As if getting shot weren’t bad enough, a bullet that stayed lodged in a man’s knee gave him lead poisoning and a nasty bout of arthritis—a whopping 14 years after it first found him.
The curious medical tale was published as a case study Thursday in the New England Journal of Medicine, as part of its regular and often quirky “Images in Clinical Medicine” section.
According to the report, the 46-year-old man came to the emergency room of a Chicago hospital with left knee pain. The man reported a history of chronic pain in the knee, likely attributable to the bullet, but it was getting increasingly worse. And by the time doctors saw him, his knee had ballooned up.
In the course of taking the man’s medical history, it came up that he had sustained a gunshot wound to that same knee 14 years ago. The doctors who treated the man for the initial wound took x-rays of his knee, which showed a mostly intact bullet lodged near the knee joint. They decided to leave the bullet where it was.
“I’m not certain why the bullet was left in place initially in 2004,” co-author Michael Schindlbeck, the interim program director of Cook County Hospital’s Emergency Medicine Residency program, told Gizmodo in an email. “I didn’t have access to his records from that time outside of his X-ray images.”
When Schindlbeck and his team performed their own x-rays 14 years later, they saw the bullet had almost completely fragmented, with metallic debris swimming in the joint and surrounding tissue. Blood tests also showed the man had high levels of lead along with anemia, a common consequence of lead poisoning. Thankfully, there didn’t seem to be any other signs of chronic lead poisoning, such as severe cognitive impairment.
The man’s tale abruptly ends in the case study. He was given some chelation therapy to strip out the lead in his system, but not the needed full course. And according to the doctors, he was supposed to stick around for a surgery to remove some of the tissue surrounding his knee joint. But the man left the hospital before the surgery could take place, and doctors weren’t able to get in touch with him again.
But according to Schindlbeck, that wasn’t the last they saw of the man.
“He has returned several times since I first submitted the case report to the New England Journal of Medicine this past March, and did have surgery to remove some of his joint capsule (the tissue that was absorbing the lead in his joint) in April,” he said. “His follow-up from that point has been spotty at best, and his serum lead levels remain pretty elevated to this day.”
As with many of these stories, there’s a teachable moment for doctors. In this case, it’s the lesson that bullets that end up near a person’s joints (known as intraarticular bullets in medical lingo) should probably be taken out as soon as possible.
“In addition to causing joint damage, intraarticular bullets can fragment and dissolve in synovial fluid, leading to lead absorption and delayed symptomatic lead poisoning,” the doctors wrote.
Amazingly, it’s a lesson that’s gone unheeded more than once. There’s no shortage of similar medical case studies throughout the years of unfortunate patients who got lead poisoning and chronic joint pain from long-buried bullets.
“Our case is inherently not unique, but having the X-ray images from 2004 and 2018 demonstrating the progression of disease provided an excellent teaching opportunity, and perhaps a means to educate physicians to prevent similar cases from happening again in the future,” Schindlbeck said.
[NEJM]
This article has been updated to include comments and further context from one of the case study authors.