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Silica granuloma induced by indwelling catheter
S54 Letters
J AM ACAD DERMATOL AUGUST 2007
Correspondence to: Howard Levy, MD, Department of Dermatology, Lincoln Medical Center, 234 Eugenio Maria De Hostos Blvd (149th St), Bronx, NY 10451 REFERENCES 1. Lichtenstein L, Scott HW, Levin MH. Pathologic changes in gout. Am J Pathol 1956;32:871-95. 2. Wernick R, Winkler C, Campbell S. Tophi as the initial manifestation of gout. Report of six cases and review of the literature. Arch Intern Med 1992;4:873-6. 3. Niemi K-M. Panniculitis of the legs with urate crystal deposition. Arch Dermatol 1977;113:655-6. 4. LeBoit PE, Schneider S. Gout presenting as lobular panniculitis. Am J Dermatol 1987;9:334-8. 5. Conejo-Mir J, Pulpillo A, Corbi MR, Linares M, Garcia Lopez A, Conde F, et al. Panniculitis and ulcers in a young man. Arch Dermatol 1998;134:499-504. 6. Snider AA, Barsky S. Gouty panniculitis: a case report and review of the literature. Cutis 2005;76:54-6. doi:10.1016/j.jaad.2006.04.006
Silica granuloma induced by indwelling catheter To the Editor: Silica granuloma is a reactive granulomatous reaction to silica (SiO2) and/or silicate traumatically inoculated into the skin. We report here multiple lesions of silica granuloma caused by silicone oil coating an indwelling catheter. A 28-year-old female received intravenous drip infusion of betamethasone and alprostadil via indwelling catheter (a regular intravenous needle) for 2 weeks to treat sudden deafness. Three days after evulsion of the catheter, she noticed small nodules on her forearms. Physical examination revealed multiple small red nodules approximately 2 mm to 5 mm in diameter on the radial aspect of the bilateral forearms (Fig 1). Nodules were located at the skin sites punctured by the indwelling catheter, and nodules appeared at skin punctures without drug infusion. Histologically, an infiltrate consisting of lymphocytes, histiocytes, and foreign bodyetype multinucleated giant cells was seen in the dermis (Fig 2, A). Within the giant cells, droplet-like particles of various sizes were seen (Fig 2, B). Energy dispersive radiographic spectroscopy (EDS) revealed that the particles contained silicon (Si; Fig 2, C ). EDS also confirmed Si on the surface of the indwelling catheter (data not shown). Laboratory findings revealed no abnormal findings suggestive of sarcoidosis, such as increased serum lysozyme or angiotensin converting enzyme. Skin lesions were therefore considered to be silica granuloma induced by the silicone oil coating of the indwelling catheter. Silica granuloma is a granulomatous reaction to silica and/or silicate that is most commonly
Fig 1. Clinical manifestations. A, Multiple small nodules were noted on the radial aspect of forearms. B, Indwelling catheter.
introduced to the skin by accidental trauma. Nodules develop after a varying asymptomatic latent period, ranging from several weeks to many years.1 The term ‘‘silicone’’ refers to a group of Si-containing compounds that include gels, rubbers, sponges, resins, and oils. We report here a case of silica granuloma induced by an indwelling catheter. Lubricant oil containing silicone was probably the source of Si, as Si was detected not only in the skin, but also on the silicone oil-coated surface of the indwelling catheter. The pathomechanisms of silica granuloma are not fully understood. Granuloma formation is thought to be mediated by foreign bodyetype reactions to large particles of silica or silicate.2 On the other hand, a previous report suggested that silicone is a potent immunogen.3 To see whether an immunological response was involved in the granuloma formation in the present case, peripheral blood mononuclear cells (PBMC) were stimulated with SiO2 in vitro. PBMC from the patient, but not those from 3 healthy donors, exhibited cell proliferation in response to SiO2 (data
Letters S55
J AM ACAD DERMATOL VOLUME 57, NUMBER 2
Fig 2. Histologic features of nodules. A, Aggregates consisting of lymphocytes and histiocytes in the dermis. B, Round translucent particles of varying sizes (arrowheads) were observed in interstitial tissues and within the foreign body giant cells. C, Energy dispersive radiographic spectroscopy revealed that the particles (arrows) contained silicon (Si).
