INTRODUCTION

Human spice consumption has increased dramatically in recent decades, with spices valued for their flavor, aroma, and potential health benefits [1]. Although spices and other foods are commonly perceived as safe, they carry health risks, including contamination with heavy metals. We present a case of markedly elevated blood lead levels in a patient who was likely exposed through the consumption of both domestically purchased and imported spices, particularly coriander.

CASE REPORT

A 61-year-old woman with a history of breast cancer, diabetes, and asthma underwent routine laboratory testing before a primary care wellness visit. Her hemoglobin concentration (6 g/dL; normal range, 11.1 to 15.9 g/dL) was considerably lower than her baseline level (14.7 g/dL, obtained 10 months prior). She had no known sources of blood loss, and an initial anemia evaluation, including iron studies, was unremarkable. Other laboratory parameters, such as electrolytes and indicators of renal function, were within normal limits. The patient’s primary care physician subsequently referred her to a hematologist, who performed a bone marrow biopsy revealing ring sideroblasts. Based on this finding, the hematologist ordered a whole blood lead level (BLL) test and referred the patient for medical toxicology evaluation after obtaining a BLL result of 115.2 mcg/dL.

At her initial medical toxicology evaluation, the patient reported a 20-pound weight loss, fatigue, dizziness, and dyspnea occurring in the month preceding the discovery of elevated BLL. She took prescription medications for her chronic medical conditions and consumed several dietary supplements (including multivitamins, vitamin C, and turmeric) purchased from domestic retail outlets. She denied smoking or illicit drug use. She lived alone in an urban apartment building, and her hobbies included walking and reading. She worked at an international financial organization and frequently traveled internationally for work and to visit relatives in Malaysia and Europe. She purchased food, cookware, and dishes from large retail chains within the United States but used spices (chili powder, cumin, coriander, and masala) imported from her travels to Malaysia.

Due to concerns about lead intoxication from imported spices, the patient was advised to avoid consuming these products. Repeat BLL, obtained 3 weeks after the initial blood draw, was 89.9 mcg/dL. Chelation therapy with dimercaptosuccinic acid (succimer) was initiated due to the persistently elevated BLL and the severity of the patient’s clinical presentation. Additionally, a residential lead assessment was requested from the local health department. The assessment revealed the presence of lead in chili powder (0.217 ppm), garlic salt (0.213 ppm), imported cough and cold medication (0.405 ppm), turmeric capsules (1.07 ppm), and ground cinnamon (1.51 ppm) found at the patient’s residence. No lead was detected in paint, water, or dust in the apartment. All other dietary supplements, food products, dishes, and cookware tested negative for lead.

During follow-up visits at the medical toxicology clinic, the patient reported a gradual improvement in symptoms. She had stopped using imported spices and reported seasoning her food with fresh herbs and spices, such as garlic and chili peppers. While her anemia resolved over the subsequent 2 months, her BLL remained elevated at 67.1 mcg/dL 4 months after the initial blood draw. She underwent a second course of chelation therapy with succimer, after which her BLL decreased to a nadir of 28.6 mcg/dL before stabilizing between 35.4 mcg/dL and 39.2 mcg/dL for several months (Figure 1). Given concerns regarding the potential for ongoing lead exposure and because the modest lead concentrations detected during the initial residential assessment seemed inconsistent with the severity of intoxication, a repeat residential lead assessment was requested. While awaiting this assessment, the medical toxicology team was contacted by public health officials from a European country, who reported that a relative of the patient residing there also exhibited high blood lead concentrations. A public health investigation in that case identified markedly elevated lead levels in coriander powder potentially purchased from a Malaysian street market.

Upon further questioning, the index patient disclosed that she had chronically consumed both coriander powder and seeds, due to their potential beneficial health effects. She used coriander powder regularly to season her food alongside other spices; furthermore, nearly daily for decades, she had consumed hot water in which she had steeped coriander seeds. The powder and seeds were purchased from a street market in her family’s hometown in Malaysia. She had obtained a new batch of coriander from the street market in the months before the onset of her symptoms and her anemia diagnosis. Unfortunately, at the time of the initial residential lead assessment, she had already depleted this spice, making it unavailable for testing by the health department.

