[Skip to Content]
[Skip to Content Landing]

Chronic Abdominal Pain and Anemia in a 59-Year-Old Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 59-year-old elementary school principal with a history of cholecystectomy and appendectomy and no use of alcohol, illicit drugs, or cigarettes presented to the emergency department for the fourth time in 3 months with diffuse abdominal pain not associated with nausea, vomiting, diarrhea, constipation, hematochezia, weight loss, fever, or anorexia. On physical examination, the patient had normal vital signs, mild diffuse abdominal tenderness without rebound or guarding, and bluish pigmentation along his gingival margin (Figure, panel A). Blood testing showed alanine aminotransferase level 51 U/L (0.85 μkat/L; reference range, 7-23 U/L [0.12-0.38 μkat/L]), aspartate aminotransaminase 68 U/L (1.14 μkat/L; reference range, 13-30 U/L [0.22-0.50 μkat/L]), total bilirubin 3.2 mg/dL (54.73 μmol/L; reference range, 0.4-1.5 mg/dL [6.84-25.66 μmol/L]) and direct bilirubin 0.9 mg/dL (15.39 μmol/L; reference range, 0.0-0.4 mg/dL [0.0-6.84 μmol/L]). Hemoglobin level was 8.7 g/dL with a normal mean corpuscular volume, and ferritin level was 637.9 ng/mL (reference range, 39.9-465 ng/mL). Blood testing revealed normal lactate dehydrogenase, haptoglobin, iron, vitamin B12, folate, zinc, and copper levels, and results of urinalysis were normal. A peripheral blood smear demonstrated small, bluish-purple punctate inclusions in erythrocytes (Figure, panel B). Results of upper and lower endoscopy and abdominal-pelvic computed tomography performed within the past 3 months were unremarkable.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Lead poisoning

A. Check blood lead concentration

The key to the correct diagnosis in this patient with unexplained chronic abdominal pain and normocytic anemia is recognition that the bluish pigmentation at his gum line (Burton line) and basophilic stippling of erythrocytes are characteristic findings in lead poisoning. ANCA testing (choice B) is not recommended because the patient did not have signs or symptoms of vasculitis. Paroxysmal nocturnal hemoglobinuria, which can cause abdominal pain and is diagnosed using flow cytometry (choice C), is unlikely because it typically causes dark or red-colored urine due to hemolysis. Testing for urinary porphobilinogen (choice D) is incorrect because although acute intermittent porphyria often causes unexplained abdominal pain, it is not associated with anemia.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity
Our websites may be periodically unavailable between 12:00am CT March 25, 2023 and 4:00pm CT March 26, 2023 for regularly scheduled maintenance.

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Mitsuyo Kinjo, MD, MPH, Okinawa Chubu Hospital, 281 Miyazato, Uruma City, Okinawa, 904-2293, Japan (kinjomitsuyo@gmail.com).

Published Online: June 24, 2022. doi:10.1001/jama.2022.9194

Conflict of Interest Disclosures: Dr K. Kinjo reported receiving book royalties from Igakushoin Ltd and Medical Science International Ltd. No other disclosures were reported.

Additional Contributions: We thank Joel Branch, MD (Shonan Kamakura General Hospital, Japan), Rita McGill, MD, MS (Department of Nephrology, University of Chicago), and Mitsuru Mukaigawara, MD, MPP (Harvard University), for their helpful comments and language correction of this manuscript. These individuals received no compensation for their contributions. We thank the patient for providing permission to share his information.

WHO Guideline for Clinical Management of Exposure to Lead. World Health Organization. Published 2021. Accessed June 13, 2022. https://www.ncbi.nlm.nih.gov/books/NBK575284/
Mason  LH , Harp  JP , Han  DY .  Pb neurotoxicity: neuropsychological effects of lead toxicity.   Biomed Res Int. Published online January 2, 2014. doi:10.1155/2014/840547PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention (CDC). CDC’s blood lead reference value. Reviewed October 27, 2021. Accessed June 13, 2022. https://www.cdc.gov/nceh/lead/data/blood-lead-reference-value.htm
Centers for Disease Control and Prevention (CDC). Adult blood lead epidemiology and surveillance (ABLES). Reviewed February 23, 2021. Accessed June 13, 2022. https://www.cdc.gov/niosh/topics/ables/default.html
US Department of Health and Human Services, Agency for Toxic Substances and Disease Registry. Toxological Profile for Lead. Published August 2020. Accessed June 13, 2022. https://www.atsdr.cdc.gov/toxprofiles/tp13.pdf
Lanphear  BP , Rauch  S , Auinger  P , Allen  RW , Hornung  RW .  Low-level lead exposure and mortality in US adults: a population-based cohort study.   Lancet Public Health. 2018;3(4):e177-e184. doi:10.1016/S2468-2667(18)30025-2PubMedGoogle ScholarCrossref
Saper  RB , Phillips  RS , Sehgal  A ,  et al.  Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet.   JAMA. 2008;300(8):915-923. doi:10.1001/jama.300.8.915PubMedGoogle ScholarCrossref
Kales  SN , Christophi  CA , Saper  RB .  Hematopoietic toxicity from lead-containing Ayurvedic medications.   Med Sci Monit. 2007;13(7):CR295-CR298.PubMedGoogle Scholar
Breeher  L , Mikulski  MA , Czeczok  T , Leinenkugel  K , Fuortes  LJ .  A cluster of lead poisoning among consumers of Ayurvedic medicine.   Int J Occup Environ Health. 2015;21(4):303-307. doi:10.1179/2049396715Y.0000000009PubMedGoogle ScholarCrossref
Questions and answers on dietary supplements. US Food and Drug Administration. Updated May 6, 2022. Accessed June 13, 2022. https://www.fda.gov/food/information-consumers-using-dietary-supplements/questions-and-answers-dietary-supplements
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.