The use of automobile radiators containing lead-soldered parts in the illicit distillation of alcohol (i.e., "moonshine") is an important source of lead poisoning among persons in some rural Alabama counties. From March 5 through October 26, 1991, eight persons were diagnosed with elevated blood lead levels (BLLs) at a local hospital and were reported to the notifiable disease surveillance system maintained by the Alabama Department of Public Health (ADPH). None of these patients had known histories of occupational or other potential sources of lead exposure, but all reported recent histories of moonshine ingestion. This report summarizes the results of an investigation of these cases conducted by the ADPH during December 1991.

A case-patient was defined as any person aged greater than or equal to 17 years who presented to the hospital from January 1, 1990, through December 31, 1991, and had a BLL greater than or equal to 15 ug/dL. Laboratory records of specimens submitted for blood lead determination, and medical records were reviewed at the hospital. In addition to the eight patients reported to the ADPH, review of laboratory records identified one patient with a BLL of 35 ug/dL during November 1990.

Patients ranged in age from 28 to 64 years (median: 33 years); five were female. Five patients resided in the county in which the hospital is located, and four lived in adjacent counties.

All nine patients had been evaluated for alcohol-related medical conditions at the hospital. Manifestations included generalized tonic-clonic seizures (six), microcytic anemia (five) (hematocrit mean: 32.1%), encephalopathy (two), upper extremity weakness (one), and abdominal colic (one). BLLs ranged from 16 ug/dL to 259 ug/dL (median: 67 ug/dL).

Seven patients required hospitalization for 48 hours or longer (range: 2-18 days). Three of these received chelation therapy; initial BLLs were 67, 228, and 259 ug/dL. One patient, whose BLL was 67 ug/dL, died during hospitalization from alcohol-withdrawal syndrome complicated by aspiration pneumonia.

Patients reported moonshine ingestion ranging from 0.2 L per day to 1.5 L per day. No specimens of moonshine consumed by the patients were available for analysis. However, the lead contents of specimens of moonshine confiscated from two radiator-containing stills in the county in 1991 were 7400 ug/L and 9700 ug/L, compared with nondetectable amounts (less than 1.0 ug/L) in municipal water from the county. Consumption of 0.5 L per day of moonshine containing 9700 ug/L lead would result in a steady state BLL of approximately 190 ug/dL. *

Reported by: T Dix, S Walker, MD, Crenshaw County Hospital, Luverne; D Cosby, Alabama Alcohol Beverage Control, Andalusia; CH Woernle, MD, State Epidemiologist, Alabama Dept of Public Health. Div of Field Epidemiology, Epidemiology Program Office; Lead Poisoning Prevention Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note: The findings in the ADPH investigation underscore the adverse health effects associated with consumption of moonshine. Specifically, this problem can result from the leaching of lead from solder used in radiators or the adjoining copper pipe during distillation; moonshine may contain up to 74 ug/L of lead (1).

In adults, manifestations of lead intoxication include gastrointestinal, hematopoietic, renal, reproductive, and neurologic findings (e.g., peripheral neuropathy and encephalopathy) (1-3). Because signs and symptoms of lead poisoning may be nonspecific, the relative contribution of lead and alcohol toxicity to illness in these patients could not be determined. However, overt signs and symptoms of neurotoxicity rarely occur in adults when BLLs are less than 40 ug/dL (1). Thus, the seizures observed in these patients with BLLs less than 40 ug/dL may have been related to alcohol withdrawal rather than lead toxicity.

This cluster of patients with elevated BLLs was detected through review of notifiable disease surveillance data. In Alabama, elevated BLLs (greater than or equal to 15 ug/dL) have been a notifiable condition since December 1990. In 1991, 612 persons aged greater than or equal to 17 years with BLLs greater than or equal to 15 ug/dL were reported to the ADPH notifiable disease registry. Of these, the two highest values (228 ug/dL and 259 ug/dL) were from patients in this cluster.

The nine patients identified in this cluster may underrepresent the number of lead toxicity cases related to moonshine ingestion in the counties involved in this study and in others throughout Alabama. Although the number of illegal stills operating in Alabama is unknown, Alabama Alcohol Beverage Control destroyed 94 stills in 1991, including 50 stills in the county where the hospital is located and in two adjacent counties (D. Cosby, Alabama Alcohol Beverage Control, personal communication, 1992). Since a typical four-barrel still can produce 75-95 L of moonshine per week, a substantially higher number of persons may be at risk for lead toxicity from moonshine ingestion. Ongoing surveillance efforts are directed toward further characterizing risk factors for elevated BLLs and may assist in determining the scope of lead poisoning from moonshine ingestion among Alabama residents.

Because of the illegal source of the alcohol, patients may be reluctant to admit to moonshine ingestion. Therefore, clinicians, particularly in rural areas, should suspect moonshine ingestion when treating alcohol-abusing patients, both to detect and treat the adverse effects of lead poisoning and to direct alcohol-prevention efforts.

References

1. Agency for Toxic Substances and Disease Registry. Toxicologic profile for lead. Atlanta: US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, 1992.

2. Baker EL, Landrigan PJ, Barbour AG, et al. Occupational lead poisoning in the United States: clinical and biochemical findings related to blood lead levels. Br J Ind Med 1979;36:314-22.

3. Goldman RH, Baker EL, Hannan M, Kamerow DB. Lead poisoning in automobile radiator mechanics. N Engl J Med 1987;317:214-8.

• Assuming an equilibrium blood lead/dietary intake slope of 0.04 ug/dL per ug/day.

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