The differential diagnosis for lucent transverse metaphyseal lines or bands may be recalled using various mnemonics: CAMEL LINING Mnemonics CAMEL C: congenital infection (e.g. [25] One, a 10-year-old boy, had elevated blood lead levels (BLLs). Common sources of exposure to this ubiquitous metal may be broadly classified as occupational (or recreational), environmental, or perinatal (primarily trans-placental). Dense metaphyseal bands (differential) Last revised by Francis Deng on 29 Jan 2020 Edit article Citation, DOI, disclosures and article data The differential diagnosis of dense metaphyseal bands is wide. see full revision history and disclosures, https://www.ncbi.nlm.nih.gov/books/NBK537329/, 1. View Imran Ahmad Khan's current disclosures, see full revision history and disclosures, Dense transverse metaphyseal lines (mnemonic). Reyes PF, Gonzalez CF, Zalewska MK, Besarab A. Intracranial calcification in adults with chronic lead exposure. [29, 30, 31] Plain radiographs, CT, angiography, and sometimes MRI may all be used to localize the missile, to determine the path it followed in the body, to assess missile and bone fragmentation, and to identify missile emboli. Cellular and Molecular Toxicity of Lead in Bone. Marta Hernanz-Schulman, MD, FAAP, FACR is a member of the following medical societies: American Institute of Ultrasound in Medicine, American Roentgen Ray SocietyDisclosure: Nothing to disclose. All DeepDyve websites use cookies to improve your online experience. Reference article, Radiopaedia.org (Accessed on 02 May 2023) https://doi.org/10.53347/rID-10519. MMWR Recomm Rep. 2007 Nov 2. Radiological Society of North America, Inc. http://www.deepdyve.com/lp/radiological-society-of-north-america-inc/the-dense-metaphyseal-band-sign1-T1YzHA6HGA. With chronic exposure to lead, patchy calcifications may be seen on MRI scans (though these are better seen on CT scans). Disturbance of enchondral bone formation can produce lucent metaphyseal bands (red arrows are oval) as in this patient with leukemia. Unlike most other animals, humans cannot produce their own vitamin C. Lack of dietary vitamin C (ascorbic acid) may be related to inadequate food intake, the destruction of vitamin C in food caused by cooking and canning, or the absence of fresh fruit in the diet. In children, the density and width of the lead bands are well correlated with the concentration of lead ingestion or inhalation, as well as with the duration of lead exposure. Start a 14-Day Trial for You or Your Team. Dense vertical striations about the metaphyses are less common than transverse bands and are found in a selected group of disorders. Pediatrics. Tutar HE, Atalay S, Uysalel A, et al. flaking) results in incorporation in soil and/or dust contamination, degradation of lead-containing pipes and solder in plumbing, contamination of illegally distilled alcohol ("moonshine"), cooking spices, traditional remedies. The syndrome is clinically characterized by developmental delay of a progressive nature, hypotonia, elevated alkaline phosphatase levels, and late-onset spastic paraplegia. Fassin D, Naud AJ. The presence of lead foreign bodies in the gastrointestinal tract (caused by pica) may highlight the diagnosis and prompt immediate intervention. Wonders of Radiology. Lead exposure: health effects, prevention and treatment. 107(6):1437-42. Although in both children the MRI scans were normal, the lead-exposed boy had significant alterations in brain metabolites, with a reduced ratio of N -acetylaspartate to creatine in both gray matter and white matter. With chronic exposure to lead, patchy calcifications may be seen on CT scans in adults. DeepDyve's default query mode: search by keyword or DOI. Aids to Radiological Differential Diagnosis. the dense metaphyseal bands and generalized osteopenia persisted, and there was clear progression of the calcification of the interosseous membrane of the forearm (Fig. Selhi H & White J. A: Some of the common causes include chronic anemia, healing rickets and renal osteodystrophy. Gunshot wounds. Patients may present with lethargy and malaise, bone pain, bleeding diathesis (e.g. Part of Springer Nature. dense metaphyseal bands; cortex and flat bones may also be slightly dense [QxMD MEDLINE Link]. 1980 Jul. Unable to process the form. His cousin, a 9-year-old boy, had not been exposed to lead. At the time the case was submitted for publication Imran Ahmad Khan had no recorded disclosures. Radiographs revealed profound sclerosis of the metaphyses and epiphyses of the long and short bones in the extremities, with a unique pattern of distribution. In infants with severe lead poisoning, the bands may be wide and may prevent normal remodeling. BLLs were normal. 