Localized Argyria Research Articles

Long-term changes in serum silver concentrations after extremity reconstruction with silver-coated megaprostheses

Silver-coated megaprostheses are considered to reduce infection rate following reconstruction of bone defects in tumour surgery or revision arthroplasty. However, little is known about systemic silver exposure and possible side effects. The aim of this study was to analyse serum silver concentrations in patients with silver-coated megaprostheses over a prolonged time period. Between 2004 and 2016, 46 patients (52.2% female, mean age at surgery 47.1 ± 24.2 years) received silver-coated megaprostheses for septic (n = 26) or oncological (n = 17; main implant since 2013) indications, or aseptic loosening (n = 3). Blood was drawn from all patients within the first few days following surgery (without silver ion levels) and thereafter every 6 months at the outpatient department (with silver ion levels). Inductively coupled plasma mass spectrometry was used to determine silver ion levels. Median follow-up was 47.3 months (IQR: 16.1–78.9). Overall, 29 revision surgeries became necessary in 20 patients, equivalent to a cumulative complication rate of 63.0%. Revisions were most commonly for periprosthetic joint infections (PJIs, n = 12) and instability/soft tissue problems (n = 10). Revision-free implant survival was 81.4%, 42.3% and 35.2% at one, 5 and 10 years. Incidence of local argyria was 8.7% (n = 4). Silver ion levels at two or more consecutive time points during follow-up were available for 26 patients. An increment of silver levels within the first months (“run-in”) was observed, followed by an unspecific undulating course. Median initial and latest follow-up (median, 49.5 months) serum silver ion levels were 16.0 ppb (IQR: 9.1–29.1) and 7.4 ppb (IQR: 2.7–14.1), respectively. According to the multivariate mixed linear random-effects model, development of PJI was associated with significantly higher silver ion levels over time (p = 0.002), irrespective of time from surgery (p = 0.274). In the current series, a cumulative complication rate of 63.0% was observed for patients receiving silver-coated megaprostheses for septic of oncological indications. An overall unspecific course of silver ion concentration was present. Development of PJI was significantly associated with increased silver ion levels over time. Yet, no systemic complication associated to high silver levels occurred. It can be concluded that silver-coated implants constitute a safe solution for megaprosthetic reconstruction, but monitoring of silver concentrations is recommended.

Local Argyria due to Silver-Coated Megaprosthesis

A 75-year-old man had a replacement of his tibia, due to a primary bone sarcoma, with a silver-coated megaprosthesis (Figure, A). At 3-year follow-up, he presented with gray-blue colored skin overlying the prosthesis (Figure, B). This indicated release of silver from the prosthesis and a diagnosis of localized argyria. There was no clinical consequence of this colored skin. Unfortunately, in the follow-up, he presented with an infection of this megaprosthesis. After several attempts to treat this infection, he asked for an amputation.

15661 Dermoscopy of localized argyria

The pigmentation of skin and mucous membranes caused by deposition of silver is called argyria. It is an uncommon condition caused by direct contact with the silver usually under occupational exposure. The dermoscopy of localized argyria (LA) has been only reported in isolated cases in the literature. Cases of argyria were searched in the database of the pathology department of our hospital. In 5 of them there were dermoscopic images, and they are the ones we included in the study. All were studied by electron microscopy and energy-dispersive spectroscopy.

Silver-coated megaprosthesis in prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about efficacy and toxicity in primary and revision surgery.

