Occult lead poisoning from Ayurvedic medicine produced, prescribed and purchased in India

To the Editor: A 28-year-old man presented to his general practitioner with a history of epigastric pain and constipation over 1 month. In addition, he had a history of chronic low back pain. Findings on physical examination were unremarkable. Laboratory investigations showed normo-chromic, normocytic anaemia with basophilic stippling (Box 1). His whole-blood lead level was subsequently estimated to be 4.12 μmol/L (level recommended by the National Health and Medical Research Centre for all Australians, < 0.48 μmol/L). The patient was referred for toxicological review. Further questioning revealed he had used three Ayurvedic medicines (Vatyog [Arya Aushadhi Pharmaceutical Works, Indore, India], Sahacharadi [Arya Vaidya Nilayam, Madurai, India] and Gandharvahastadi [Arya Vaidya Nilayam, Madurai, India]) for back pain, dispensed to him 3 months earlier during a trip to India. He ceased taking the medications, and a 19-day course of oral chelation with succimer was administered. His blood lead concentration fell rapidly, with a moderate rebound 6 weeks after the completion of chelation therapy. A negative blood lead result for the patient’s pregnant partner excluded environmental exposure in the patient’s home.

Vatyog and Sahacharadi were analysed for heavy metals (Gandharvahastadi was not available for analysis). Sahacharadi was lead-free, but the Vatyog tablet tested contained 448 μg of lead. The patient had potentially ingested 896 μg of lead daily for 3 months. World Health Organization guidelines recommend daily lead intake should not exceed 3.5 μg/kg/day.1 Dietary intake of lead in developed nations has been reported to be about 0.1–0.7 μg/kg/day.1

Ayurvedic medicine originated in India more than 2000 years ago and relies heavily on herbal products.2 Many people take Ayurvedic medicine without any problems. In some traditional remedies, salts of heavy metals are included as active ingredients.3 A study in the United States found that one-fifth of Ayurvedic herbal products manufactured in South India and sold in Boston contained potentially harmful concentrations of lead, mercury or arsenic, or combinations of these.2 In Australia, traditional Indian and Chinese medicines authorised for supply are regulated as complementary medicines and must meet manufacturing and quality standards that ensure the absence of contaminants.3 However, there is no quality control of medications imported for personal use or purchased over the internet. Importantly, this case involved tablets prepared by a registered pharmaceutical manufacturer and presented in sophisticated packaging (Box 2). Reports of lead contamination from traditional Indian and Chinese medicines have been intermittently publicised4,5 and include recent warnings from the New South Wales Health Department concerning Ayurvedic medicines.

Patients with lead toxicity commonly present with non-specific clinical features, and lead poisoning might only be suspected when a blood film shows anaemia with basophilic stippling. While enquiring about a patient’s environmental, occupational and social history is important for determining possible sources of lead exposure, clinicians should also ask patients if they have used alternative and complementary medicines and whether these were obtained in Australia or from overseas.

1 Blood film from the patient showing coarse basophilic stippling

2 Packaging from the lead-containing Ayurvedic medicine