56:1-16. Taybi H, Lachman RS. Taybi H, Lachman RS. Specht AJ, Weisskopf MG, Nie LH. [24]. Osseous changes occurred on CT in 69% of patients, and on computed chest radiography in 53%. Pounds J, Long G, Rosen J. Common causes of dense transverse metaphyseal lines can be remembered using the mnemonics: DENSE LINES PRINCES Mnemonics DENSE LINES D: D-vitamin intoxication E: elemental arsenic and heavy metals ( lead, bismuth, phosphorus) N: normal variation S: systemic illness E: estrogen to mother during pregnancy L: leukemia, lymphoma I infection ( TORCH) Imaging: dense metaphyseal bands, suture separation due to lead encephalopathy (brain edema), dense ingested lead containing objects in GI tract Clinical: abdominal distension + pica Radiology Cases of Lead Poisoning 1996;34(1):107-8. Lead poisoning. The child was advised to practice sports. This website also contains material copyrighted by 3rd parties. Arch Environ Health. 1993 Apr. 1. K-shell x-ray fluorescence (KXRF) techniques have been used in epidemiologic studies to establish rates of environmental lead exposure in high-risk communities. At the time the article was last revised Francis Deng had no recorded disclosures. [16] A portable x-ray fluorescence (XRF) device has been developed to overcome these disadvantages, but introduced a measurement dependency on soft tissue thickness. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y. Sachs HK. 4B, C). 26(3):479-81. Radiology Sci Total Environ. The differential diagnosis of dense metaphyseal bands is wide. APPEARANCE Dense metaphyseal bands, less commonly known as dense metaphyseal lines, transverse bands, or "lead lines," indicate radiopaque bone (thicker than the adjacent diaphyseal cortex) at the metaphysis of growing bone, particularly at the wrists and knees ( Figs 1 , 2 ). Ian Turnbull, MBChB, DMRD, FRCR Former Lecturer, Department of Radiology, University of Manchester Medical School; Former Consulting Neuroradiologist, Hope Hospital, Salford, Manchester and North Manchester General Hospital, UKDisclosure: Nothing to disclose. Frankel line: dense zone of provisional calcification Trmmerfeld zone: lucent metaphyseal band underlying Frankel line Pelkin spur: metaphyseal spurs that result in cupping of the metaphysis Pelkin fracture: metaphyseal corner fracture Adults osteopenia pathological fractures [QxMD MEDLINE Link]. 1991 Oct. 59(10):413-24. Raber, S. (1999). Johnston MV, Nishimura A, Harum K, et al. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Price excludes VAT (USA) May become dense bands after treatment Most often seen in distal femur, proximal tibia (around knee), proximal humerus, distal radius, ulna Imaging Findings Lucent transverse band in the metaphysis of rapidly growing bones Generally appear of uniform thickness across metaphysis Differential Diagnosis Lymphoma [11] They described a 43-year-old man who was referred by a veterinary surgeon who evaluated the man's dog for a seizure; the veterinarian suspected a toxic lead exposure in both the dog and its owner. Biomed Environ Sci. J Neurol Neurosurg Psychiatry. These bands were preceded and perhaps presaged by abnormalities of the metaphyses and growth plate that were present at birth. 8. Albers JW, Bromberg MB. Albers and Bromberg reported a case of X-linked bulbospinomuscular atrophy, or Kennedy disease, masquerading as lead neuropathy. Piomelli S. Childhood lead poisoning. 1988 May. In addition, the distal ends of the long bones may disappear and appear clubbed. AJR Am J Roentgenol. These findings suggest that an increase in lead burden leads to an increase in the release of CPK-MB from the myocardial cells and that slight myocardial damage occurs, which might conceivably impair diastolic cardiac function. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Omare M, Kibet J, Cherutoi J, Kengara F. A Review of Tobacco Abuse and Its Epidemiological Consequences. 2002 Jan. 23(1):25-41. [28] A slightly elevated blood lead level (BLL) of the patient was alarming because of the possibility of subsequent lead poisoning associated with retained pellets. Bookmark this article. [18] The investigators used a questionnaire to gather information about the participants' occupational and environmental lead exposure. [QxMD MEDLINE Link]. Several mental retardation syndromes and cognitive disorders have been recognized as being secondary to genetic disruption of intracellular signaling cascades. 1976 JUN. 54(2):271-94, viii. Lead encephalopathy: CT and MR findings. Lead environmental pollution is a major health hazard throughout the world. If normal BLLs are maintained, the lead lines gradually decrease in density and disappear after about 4 years. Distinctive histology (irregular arrangement or mesh-like appearance of lamellae). 