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Subcutaneous mercury granulomas
516
Lettersto the Editor
For the record, active rabbit knee motion is 40~ ~, and 0~ ~ passively under anesthesia.
Clayton A. Peimer, MD Hand Center of Western New York Millard Fillmore Hospital 3 Gates Circle Buffalo, NY 14209
References
intoxication, and it must be remembered that chronic use of such agents has the risk of adverse side effects. 3 If systemic mercury levels do not fall after granuloma resection, then this may reflect ongoing absorption from embolic sites such as the brain and lungs (and xray films will identify these embolic sites) (Fig. 2); alternatively, repeated self-injection should be suspected and follow-up x-ray films of possible sites of reinjection should be performed. 4
1. Swanson AB. A grommet bone liner for flexible implant arthroplasty. Bull Pors Res Rehab Engin Res Devel BPR10 1981 ;35:108-14. 2. Minamikawa Y, Peimer CA, Ogawa R, Fujimoto K, Sherwin FS, Howard C. In vivo experimental analysis of silicone implants used with titanium grommets. J Hand Surg 1994; 19A:567-74. 3. Minamikawa Y, Peimer CA, Ogawa R, Sherwin FS, Howard C. In vivo analysis of silicone implants on bone and soft tissues. J Hand Surg 1994; 19A:575-83. 4. Hagen CG. Implants designed for finger joints. Scand J Plast Reconstr Surg 1975;9:53-63.
Subcutaneous Mercury Granulomas To the Editor: I read with interest the article titled "Focal Mercury Toxicity: A Case Report" by Dr. Cole et al. (J Hand Surg 1994;19A:602). Subcutaneous mercury inoculation may lead to a bizarre array of puzzling local and systemic signs and symptoms.l For a variety of reasons (frequently because of factitious injection, or because o f accidental exposure not appreciated by the patient) there is often no history of mercury exposure. It is important to perform xray evaluation o f every chronic granulomatous lesion in an extremity. This evaluation may reveal a persistent radiopaque foreign object that accounts for the failure of the wound to heal. The foreign material identified radiographically, both in a report we presented 1 and that of the authors, ultimately proved to be mercury (Fig. 1). The definitive treatment for local inoculation of mercury is surgery. At the least, this will help overcome the local tissue reaction and allow the wound to heal. Furthermore, considerable quantities of mercury may be excised at the granuloma site, thus enabling potentially toxic systemic mercury levels to be reducedfl The authors correctly point out that complete removal of the local deposits of mercury should be confirmed radiographically. Generally, chelating agents have not been found to be helpful in patients with chronic mercury
Figure 1. (A) X-ray film showing opaque mercury deposits in antecubital fossa. (B) Foreign body granuloma in antecubital fossa with skin breakdown and sinus tracks.
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
517
2. Hill DM. Self-administration of mercury by subcutaneous injection. BMJ 1967;1:342-3. 3. Ambre JJ, Welsh MJ, Sbare CW. Intravenous elemental mercury injection: blood levels and excretion of mercury. Ann Intern Med 1977;87:451-3. 4. Burton EM, Weaver DL. Repeated systemic mercury embolization. South Med J 1988;81:1190-2. 5. Johnson HRM, Coumides O. Unusual case of mercury poisoning. BMJ 1967;1:340-1. 6. Celli B, Khan MA. Mercury embolization of the lung. N Engl J Med 1976;295:883-5.
In Reply: I agree fully with the points made in Dr. Netscher's letter. Mercury toxicity should be considered when treating any patient with a chronic granuloma.
John L. Holbrook, MD Orthopaedic Associates 310 State of Franklin Road Suite 101 Johnson City, TN 37604
Figure 2. Chest X-ray film showing embolic foci of mercury.
Cryptococcal Infection To the Editor:
The authors also identify a case of mercury injection in a psychiatric patient, where the mercury was inoculated for the "quick silver effect. ''5 In our review, we noted a report of a boxer who selfadministered mercury ostensibly to "strengthen his punches. ''6 Patients who have subcutaneous mercury deposits, and in whom accidental exposure cannot be verified, frequently require psychiatric assistance. A thorough medical evaluation for clinical features of mercury toxicity is required. Finally, surgical removal of the granuloma may be quite complex, especially if it surrounds neurovascular structures as may occur with injection in the antecubital fossa (even requiring flap soft tissue coverage of the exposed vital structures). 1
David T. Netscher, MD Division of Plastic Surgery Baylor College of Medicine 6560 Fannin, Suite 800 Houston, TX 77030
References 1. Netscher DT, Friedland JA, Guzewicz RM. Mercury poison from intravenous injection: treatment by granuloma resection. Ann Plast Surg 1991;26:592-6.
With regard to the article, "Cryptococcus Infection of the Hand" in the September 1994 issue (J Hand Surg 1994;19A:813-4). we suggest to the authors that their patient's unremitting cryptococcal infection of the hand was not due to dissemination of the infection from her recently created A-V shunt. If dissemination occurred from the shunt, infection probably would have been proximal, not distal, to the A-V shunt in her forearm. In our experience in patients with an A-V shunt, we note that vascularity to the hand is usually compromised (steal phenomenon). Improvement in blood flow can be demonstrated with compression at the fistula, which results in perceptible improvement in the distal pulses. Noninvasive vascular studies can confirm this. These patients may be asymptomatic and present with signs and symptoms of vascular insufficiency, nerve compression, and chronic infection. 1 This patient's immunocompromised state, resulting from diabetes mellitus, renal failure, use of steroids, and avascular insufficiency, contributed to her unremitting cryptococcal hand infection, despite what appeared to be adequate pharmacologic and surgical treatment. The ultimate removal of the A-V
Lettersto the Editor
For the record, active rabbit knee motion is 40~ ~, and 0~ ~ passively under anesthesia.
