Burton line

Q: 62 years male who has worked at a shooting range his entire life is admitted to the ICU with accelerated hypertension. Patient on history taking also complains of colicky abdominal pain getting worse over the years, arthralgia, myalgia, fatigue, insomnia, decreased libido, loss of short-term memory, irritability, tremor, and depression. On exam, a Burton line was noted on the gums. CBC is reported with basophilic stippling. Which poisoning is expected?

Answer: Lead

Burton line is a bluish gingival pigmentation at the gum-tooth line. This occurs due to the reaction of lead with bacteria in dental plaque that causes the formation of lead sulfide. If present with other symptoms, it is probably lead toxicity, which can be proven otherwise. 

At shooting ranges, dust generated from the use of leaded bullets and leaching from bullets is a known cause of higher blood lead levels.

#toxicity

References:

1. Helmich F, Lock G. Burton's Line from Chronic Lead Intoxication. N Engl J Med. 2018 Nov 8;379(19):e35. doi: 10.1056/NEJMicm1801693. PMID: 30403939.

2. Karami M, Mohammed LM, Dehghan SF, Hashemi SS, Baiee H. Burton's Line on the Gum Seen in Lead Poisoning Among Petroleum Refinery Workers in Kirkuk City, Iraq: A Case Series. Cureus. 2024 May 10;16(5):e60050. doi: 10.7759/cureus.60050. PMID: 38854344; PMCID: PMC11162749.

3. Morita T, Nishizawa T, Morikawa T. Burton line and basophilic stippling in lead poisoning. CMAJ. 2024 Apr 14;196(14):E487. doi: 10.1503/cmaj.231405. PMID: 38621780; PMCID: PMC11019604.