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Localized Argyria After Exposure to Aerosolized Solder

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Localized Argyria After Exposure to Aerosolized Solder CONTINUING MEDICAL EDUCATION Localized Argyria After Exposure to Aerosolized Solder Ani L. Tajirian, BA; Ross M. Campbell, MD; Leslie Robinson-Bostom, MD GOAL To understand localized argyria to better manage patients with the condition OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Discuss how localized and generalized argyria differ. 2. Describe how to diagnose argyria. 3. Identify treatment options for argyria. CME Test on page 320. This article has been peer reviewed and approved Einstein College of Medicine is accredited by by Michael Fisher, MD, Professor of Medicine, the ACCME to provide continuing medical edu- Albert Einstein College of Medicine. Review date: cation for physicians. October 2006. Albert Einstein College of Medicine designates This activity has been planned and imple- this educational activity for a maximum of 1 AMA mented in accordance with the Essential Areas PRA Category 1 CreditTM. Physicians should only and Policies of the Accreditation Council for claim credit commensurate with the extent of their Continuing Medical Education through the participation in the activity. joint sponsorship of Albert Einstein College of This activity has been planned and produced in Medicine and Quadrant HealthCom, Inc. Albert accordance with ACCME Essentials. Ms.Tajirian and Drs. Campbell and Robinson-Bostom report no conflict of interest. The authors report no discussion of off-label use. Dr. Fisher reports no conflict of interest. We describe a patient with a rare case of localized ocalized argyria is a rare disorder that occurs less argyria following exposure to aerosolized solder that frequently than generalized argyria. The patho- clinically resembles generalized argyria. Classically, L genesis involves direct implantation of silver in localized argyria presents with sharply demarcated the skin or, more rarely, percutaneous absorption of blue-gray macules, while generalized argyria pre- silver salts via the eccrine glands. The silver salts are sents with diffuse blue-gray pigmentation. Our case released into the surrounding tissues. Occupational is unusual because the patient presented with dif- exposure is the most common cause of localized fuse pigmentation seen with generalized argyria but argyria and occurs most frequently in miners, pho- restricted to the face and neck. tographic laboratory workers, and jewelers. Round Cutis. 2006;78:305-308. or oval well-demarcated blue-gray macules typically are seen. Accepted for publication June 8, 2006. Generalized argyria most often results from From Rhode Island Hospital, Brown Medical School, Department systemic treatment with drugs that contain silver of Dermatology, Providence, Rhode Island. Ms.Tajirian is a medi- cal student, Dr. Campbell is Associate Instructor in Dermatology, salts or from inhalation of silver particulates in the 1 and Dr. Robinson-Bostom is Associate Professor of Dermatology. workplace. Generalized argyria usually presents Reprints not available from the authors. with blue-gray discoloration of the skin, including VOLUME 78, NOVEMBER 2006 305 Localized Argyria non–sun-exposed skin, the lips, tongue, mucous Comment membranes, lunulae, and sclera. Permanent diffuse Localized argyria is a rare disorder that presents with blue-gray pigmentary change of the skin is observed asymptomatic blue-gray macules.2 The lesions may be with generalized argyria. large and ill defined or sharply demarcated, resem- bling blue nevi.1 The most common cause of localized Case Report argyria is occupational exposure; small silver particles A 58-year-old man presented with an ashen color to enter the skin by mechanical impregnation of workers his face that had progressed over several years. The involved in silver mining, silver refining, silverware patient denied taking any medications and had no and metal alloy manufacturing, and photographic significant past medical history. The results of a com- processing.3 Localized argyria also has been attributed plete blood count, chemistry panel, liver function to surgical and dental procedures, silver earrings, test, and hepatitis panel were within reference range. and acupuncture needles.4-6 Additionally, localized His serum silver level also was within reference range argyria may be caused by percutaneous absorption of at 11 ng/mL (reference range, 0–14 ng/mL). silver salts via the eccrine glands, which most likely The results of a physical examination revealed occurred in this case. diffuse blue-gray pigmentation distributed over the Generalized argyria most commonly results from face and neck with a sharp line of demarcation at long-term systemic use of silver-containing nose the collar (Figure 