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A 49-year-old man presented with confusion, hallucinations, and seizure-like episodes. Evaluation revealed severe anemia and knee imaging showed lead synovitis from a gunshot wound received 27 years previously. Substance-related causes initially complicated the clinical picture, but further testing identified a critically elevated blood lead level. The patient was treated with chelation therapy and surgery to remove a retained bullet fragment and inflamed, metal-stained synovial tissue. After treatment, his mental status normalized and blood lead levels steadily declined.

This case highlights that retained intra-articular bullets can cause severe lead poisoning decades later, requiring early recognition and combined medical/surgical management.