Prosthetic joint infection (PJI) is a common complication following orthopedic megaprosthetic implantations (EPR), estimated up to 50%. Silver coatings were introduced in order to reduce the incidence of PJI, by using the antibacterial activity of silver. Three different silver coatings are available: MUTARS® (Implantcast), Agluna® (Accentus Medical), PorAg® (Waldemar Link). The aim of this review is to provide an overview on efficacy and safety of silver-coated EPR both in primary and revision surgery, comparing infection rate according to the type of implant. Through an electronic systematic search, we reviewed the articles concerning silver-coated EPRs. Infection rate, silver-related complications, local and blood concentrations of the silver were evaluated. Meta-analyses were performed to compare results from each study included. Nineteen studies were included. The overall infection rate in patients with silver-coated implants was 17.6% (133/755). Overall infection rate in primary silver-coated EPR was been 9.2% (44/445), compared to 11.2% (57/507) of non-silver-coated implants. The overall infection rate after revisions was 13.7% (25/183) in patients with silver-coated EPR and 29.2% (47/161) when uncoated EPR were used, revealing a strength statistically significative utility of silver coatings in preventing infections in this group (p: 0.019). Generally, the use of MUTARS® EPR had produced an almost constant decrease in the incidence of primary PJI but there are few data on the effectiveness in revisions. The results from the use of Agluna® in both primary and revisions implants are inconstant. Conversely, PorAg® had proven to be effective both in PJI prevention but, especially, when used in PJI revision settings. Local argyria was reported in 8 out of 357 patients (2.2%), while no systemic complications were described. Local and blood concentrations of silver were always reported very far to the threshold of toxicity, with the lowest concentration found using PorAg®. Silver-coated EPRs are safe and effective in reduction in PJI and re-infection rate, in particular when used in higher risk patients and after two-stage revisions to fight PJI.

Silver coating on tumour prostheses

Modular endoprostheses, so-called "tumour or megaprostheses" are mainly used for limb salvage surgery after resection of malignant soft tissue or a bone tumour. Sometimes, this type of prosthesis is also used for revision surgeries after failed primary joint arthroplasty. Despite continuously improving techniques and quality management systems, periprosthetic infection is one of the most serious complications. Review of the literature in the PubMed data base with the main focus on silver coatings in joint arthroplasty and their effect on infection rate, outcome and patients' safety. The current literature shows that there is abeneficial role of silver coatings in megaprostheses in terms of revision rates for septic complications, especially following tumour resection with bad soft tissue coverage or in (multimorbid) high-risk patients, compared to uncoated implants. Based on the results of previous publications examining blood or serum silver concentrations or silver levels in urine, silver coatings do not appear to have side effects, except for local argyria. Continuous monitoring of silver levels in blood or serum is still recommended, and additional long-term studies will be necessary to verify the effectiveness and safety of silver coatings.

Localized cutaneous argyria: Report of two patients and literature review

BackgroundLocalized cutaneous argyria is a rare skin condition caused by direct contact with silver or silver particles. It presents as asymptomatic gray or blue-gray macules that appear similar to blue nevi. Histologic features include brown-colored or black-colored silver granules in the basement membrane and dermis, most commonly surrounding eccrine glands, elastic fibers, and collagen fibrils. The condition is most frequently observed in individuals who are regularly exposed to small silver particles, such as silversmiths and welders. However, localized cutaneous argyria has also been associated with acupuncture needles, silver earrings, and topical medications containing silver nitrate. Although the condition is benign, patients who are concerned about the cosmetic features of localized cutaneous argyria may benefit from laser therapy.PurposeWe describe the clinical and pathologic findings of two women who developed localized cutaneous argyria. We also review the characteristics of other patients with localized cutaneous argyria and summarize the differential diagnosis and treatment options for this condition.Materials and methodsThe features of two women with localized cutaneous argyria are presented. Using PubMed, the following terms were searched and relevant citations assessed: acquired localized argyria, acupuncture, argyria, argyrosis, colloidal silver, cutaneous argyria, and localized cutaneous argyria. In addition, the literature on localized cutaneous argyria is reviewed.ResultsTwo women presented with small, asymptomatic blue-gray macules appearing at sites directly adjacent to ear piercings. A punch biopsy was performed on one woman. Microscopic examination revealed a yellowish-brown colored granular material found adjacent to elastic fibers. Based on correlation of the clinical presentation and histopathologic findings, a diagnosis of localized cutaneous argyria was established. The second woman did not undergo a biopsy. However, the clinical presentation was highly suggestive of localized cutaneous argyria. Both women were reassured of the benign nature of the condition and agreed to return for clinical follow-up if they observed any changes in the appearance of the lesions.