1). There was no photoaccentua- drops or colloidal silver–containing dietary supple- tion and no involvement of the nails, mucous mem- ments,7 homemade silver solution,8 and ingested or brane, or sclera. For the past 20 years, the patient topical silver nitrate.9 Inhalation of silver-bearing worked as an electronics technician soldering silver- dust in industries such as silver refining or metal containing wire in the construction of electronic grinding also may cause generalized argyria. Corneal devices. He wore gloves, long-sleeved shirts, and argyrosis associated with silver soldering has been pants but no protective mask. previously reported10,11; full cutaneous examination The biopsy specimen revealed small, black, was not described in these patients. refractile granules within the membrane propria The presentation of generalized argyria typi- of the eccrine glands (Figure 2). Additional cally begins with gray-brown staining of the biopsy specimens were taken from the healthy gums that progresses to involve the skin diffusely. skin of the right upper back and revealed no silver The mucocutaneous findings in argyria are the granules. These histologic features were consistent results of elevated serum silver levels, which lead with argyria. to dermal and mucosal deposition of the metal. Figure 1. Line of demarcation at the collar. 306 CUTIS® Localized Argyria of only exposed skin favors a diag- nosis of localized argyria because of percutaneous silver absorption via the eccrine glands. A careful history is necessary in the diagnosis of argyria, with inqui- ries about possible occupational and environmental exposure and the use of dietary supplements containing colloidal silver protein. Habitual use of silver-based nose drops may produce pigmentation that is most apparent on the nose and nail lunulae. Scar-localized argyria may occur sec- ondary to the use of silver sulfadia- zine cream.16 Other causes of diffuse blue-gray pigmentation include medi- cations (eg, phenothiazines, antima- larials, amiodarone, minocycline), Figure 2. Small, black, refractile granules in the eccrine glands (H&E, heavy metal exposure (eg, mercury, original magnification 340). bismuth, arsenic, gold, lead), hemo- chromatosis, ochronosis, cyanosis, Histopathology evaluations reveal black-silver gran- polycythemia vera, and diffuse melanosis in meta- ules around the eccrine glands, in the walls of blood static melanoma.17 vessels, and along elastic fibers. The granules occa- The average human body contains approximately sionally are found in the arrector pili muscles, peri- 1 mg of silver.18 Serum silver has a reference range neural tissue, and around collagen fibrils. The slate of 0 to 14 ng/mL. The smallest amount of silver gray, metallic, or blue-gray pigmentation seen in reported to produce generalized argyria in humans argyria may be clinically apparent after a few months ranges from 5 to 40 g.19 Although the amount but usually takes years to develop and depends on the of silver in argyria usually results in no serious degree of exposure.12,13 In some patients, the entire effects on human health, a few cases of notable clini- skin may acquire a slate blue–gray color. Hyperpig- cal symptoms and signs have been documented. Some mentation is most apparent in sun-exposed areas of of the complications of systemic toxic effects of silver the skin, especially the forehead, nose, and hands. include gastrointestinal tract catarrh, tissue wasting, Although pigmentary changes occur primarily in uremia, albuminuria, fatty degeneration of the liver, sun-exposed sites, the granules are deposited evenly hemorrhage, and idiopathic thrombocytopenia.20 throughout the skin. Light causes silver-containing The treatment of both localized and general- compounds complexed with proteins in the skin to ized argyria is difficult. Hydroquinone, depigment- be reduced to elemental silver, similar to the process ing creams, and dermabrasion are not successful.9 of developing photographs.14 In addition, the silver Selenium and sulfur have been shown to have favor- stimulates melanocyte tyrosinase activity, which able modifying effects on the metabolism and toxicity results in an increase in melanin production.15 The of silver by forming complexes with the silver. The sclerae, nail beds, and mucous membranes also may Q-switched double-frequency Nd:YAG laser, which become hyperpigmented. Viscera, including the has been used in the treatment of tattoos, also may spleen, liver, and gut, tend to show a blue discolor- be effective in the treatment of localized argyria.21 ation that is evident during abdominal surgery or at Unfortunately, no completely satisfactory treatment postmortem examination. modality exists and some pigmentation remains Our patient is unique because he presented permanent. However, sunscreens and
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