not shown). Thus, the granulomatous reaction to silicone oil in the present case was apparently caused by immunological hyper-reactivity to Si. In this context, it was intriguing to note that, in the present case, nodules appeared after a very short latent period. Differential diagnosis included scar sarcoidosis, which is another type of granulomatous reaction in response to traumatically implanted silica and/or silicate. In addition, a close association between sarcoidosis and silica granuloma has been suggested.4 The patient did not have any clinical manifestations suggestive of sarcoidosis, but long-term follow-up to determine whether the patient develops sarcoidosis is required. Atsuko Kenmochi, MD, Takahiro Satoh, MD, PhD, Ken Igawa, MD, PhD, and Hiroo Yokozeki, MD, PhD Department of Dermatology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan.
Funding sources: None. Conflicts of interest: None declared. Correspondence to: Takahiro Satoh, MD, PhD, Department of Dermatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan E-mail: [email protected] REFERENCES 1. Bovenmyer DA, Landas SK, Bovenmyer JA. Spontaneous resolution of silica granuloma. J Am Acad Dermatol 1990;23:322-4. 2. Epstein WL, Skahen JR, Krasnobrod H. The organized epithelial cell granuloma: differentiation of allergic (zirconium) from colloidal (silica) types. Am J Pathol 1963;43:391-405. 3. Rank BK, Hicks JD, Lovie M. Pseudotuberculoma granulosum silicoticum. Br J Plast Surg 1972;25:42-8. 4. Payne CM, Thomas RH, Black MM. From silica granuloma to scar sarcoidosis. Clin Exp Dermatol 1983;8:171-5.
doi:10.1016/j.jaad.2006.05.055
J AM ACAD DERMATOL AUGUST 2007
Correspondence to: Howard Levy, MD, Department of Dermatology, Lincoln Medical Center, 234 Eugenio Maria De Hostos Blvd (149th St), Bronx, NY 10451 REFERENCES 1. Lichtenstein L, Scott HW, Levin MH. Pathologic changes in gout. Am J Pathol 1956;32:871-95. 2. Wernick R, Winkler C, Campbell S. Tophi as the initial manifestation of gout. Report of six cases and review of the literature. Arch Intern Med 1992;4:873-6. 3. Niemi K-M. Panniculitis of the legs with urate crystal deposition. Arch Dermatol 1977;113:655-6. 4. LeBoit PE, Schneider S. Gout presenting as lobular panniculitis. Am J Dermatol 1987;9:334-8. 5. Conejo-Mir J, Pulpillo A, Corbi MR, Linares M, Garcia Lopez A, Conde F, et al. Panniculitis and ulcers in a young man. Arch Dermatol 1998;134:499-504. 6. Snider AA, Barsky S. Gouty panniculitis: a case report and review of the literature. Cutis 2005;76:54-6. doi:10.1016/j.jaad.2006.04.006
Silica granuloma induced by indwelling catheter To the Editor: Silica granuloma is a reactive granulomatous reaction to silica (SiO2) and/or silicate traumatically inoculated into the skin. We report here multiple lesions of silica granuloma caused by silicone oil coating an indwelling catheter. A 28-year-old female received intravenous drip infusion of betamethasone and alprostadil via indwelling catheter (a regular intravenous needle) for 2 weeks to treat sudden deafness. Three days after evulsion of the catheter, she noticed small nodules on her forearms. Physical examination revealed multiple small red nodules approximately 2 mm to 5 mm in diameter on the radial aspect of the bilateral forearms (Fig 1). Nodules were located at the skin sites punctured by the indwelling catheter, and nodules appeared at skin punctures without drug infusion. Histologically, an infiltrate consisting of lymphocytes, histiocytes, and foreign bodyetype multinucleated giant cells was seen in the dermis (Fig 2, A). Within the giant cells, droplet-like particles of various sizes were seen (Fig 2, B). Energy dispersive radiographic spectroscopy (EDS) revealed that the particles contained silicon (Si; Fig 2, C ). EDS also confirmed Si on the surface of the indwelling catheter (data not shown). Laboratory findings revealed no abnormal findings suggestive of sarcoidosis, such as increased serum lysozyme or angiotensin converting enzyme. Skin lesions were therefore considered to be silica granuloma induced by the silicone oil coating of the indwelling catheter. Silica granuloma is a granulomatous reaction to silica and/or silicate that is most commonly
Fig 1. Clinical manifestations. A, Multiple small nodules were noted on the radial aspect of forearms. B, Indwelling catheter.