Dystrophic Calcification and Accentuated Localized Argyria After Fractionated Carbon Dioxide Laser Therapy of Hypertrophic Scars

Fractionated, ultrapulsed carbon dioxide (CO2) laser therapy is a powerful tool for the treatment of scars. Common adverse effects of this therapeutic modality have been previously documented. We describe 2 unreported adverse effects of ultrapulsed CO2 laser treatment of mature scars in a patient previously treated with silver-impregnated dressings. A teenage survivor of toxic epidermal necrolysis presented with faint but diffuse dyschromia clinically and histologically consistent with localized argyria secondary to silver-impregnated dressings used years earlier. The patient was subsequently treated with fractionated CO2 for her scarring, but her hyperpigmentation worsened with each treatment. A subsequent biopsy specimen revealed a zone of dystrophic calcification with adjacent pseudo-ochronotic fibers that were not appreciated on biopsy specimens taken before CO2 laser treatment, suggesting unique complications not previously reported. We present 2 unique complications secondary to ultrapulsed, fractionated CO2 laser treatment in a patient previously treated with silver-impregnated dressings: (1) the appearance of pseudo-ochronotic fibers in areas of worsening pigmentation and (2) evidence of dystrophic calcification limited to columns of fractionated laser ablation. Therefore, a history of argyria or treatment with silver-impregnated dressings should be considered before treatment with fractionated CO2 lasers.

Iatrogenic Rhinopharyngeal Isolated Argyria Induced by Silver-Containing Nasal Drug

Localized nasal argyria has been reported in 3 published articles as secondary to occupational exposure and involving the anterior part of the nose. No previous cases of such pathology involving the rhinopharynx were described. Here we report the first case of localized argyria of the roof and of the posterior wall of the rhinopharynx secondary to prolonged use of nasal drops containing colloidal silver protein. The recognition of such pathology can be useful to increase the number of conditions that must be considered in the differential diagnosis of rhinopharyngeal mucosa alterations.

Localized Argyria Caused by Metallic Silver Aortic Grafts: A Unique Adverse Effect

Silver-coated grafts are designed to prevent vascular graft infections. Silver is a safe element but toxic effects have been reported. We describe two cases of possible localized argyria after silver graft implantation. Two patients presented with perigraft groin collections after implantation of silver grafts. During reoperation, an ashen-grey necrotic substance was seen surrounding the grafts. The grafts were explanted and lower limb perfusion restored. Cultures were negative and both patients had uneventful recoveries. Our cases are highly suggestive of a possible unique adverse effect: a combination of localized silver toxicity and neutrophilic mediated tissue destruction.

Localized Argyria Caused by Metallic Silver Aortic Grafts: A Unique Adverse Effect

Silver-coated grafts are designed to prevent vascular graft infections. Silver is a safe element but toxic effects have been reported. We describe two cases of possible localized argyria after silver graft implantation. Two patients presented with perigraft groin collections after implantation of silver grafts. During reoperation, an ashen-grey necrotic substance was seen surrounding the grafts. The grafts were explanted and lower limb perfusion restored. Cultures were negative and both patients had uneventful recoveries. Our cases are highly suggestive of a possible unique adverse effect: a combination of localized silver toxicity and neutrophilic mediated tissue destruction.

Argyria following the use of silver-coated megaprostheses

The aims of this study were to evaluate the incidence of local argyria in patients with silver-coated megaprostheses and to identify a possible association between argyria and elevated levels of silver both locally and in the blood. Between 2004 and 2011, 32 megaprostheses with silver coatings were implanted in 20 female and 12 male patients following revision arthroplasty for infection or resection of a malignant tumour, and the levels of silver locally in drains and seromas and in the blood were determined. The mean age of the patients was 46 years (10 to 81); one patient died in the immediate post-operative period and was excluded. Seven patients (23%) developed local argyria after a median of 25.7 months (interquartile range 2 to 44.5). Patients with and without local argyria had comparable levels of silver in the blood and aspiration fluids. The length of the implant did not influence the development of local argyria. Patients with clinical evidence of local argyria had no neurological symptoms and no evidence of renal or hepatic failure. Thus, we conclude that the short-term surveillance of blood silver levels in these patients is not required.

