We thank Dr Brown for drawing attention to an unusual cause of anemia that can affect elderly persons. Although the magnitude of risk from hair dyes is uncertain,1-3 environmental exposure to lead is common enough that lead intoxication should routinely be considered in the differential diagnosis of unexplained anemia, especially in patients from outside the United States.4 In addition to the paint and toys mentioned by Dr Brown, nonoccupational sources of lead exposure have included ceramic glazes5 (a potential danger for nursing home residents participating in ceramic arts programs6), traditional medicines,7 cosmetics (especially kohl-based eyeliner8), candy,9 metal lunchboxes,10 and several others. Although the peripheral blood smear often reveals basophilic stippling in lead intoxication, this test is neither specific nor highly sensitive, and other assays such as blood lead and erythrocyte zinc protoporphyrin measurements might be necessary to make the diagnosis.