introduced to the skin by accidental trauma. Nodules develop after a varying asymptomatic latent period, ranging from several weeks to many years.1 The term ‘‘silicone’’ refers to a group of Si-containing compounds that include gels, rubbers, sponges, resins, and oils. We report here a case of silica granuloma induced by an indwelling catheter. Lubricant oil containing silicone was probably the source of Si, as Si was detected not only in the skin, but also on the silicone oil-coated surface of the indwelling catheter. The pathomechanisms of silica granuloma are not fully understood. Granuloma formation is thought to be mediated by foreign bodyetype reactions to large particles of silica or silicate.2 On the other hand, a previous report suggested that silicone is a potent immunogen.3 To see whether an immunological response was involved in the granuloma formation in the present case, peripheral blood mononuclear cells (PBMC) were stimulated with SiO2 in vitro. PBMC from the patient, but not those from 3 healthy donors, exhibited cell proliferation in response to SiO2 (data
Letters S55
J AM ACAD DERMATOL VOLUME 57, NUMBER 2
Fig 2. Histologic features of nodules. A, Aggregates consisting of lymphocytes and histiocytes in the dermis. B, Round translucent particles of varying sizes (arrowheads) were observed in interstitial tissues and within the foreign body giant cells. C, Energy dispersive radiographic spectroscopy revealed that the particles (arrows) contained silicon (Si).
not shown). Thus, the granulomatous reaction to silicone oil in the present case was apparently caused by immunological hyper-reactivity to Si. In this context, it was intriguing to note that, in the present case, nodules appeared after a very short latent period. Differential diagnosis included scar sarcoidosis, which is another type of granulomatous reaction in response to traumatically implanted silica and/or silicate. In addition, a close association between sarcoidosis and silica granuloma has been suggested.4 The patient did not have any clinical manifestations suggestive of sarcoidosis, but long-term follow-up to determine whether the patient develops sarcoidosis is required. Atsuko Kenmochi, MD, Takahiro Satoh, MD, PhD, Ken Igawa, MD, PhD, and Hiroo Yokozeki, MD, PhD Department of Dermatology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan.
Funding sources: None. Conflicts of interest: None declared. Correspondence to: Takahiro Satoh, MD, PhD, Department of Dermatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan E-mail: [email protected] REFERENCES 1. Bovenmyer DA, Landas SK, Bovenmyer JA. Spontaneous resolution of silica granuloma. J Am Acad Dermatol 1990;23:322-4. 2. Epstein WL, Skahen JR, Krasnobrod H. The organized epithelial cell granuloma: differentiation of allergic (zirconium) from colloidal (silica) types. Am J Pathol 1963;43:391-405. 3. Rank BK, Hicks JD, Lovie M. Pseudotuberculoma granulosum silicoticum. Br J Plast Surg 1972;25:42-8. 4. Payne CM, Thomas RH, Black MM. From silica granuloma to scar sarcoidosis. Clin Exp Dermatol 1983;8:171-5.
doi:10.1016/j.jaad.2006.05.055