Localized cutaneous argyria in a silversmith

ejd.2012.1894 Auteur(s) : Koji Kamiya, Osamu Yamasaki yamasa-o@cc.okayama-u.ac.jp, Seiko Tachikawa, Keiji Iwatsuki Department of Dermatology, Okayama University Graduate School of Medicine, 2-5-1 Shikata-cho Kitaku Okayama, 700-8558, Japan Argyria is the relatively rare skin discoloration caused by depositions of silver granules in the skin. We report a case of localized argyria associated with occupational exposure. A 48-year-old woman was referred to our hospital with progressive skin pigmentation [...]

Cutaneous amalgam tattoo in a dental professional: an unreported occupational argyria

Funding sources: This work was supported by the Brazilian Federal Agency of Support and Evaluation of Postgraduate Education (CAPES). Conflicts of interest: none declared. Madam, Amalgam tattoo is the most common exogenous pigmentation of the oral mucosa1, 2; surprisingly, there are no reports of similar lesions on the skin. It is caused by traumatic implantation of amalgam fragments into the oral mucosa following dental treatment, particularly when amalgam fillings are removed with high‐speed instruments. Amalgam tattoo occurs mostly in the gingiva and alveolar mucosa. Clinically it presents as an asymptomatic bluish to black macule, eventually observed by the patient or discovered during routine dental treatment. Histologically it shows brown to black aggregates of granules interspersed among collagen fibres and around blood vessels. Most cases show a slight inflammatory response, and eventually a foreign body granulomatous reaction is found.1–4 Cases of cutaneous localized argyria are uncommon, and are usually attributed to trauma, acupuncture, topical silver‐based medication or use of pieces of jewellery such as earrings.5–7 We report a case of cutaneous amalgam tattoo caused by implantation of amalgam particles on the skin of the eyebrow of a dental surgeon.

Nasal argyria (deposition of silver-selenium) in the photographic film industry: histopathology and microanalysis

Argyria is grayish black discoloration of skin or mucous membrane caused by silver deposition; it may be localized or diffuse. Diffuse argyria occurs as a result of elevated silver levels in blood, whereas localized argyria occurs when there is direct deposition from an external source. Exposure to silver was common in the last century; however, in the present times, argyria is an uncommon entity because of the restrictive use of silver-containing medicines and decreased industrial exposure. Occupational exposure is common among silversmiths [1], mineworkers, photographic film laboratory workers, and individuals involved in the electroplating industry. Cases after prolonged use of silver salts for wound dressing, acupuncture needles, silver earrings [2], eyedrops containing silver, and irrigation of urethral or nasal mucous membranes with silver-containing solutions have been reported. Argyria has also been seen among patients undergoing dental procedures, such as silver amalgam tattooing. 2. Case presentation A 66-year-old man had nasal blockage and intermittent drainage from both nares for many years. The drainage was watery and persistent even after being treated with multiple medications. Nasal examination revealed bilateral bluish black pigmentation of mucosa in the superior-anterior portion of the nasal septum. There was no other area of pigmentation either on the skin or elsewhere. The patient’s history is significant for stroke, myocardial infarction, and hypertension. He worked as a supervisor in the chemical sensitizing paper unit of a photographic film–producing company before retiring in 1992 and was exposed to a large number of chemicals, including silver nitrate. In 2004, a computed tomographic scan of the patient’s paranasal sinuses showed minimal mucosal thickening in the left maxillary sinus. A small biopsy specimen of the pigmented nasal mucosa was taken under local anesthesia and sent for routine histopathologic analysis. Subsequently, analysis using scanning electron microscopy (SEM) and energy dispersive x-ray spectroscopy (EDS) was also performed.

Local cutaneous argyria mimicking melanoma metastases in a patient with disseminated melanoma

Local cutaneous argyria mimicking melanoma metastases in a patient with disseminated melanoma

Scar-localized argyria secondary to silver sulfadiazine cream

Silver sulfadiazine cream is a topical antibacterial agent that combines the antibacterial effects of both silver and sulfadiazine. Its reported cutaneous side effects include hypersensitivity reactions, allergic contact dermatitis, erythema multiforme, and systemic argyria. We report the case of a patient who had localized argyria develop in a scar after the use of silver sulfadiazine cream. In this case, the silver sulfadiazine cream was applied to and argyria developed within a postsurgical wound and area of severe contact dermatitis.

