Foreign bodies such as bullets, shotgun pellets, and shrapnel can cause clinical symptoms by mechanical compression [
43], lumen obstruction [
44], irritation of nearby structures [
45], systemic heavy metal intoxication [
5], or tumor formation [
46‐
49]. The first report of the systemic toxicity of the retained bullet dates back to the eighteenth century. Usually, metallic objects embedded into the soft tissue become encapsulated and do not release metals into systemic circulation. However, there are exceptions to this rule [
45]. Missiles close to bone, especially if a fracture is present, are prone to systemic toxicity [
50]. It is thought that initial impact with bone, fragments the missile with subsequent release [
7]. Missiles lodged in or close to joints and intervertebral disks are continuously bathed with synovial fluid, which eventually washes off Pb from the bullets resulting in systemic toxicity [
51‐
55]. Females are especially vulnerable to this form of toxicity [
56]. It is logical to assume that the anatomical structures in close proximity to the retained bullets will suffer the most. For example, one study has demonstrated that bone fracture healing is impaired if there is a foreign metallic bullet [
57]. Local metallosis is a well-known complication of metallic implants due to deposition of metallic parts and building up in the soft tissues [
58]. Metallosis has been shown to affect nearby neural structures by causing granuloma/pseudotumor formation with mechanical compression [
59‐
64].
In SAM images, the AI increased as the distance between the metallic body and the tissue sample decreased, which is evidence of Pb mobilization from a gunshot. Heavy metals accumulated in the tissue increases the elasticity, therefore, the AI of the tissue. In the tissue close to the gunshot, the AI was measured to be higher than 2 MRayl almost everywhere, while, in the tissue away from the gunshot, the AI was greater than 2 MRayl only at certain locations. SEM images demonstrate that the tissue obtained far away from the gunshot is found to keep its original structure, whereas the tissue obtained near to the gunshot is deformed and torn up. EDS and ICP-OES results show that Pb, Fe, Cr, and Mn levels are found to be higher in the region close to the gunshot when compared to the distant region. The differences in elemental composition in both regions can also play a role in changing the morphology of tissues. Elements measured in blood and serum do not express an apparent residue mobilization since it has been found that during the first 6 months after a trauma, there was a tendency of blood Pb level elevation and then stabilization after that period [
7]. In the literature, we came across no data on the relationship between trace and toxic elements in the gluteal area with one metallic pellet close to the sciatic nerve and our results pointed out that Pb mobilizes from the gunshot into the tissues of the critical organs and changes the concentrations of elements such as Fe, Cr, Mn, and Zn in these organs.
Our findings indicate that tissues closest to metallic bullets suffer from local metallosis. We cannot be absolutely sure about the leading cause of neuropathy in our patient; however, no improvement after the first surgery for lumbar disc herniation indicated another factor. She had local tenderness in the deep gluteal area, which is a sign of sciatic nerve injury. Another possibility was that she suffered from “double hit” where sciatic nerve injury compression aggravated each other. We did not try to obtain a biopsy from the sciatic nerve since it causes damage to a nerve with subsequent neurological deterioration.