiesis - in the absence of features of beta thal, and in conjunction with microcytosis, this is suggestive of lead poisoning.

Normal Neutrophil

It's absolutely worth commenting in this blood film that the white cell and platelet morphology is normal. This really helps to narrow down the problem.

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