Clayton A. Peimer, MD Hand Center of Western New York Millard Fillmore Hospital 3 Gates Circle Buffalo, NY 14209
References
intoxication, and it must be remembered that chronic use of such agents has the risk of adverse side effects. 3 If systemic mercury levels do not fall after granuloma resection, then this may reflect ongoing absorption from embolic sites such as the brain and lungs (and xray films will identify these embolic sites) (Fig. 2); alternatively, repeated self-injection should be suspected and follow-up x-ray films of possible sites of reinjection should be performed. 4
1. Swanson AB. A grommet bone liner for flexible implant arthroplasty. Bull Pors Res Rehab Engin Res Devel BPR10 1981 ;35:108-14. 2. Minamikawa Y, Peimer CA, Ogawa R, Fujimoto K, Sherwin FS, Howard C. In vivo experimental analysis of silicone implants used with titanium grommets. J Hand Surg 1994; 19A:567-74. 3. Minamikawa Y, Peimer CA, Ogawa R, Sherwin FS, Howard C. In vivo analysis of silicone implants on bone and soft tissues. J Hand Surg 1994; 19A:575-83. 4. Hagen CG. Implants designed for finger joints. Scand J Plast Reconstr Surg 1975;9:53-63.
Subcutaneous Mercury Granulomas To the Editor: I read with interest the article titled "Focal Mercury Toxicity: A Case Report" by Dr. Cole et al. (J Hand Surg 1994;19A:602). Subcutaneous mercury inoculation may lead to a bizarre array of puzzling local and systemic signs and symptoms.l For a variety of reasons (frequently because of factitious injection, or because o f accidental exposure not appreciated by the patient) there is often no history of mercury exposure. It is important to perform xray evaluation o f every chronic granulomatous lesion in an extremity. This evaluation may reveal a persistent radiopaque foreign object that accounts for the failure of the wound to heal. The foreign material identified radiographically, both in a report we presented 1 and that of the authors, ultimately proved to be mercury (Fig. 1). The definitive treatment for local inoculation of mercury is surgery. At the least, this will help overcome the local tissue reaction and allow the wound to heal. Furthermore, considerable quantities of mercury may be excised at the granuloma site, thus enabling potentially toxic systemic mercury levels to be reducedfl The authors correctly point out that complete removal of the local deposits of mercury should be confirmed radiographically. Generally, chelating agents have not been found to be helpful in patients with chronic mercury
Figure 1. (A) X-ray film showing opaque mercury deposits in antecubital fossa. (B) Foreign body granuloma in antecubital fossa with skin breakdown and sinus tracks.
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
517
2. Hill DM. Self-administration of mercury by subcutaneous injection. BMJ 1967;1:342-3. 3. Ambre JJ, Welsh MJ, Sbare CW. Intravenous elemental mercury injection: blood levels and excretion of mercury. Ann Intern Med 1977;87:451-3. 4. Burton EM, Weaver DL. Repeated systemic mercury embolization. South Med J 1988;81:1190-2. 5. Johnson HRM, Coumides O. Unusual case of mercury poisoning. BMJ 1967;1:340-1. 6. Celli B, Khan MA. Mercury embolization of the lung. N Engl J Med 1976;295:883-5.
In Reply: I agree fully with the points made in Dr. Netscher's letter. Mercury toxicity should be considered when treating any patient with a chronic granuloma.
John L. Holbrook, MD Orthopaedic Associates 310 State of Franklin Road Suite 101 Johnson City, TN 37604
Figure 2. Chest X-ray film showing embolic foci of mercury.
Cryptococcal Infection To the Editor:
The authors also identify a case of mercury injection in a psychiatric patient, where the mercury was inoculated for the "quick silver effect. ''5 In our review, we noted a report of a boxer who selfadministered mercury ostensibly to "strengthen his punches. ''6 Patients who have subcutaneous mercury deposits, and in whom accidental exposure cannot be verified, frequently require psychiatric assistance. A thorough medical evaluation for clinical features of mercury toxicity is required. Finally, surgical removal of the granuloma may be quite complex, especially if it surrounds neurovascular structures as may occur with injection in the antecubital fossa (even requiring flap soft tissue coverage of the exposed vital structures). 1
David T. Netscher, MD Division of Plastic Surgery Baylor College of Medicine 6560 Fannin, Suite 800 Houston, TX 77030
References 1. Netscher DT, Friedland JA, Guzewicz RM. Mercury poison from intravenous injection: treatment by granuloma resection. Ann Plast Surg 1991;26:592-6.
With regard to the article, "Cryptococcus Infection of the Hand" in the September 1994 issue (J Hand Surg 1994;19A:813-4). we suggest to the authors that their patient's unremitting cryptococcal infection of the hand was not due to dissemination of the infection from her recently created A-V shunt. If dissemination occurred from the shunt, infection probably would have been proximal, not distal, to the A-V shunt in her forearm. In our experience in patients with an A-V shunt, we note that vascularity to the hand is usually compromised (steal phenomenon). Improvement in blood flow can be demonstrated with compression at the fistula, which results in perceptible improvement in the distal pulses. Noninvasive vascular studies can confirm this. These patients may be asymptomatic and present with signs and symptoms of vascular insufficiency, nerve compression, and chronic infection. 1 This patient's immunocompromised state, resulting from diabetes mellitus, renal failure, use of steroids, and avascular insufficiency, contributed to her unremitting cryptococcal hand infection, despite what appeared to be adequate pharmacologic and surgical treatment. The ultimate removal of the A-V