Ethics Statement

Written consent for the publication of this case report was obtained from the patient.

DISCUSSION

Spices are derived from plant roots, seeds, and bark, making them susceptible to contamination from environmental sources such as insects, rodent excrement, and mycotoxins [2]. Anthropogenic soil contamination with heavy metals can further promote the uptake of lead and other toxins into plants intended for use as spices [3]. Additionally, lead contamination can unintentionally occur during spice production and processing, particularly due to the presence of lead in mills used for grinding spices [4]. Lead contamination of mills has been linked to leaded fillings used to connect the mill to the driveshaft, as well as the use of molten lead during mill repairs [4,5].

Individuals who consume spices contaminated with lead may experience signs and symptoms of lead intoxication. Infants and toddlers are particularly susceptible to the toxic effects of lead, and even low-level pediatric lead exposure is associated with developmental delays and behavioral disorders [6]. Compared with children, adults are less likely to exhibit symptoms following mild lead exposure. Moderate lead exposure in adults can result in hypertension, anemia, and renal dysfunction, while neurocognitive deficits are uncommon at blood lead concentrations below 40 mcg/dL [7]. Identifying and eliminating the source of exposure is paramount, as both blood lead concentrations and symptoms generally improve in exposed patients once the source is removed [7]. Chelation therapy is typically initiated in adults when blood lead concentrations exceed 80 mcg/dL; however, those with lower concentrations may also benefit from therapy depending on their symptoms and duration of exposure [8].

Although lead contamination in spices is well-documented in the medical literature, it commonly pertains to imported spices rather than those purchased domestically [9]. In the case presented above, lead was detected in turmeric capsules and ground cinnamon bought from well-known United States retail chains. Limited regulatory oversight of dietary supplements (e.g., turmeric capsules) in the United States increases the risk of undetected contamination or adulteration. Additionally, the United States currently has no federal standards or permissible reference values for lead in spices, complicating the ability of retailers and consumers to recognize the potential for heavy metal contamination [10]. Given that more than three-quarters of spices consumed in the United States are imported, it can be difficult for consumers to ascertain whether domestically purchased spices have been unintentionally contaminated with lead. Biochemical and molecular analytical techniques have been developed to detect spice adulteration, but widespread use of these methods is limited due to cost and technical barriers [2].

Spices may also become contaminated with lead through economic adulteration. Defined as the intentional addition of non-authentic substances to a consumer product to reduce production costs or increase sale price, economic adulteration represents an emerging risk in the global food supply [11]. Economic adulteration can impact various foods, including dairy products, alcohol, and produce, posing public health risks and undermining consumer confidence [12]. Due to their typically high value and the need for processing before sale, spices are especially vulnerable to economic adulteration [13]. Compared with seeds or other spice formulations, powdered spices are more prone to adulteration, as the milling and grinding processes can readily conceal contaminants in the final product [2]. Brightly pigmented spices, such as turmeric and paprika, have been linked to lead intoxication from adulteration with lead chromate and lead tetroxide [14,15]. Although coriander has not been commonly reported as economically adulterated, the markedly elevated lead levels detected in the coriander tested by European public health authorities in this case suggest economic adulteration as the most probable cause of contamination. While the coriander consumed by the index patient was unavailable for lead testing, similarities between this patient and her relative raised concerns about a shared source of exposure. Unfortunately, investigators could not confirm whether both patients obtained coriander from the same Malaysian street market or from different sources, limiting the public health response.

Coriander powder is susceptible to lead contamination from both anthropogenic sources and economic adulteration, and consumption of lead-contaminated spices, including coriander, can have significant adverse health effects. Consumers and medical professionals should be aware that domestically purchased and imported spice products may contain undesirable contaminants, including lead and other metals.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

None.

Author Contributions

Conceptualization: Johnson-Arbor K, Dike G, Taha S. Data curation: Johnson-Arbor K, Dike G. Formal analysis: Johnson-Arbor K, Dike G, Taha S. Funding acquisition: None. Writing – original draft: Johnson-Arbor K. Writing – review & editing: Johnson-Arbor K, Dike G, Taha S.

Figure. 1.

Changes in blood lead concentration over time.

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