When Heavy Metals Weigh on the Mind: A Case Report of Neuropsychiatric Manifestations of Lead Toxicity From a Retained Bullet

Lead toxicity is a rare but potentially serious clinical condition that can manifest with a wide range of neuropsychiatric and systemic symptoms. We present the case of a 29-year-old male patient from Medellín, Colombia, who experienced delayed-onset neuropsychiatric symptoms secondary to chronic lead exposure from a retained bullet fragment in the left ankle, following a firearm injury sustained 13 years earlier. The patient initially presented with essential tremor in both upper and lower limbs, nausea, vomiting, subjective fever, a metallic taste in the mouth, mood disturbances, significant unintentional weight loss, and chronic mixed-type ankle pain with localized edema. A blue line on the gums (Burton's line) was observed on physical examination, raising suspicion for lead poisoning. Blood lead level testing confirmed severely elevated levels, supporting the diagnosis of chronic lead intoxication. Additional laboratory tests revealed moderate to severe normocytic anemia and transiently elevated serum creatinine. Despite the persistence of symptoms for approximately three years, diagnosis and treatment were delayed. The bullet was surgically removed after approximately seven months of clinical deterioration. The case highlights the systemic impact of chronic lead exposure and the importance of recognizing non-occupational sources, such as retained ammunition fragments, as potential causes. This report emphasizes the need for early recognition of atypical neuropsychiatric presentations, particularly in patients with a history of trauma or exposure to heavy metals. It also reinforces the relevance of integrating clinical findings with occupational and environmental history to guide diagnosis. Lead intoxication remains a significant public health issue, especially in regions with limited regulation or awareness, and should be considered in the differential diagnosis of unexplained systemic and cognitive symptoms.