1990 Apr. show answer. Caffeys Pediatric Diagnostic Imaging, 11th Ed. Infantile scurvy, historically also known as Barlow disease, is named after Sir Thomas Barlow (1845-1945), Professor of Medicine at University College London 1895-1907 5. Manifestations differ based on a myriad of features including chronicity, exposure intensity, and age. The authors examined 2 male cousins who were living in the same household. The pellet was localized by means of 2-dimensional echocardiography of the left ventricular apical wall. {"url":"/signup-modal-props.json?lang=us"}, Jones J, Niknejad M, Qureshi P, et al. 1981 Apr. Blickman JG, Wilkinson RH, Graef JW. Radiology Review Manual. 48:1-38. [7]. As with CT, MRI plays a minor role in the diagnosis of lead poisoning. Become a Gold Supporter and see no third-party ads. His cousin, who was not exposed to lead, had normal neuropsychological function. The remainder had BLLs up to 21 mcg/g. Also, see eMedicineHealth's patient education article Poisoning. 1986 Feb. 146(2):267-70. J Comput Assist Tomogr. It does not occur before six months of age because maternal stores are maintained until then. These bands are not pathognomonic, and the differential diagnosis for cases involving opaque metaphyseal lines is wide and includes poisoning with other heavy metals; hypervitaminosis D; and the healing stages of leukemia,rickets, andscurvy. 2002 May-Jun. Osteosclerotic metaphyseal dysplasia: a skeletal dysplasia that may mimic lead poisoning in a child with hypotonia and seizures. Radiology. [from HPO] Term Hierarchy GTR MeSH CClinical test, RResearch test, OOMIM, GGeneReviews, VClinVar 1986 Feb. 146(2):245-7. Plain abdominal radiographs may also guide therapy in preventing further absorption through gastrointestinal decontamination. Year Book Medical Pub. A normal skeletal radiograph does not rule out lead poisoning in children. Ralph Weissleder, Jack Wittenberg, Mukesh G. Harisinghani. Gunshot wounds: 2. Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine Had a bone marrow transplant recently. no financial relationships to ineligible companies to disclose. 3. Perelman et al reported a case in which MRI results excluded a focal mass, and early treatment of edema prevented neurosurgical exploration. The decision was made at this time to commence treatment with pamidronate. 2017 Mar. Specht AJ, Lin Y, Xu J, Weisskopf M, Nie LH. 626:96-98. Differential diagnosis Common chronic anemia, e.g. Ahlgren L, Liden K, Mattsson S, Tejning S. X-ray fluorescence analysis of lead in human skeleton in vivo. [QxMD MEDLINE Link]. 2023 Springer Nature Switzerland AG. Radiographic findings in congenital lead poisoning. renal osteodystrophy; poisoning. Acta Paediatr. Theoretical modeling of a portable x-ray tube based KXRF system to measure lead in bone. Robbins and Cotran Pathologic Basis of Disease. Reassurance was given to the parents. [QxMD MEDLINE Link]. A 40-year-old man with end-stage kidney disease and calcium oxalate nephrolithiasis presented to the emergency department with joint pain. Read and print from thousands of top scholarly journals. Search At the time the article was created Abhi Datir had no recorded disclosures. These included striking rickets-like changes and marked osteopenia. 1985 Aug. 48(8):814-8. Arch Pediatr Adolesc Med. [Full Text]. Sources of occupational and recreational exposures include: automobile work (especially related to radiators). Bone-within-bone appearance in the spine and ossification centers was identified on computed radiography in 36%. Check for errors and try again. Plumbism reinvented: childhood lead poisoning in France, 1985-1990. Opaque metaphyseal bands in the upper and lower tibia and the upper fibula secondary to lead poisoning in a child. If the lead exposure is prolonged, there may be lack of bone modeling. Males and females are equally affected. Young children and older persons are predisposed to scurvy due to their diet or the overheating of food. {"url":"/signup-modal-props.json?lang=us"}, Niknejad M, Bell D, Deng F, et al. Submitting a report will send us an email through our customer support system. Its chemical symbol Pb,is short for plumbum, the Latin word for lead. Their results imply that MRS may depict metabolic abnormalities in individuals with lead poisoning. The Secret Life of the Periodic Table. Zou HJ, Ding Y, Huang KL, et al. AJR Am J Roentgenol. Check for errors and try again. [QxMD MEDLINE Link]. At the time the article was created Owen Kang had no recorded disclosures. In addition, T2-weighted MRI showed high signal intensity in the periventricular white matter, basal ganglia, insula, posterior thalamus, and pons. [Full Text]. Pediatrics. (2015) Interdisciplinary toxicology. Usama Munir, MBBS, FRCS Orthopedic Surgeon, Department of Surgery, Whiston Hospital, UKDisclosure: Nothing to disclose. volume50,pages 877878 (2020)Cite this article. Lead resists corrosion; in fact, lead pipes bearing the insignia of Roman emperors that were used as drains from the baths are still in service. [17]. Dense metaphyseal bands Case contributed by Dr Imran Ahmad Khan Diagnosis certain Share Add to Citation, DOI & case data Presentation Severe knee pain. Include any more information that will help us locate the issue and fix it faster for you. lead. Trope et al found that that magnetic resonance spectroscopy (MRS) may have a role as a noninvasive technique for the in vivo examination of the brain of children exposed to lead. 37 (5):231-46. 