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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.

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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.

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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.

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