Localized argyria with pseudo-ochronosis

Background: Localized argyria is uncommon and presents clinically as asymptomatic slate gray macules or blue macules resembling blue nevi. Its histopathologic features are usually similar to those of generalized argyria in which silver granules are found most commonly around the eccrine glands, in the walls of blood vessels, and along elastic fibers. Ochre swollen homogenized collagen bundles resembling ochronosis have not been previously described. Objective: The purpose of this study is to report a series of 5 patients with localized argyria with the histologic feature of “pseudo-ochronosis.” In one patient, biopsy was performed on 2 distinct lesions. Methods: All patients underwent skin biopsies for light microscopy and darkfield microscopy. In two patients, the biopsy specimens were analyzed with a mass spectrophotometer; scanning electron microscopy and energy-dispersive x-ray analysis were performed. In one patient, the biopsy specimen was decolorized with 1% potassium ferricyanide in 20% sodium thiosulfate. Results: All 5 patients presented with the typical clinical and histologic features of localized argyria. Ochre swollen and homogenized collagen bundles were seen in all cases. In addition, light microscopy in 4 cases revealed an ellipsoid black globule within a zone of collagen degeneration. Conclusion: The histologic features of localized argyria include swollen and homogenized collagen bundles resembling ochronosis, “pseudo-ochronosis,” which may be more common than previously recognized. (J Am Acad Dermatol 2002;46:222-7.)

Systematic review of adverse events following acupuncture: the Japanese literature

Context: Many Japanese cases of adverse events after acupuncture are not listed in medical databases such as Medline. Therefore, they are not easily accessible to researchers outside Japan. Objective: To complement existing reviews of adverse events after acupuncture in the West and to provide more detailed discussion and analysis. Data sources: Literature search using ‘Igaku Chuo Zasshi (Japana Centra Revuo Medicina) CD-ROM version’ covering the period of 1987–1999. Study selection: Case reports of adverse events, which were suspected to be due to acupuncture treatment, were included. Experimental studies, surveys, and news articles were excluded. Data extraction: Two independent reviewers extracted data from located articles in a pre-defined structured way, and assessed likelihood of causality in each individual case. Data synthesis: 89 articles which reported 124 cases were located. The most frequent adverse events were: pneumothorax (25 cases), spinal cord injury (18 cases), acute hepatitis B (11 cases), and localized argyria (10 cases). There were two fatalities from infections. Forty-eight events were caused by needle breakage including 26 cases of intentionally embedded needle and 16 cases of accidental breakage. There were also 10 cases of injury from self-treatment. Conclusion: Although it has already been demonstrated that severe adverse events seem to be uncommon in standard practice, many serious cases of negligence have been found in the present review, suggesting that training system for acupuncturists (including medical doctors) should be improved and that unsupervised self-treatment should be discouraged.

Localized argyria with chrysiasis caused by implanted acupuncture needles: Distribution and chemical forms of silver and gold in cutaneous tissue by electron microscopy and x-ray microanalysis

A case of localized argyria with chrysiasis caused by implanted acupuncture needles in a 41-year-old Japanese woman was studied by electron microscopy and x-ray microanalysis. Large amounts of silver granules with selenium and sulfur were detected around eccrine secretory cells in much greater amounts than around ductal cells. Many granules were also observed along the outer edge of the basement membrane but never within cells or intercellular spaces. The granules were also present around blood vessels, lymphatics and nerve fibers, and in elastic fibers. Small numbers of gold fragments were also seen, mostly within macrophages. These results suggest that silver deposits extracellularly as selenide and sulfide, whereas free gold is found intracellularly.

An unusual case of acquired localized argyria

We report an unusual cause of localized cutaneous argyria, due to the cutaneous implantation of a silver earring back.