2023 DeepDyve, Inc. All rights reserved. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Benson and Price evaluated elderlypersons who grew up in a high-lead environment in Queensland, Australia, and experimental and neuropathologic studies demonstrated an association between exposure to lead and perivascular cerebellar calcification Schrote and associates reported a case of a 59-year-old potter who presented with lead polyneuropathy after 37 years of occupational exposure and noted that cranial CT showed extensive, bilateral, symmetrical calcification in the cerebellar hemispheres and minor calcification in the subcortical area of the cerebral hemispheres and basal ganglia. Case 4: bisphosphonate therapy - osteogenesis imperfecta, View Mohammadtaghi Niknejad's current disclosures, see full revision history and disclosures, Alternating lucent and dense metaphyseal bands. Common causes of dense transverse metaphyseal linescan be remembered using the mnemonics: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. OS patients treated with pamidronate can develop metaphyseal sclerotic bands as well as epiphyseal and vertebral endplate sclerosis progressing to a bone-within-bone appearance. bleeding gums, petechiae), and impaired wound healing. In 6 infants, there was evidence of multiple lead lines, indicating previous episodes of exposure to lead. Gunshot wounds: 1. 7. steroids, radiation injury from bone-seeking isotopes (strontium-90, yttrium-90, phosphorus-32), 1. In healthy infants 3 years of age or younger, the finding of increased metaphyseal opacity is not unusual. Curr Rev Musculoskelet Med 9:435444, Article 2. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. [12] The patient presented with hypotonia, developmental delay, and complex seizures. 4. [QxMD MEDLINE Link]. 1952;68 (5): 709-24. Become a Gold Supporter and see no third-party ads. Results of cranial CT, which is more sensitive than skull radiography, has confirmed that cerebellar and basal ganglia calcification occurs more commonly in patients examined in Queensland than in patients in North America. The decrease in diastolic cardiac function was more significant in the lead-intoxication group than in the nonexposed group. - 173.236.152.13. no financial relationships to ineligible companies to disclose. 7. Karl Francis Pelkan(1890-1992), an Austrian-American pediatrician described his eponymous spurs in a paper published in 1925 6,7. differential diagnosis for dense metaphyseal bands, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Ultrasonography is not routinely used in the diagnosis of lead intoxication, though transcranial sonography may be used to investigate congenital lead poisoning and lead intoxication in infant patients presenting with lead encephalopathy. Opaque metaphyseal bands are also seen after poisoning with other heavy metals; with hypervitaminosis D; and during the healing stages of leukemia, rickets, and scurvy. Search and discover articles on DeepDyve, PubMed, and Google Scholar, Organize articles with folders and bookmarks, Collaborate on and share articles and folders. (2003) ISBN: 0323023282 -, 2. They were placed on your computer when you launched this website. Pediatrics. milder pediatric cases may manifest with disturbances in behavior, growth, hearing and cognition, severe pediatric cases may progress to encephalopathy with seizures, coma, ataxia, cerebral edema, adults may similarly demonstrate mild (tired, irritable) symptoms or a severe encephalopathy, peripheral motor neuropathy may also develop, elevations (chronic) in zinc and erythrocyte protoporphyrin, may impair spermatic function and spermatogenesis, bone remodeling and growth may be affected in pediatric cases, with proposed mechanisms including 10, alterations in circulating endocrine factors such as parathyroid hormone and activated vitamin D, derangement in paracrine signaling factors such as osteocalcin, direct cellular toxicity, particularly affecting osteoclasts, growth trajectory and height may be affected, pathologically increased deposition of calcium in the zones of provisional calcification responsible for the dense metaphyseal bands on radiographs referred to as "lead lines", including aminolevulinic acid dehydratase and ferrochelatase 9, may impair production of erythropoeitin 6, erythrocyte functional and structural derangements, inhibition of erythrocyte sodium-potassium pump 8, predisposing to breakdown of the cell membrane and hemolysis, residual nucleotide clumps in cytosol appear as basophilic stippling, may show bands of increased density at the metaphyses, can affect any metaphysis, but the involvement of the proximal fibula and distal ulnar metaphyses is highly suggestive, abdominal radiographs utile for identification of exposure source and anatomic location if an ingestion is suspected 7, intra-luminal radio-opaque foreign body (or multiple punctate densities), serial radiographs may be used to monitor effectiveness of bowel decontamination, identification of source crucial to prevent ongoing toxicity 6, decontamination of ongoing sources of enteral absorption (paint chips, foreign bodies), some patients may require chelating agents to enhance elimination, also known as "British anti-Lewisite" or BAL, also known as succimer, the favored available oral chelating agent over d-penicillamine. At the time the article was last revised David Carroll had Balani A, Golla N, Dey AK, Mahankali S, Seelam S. Image of the month: Intracranial calcifications due to chronic lead exposure. Please confirm that you would like to log out of Medscape. 1990 Nov-Dec. 45(6):335-41. A workup was notable for nephrocalcinosis on imaging;. [QxMD MEDLINE Link]. Vet World. [25], In another study, Trope et al concluded that lead has an effect on brain metabolites, as detected by MRS in vivo. The Hand in Radiologic Diagnosis, With Gamuts and Pattern Profiles. The overall appearances were suggestive of lead poisoning. Pediatr Clin North Am. The symptoms of lead encephalopathy are mainly those associated with cerebral edema. Evidence suggests that cerebellar calcification is a marker of previous lead intoxication. 2016;9(10):1129-34. At the time the article was last revised Mostafa El-Feky had Eur Spine J. You can use Radiopaedia cases in a variety of ways to help you learn and teach. 9 (8):e105308. [26]. Several mental retardation syndromes and cognitive disorders have been recognized as being secondary to genetic disruption of intracellular signaling cascades. Check for errors and try again. Perelman S, Hertz-Pannier L, Hassan M, Bourrillon A. Radiology. 3. [6]. Opaque metaphyseal bands in the lower femur, upper tibia, and the upper fibula secondary to lead poisoning in a child. (2010) ISBN: 9781449976453 -. Year Book Medical Pub. These excess neurologic units are "sculpted" away during early brain development before the mature brain finally develops. Wolfgang Dhnert. Stanley Leonard Robbins, Vinay Kumar, Ramzi S. Cotran. The evolution of the radiologic lead line. (adsbygoogle = window.adsbygoogle || []).push({}); Lucent Metaphyseal Bands in Leukemia. 1998 Jun. Check for errors and try again. Functional MRI now offers the means to noninvasively study this plastic reorganization of the brain in children and adults. Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular ImagingDisclosure: Nothing to disclose. Young children undergoing CT or MRI may need heavy sedation or general anesthesia. Sclerosis involved the anterior ribs, iliac crests, talus, and calcaneus. Table 1. Goldfrank's Toxicologic Emergencies, Tenth Edition. Other clinical disorders, such as metabolic and epileptic encephalopathies and psychosocial deprivation, may be associated with disrupted brain plasticity. Eugen Fraenkel(1853-1925), a German pathologist, was the first person to be appointed a full Professor of Pathology at the University of Hamburg in 1919 6,8. Defective collagen cross-linking compromises skin, joint, bone, and vascular integrity. 50(4):337-40. The mean lead concentration in the skeletons of the 5 metal workers was estimated to be 62 mcg/g; the standard error was 5 mcg/g. Unable to process the form. [8], With the advent of electrophysiology, it has become obvious that spinal cord involvement is the cause of lead neuropathy. No other abnormality was depicted on CT. At the time the article was created Jeremy Jones had no recorded disclosures. Anton Sebastian. Hollerman JJ, Fackler ML, Coldwell DM, Ben-Menachem Y. However, prominent vertical trabecular formation may also represent normal anatomical variation in otherwise normal subjects. The lead lines may persist after the lead exposure ends. Analysis of the metaphyseal bone changes should help distinguish OMD from lead poisoning and other causes of metaphyseal sclerosis. This patient was encephalopathic and anemic and had a lead level of 60 g/dL (2.898 mol/L) at admission. Seo J, Lee BK, Jin SU, Park JW, Kim YT, Ryeom HK, et al.
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