Longitudinal medical surveillance showing lack of progression of argyrosis in a silver refiner

Silver is a recognized cause of argyrosis and argyria. This case report describes blood silver levels and longitudinal ophthalmological examination in a previously reported case of argyrosis over a 5-year period.

Argyremia in septal cauterization with silver nitrate

OBJECTIVE

The purpose of this study was to demonstrate silver absorption in blood and hair specimens after septal cauterization with silver nitrate and to discuss the potential toxicity of silver.

METHOD

A prospective study of 11 volunteers without any known occupational exposure to silver products or past history of septal cauterization with silver nitrate was undertaken. Subjects were recruited in an academic tertiary care centre from October 1996 to September 1997. The study population consisted of five patients with anterior epistaxis and six healthy volunteers without any bleeding problem. Cauterization was done with one or two silver nitrate applicators directly on the bleeding vessel or Kiesselbach's area. Blood was sampled before cauterization and at specified times after application, while hair strands were sampled only 3 months later. Measurements of silver concentration in whole blood and in hair segments were obtained by inductively coupled plasma mass spectrometry.

RESULTS

Silver concentrations in whole blood increased significantly after cauterization (p = .02). The measured peak level seemed to correlate with the number of applicators used. No significant increase in silver concentration was observed in hair samples.

CONCLUSIONS

Effective silver absorption occurs with only one or two silver nitrate applicators. Hair has not been as reliable as whole blood to document an acute and fragmentary exposure. The indiscriminate use of silver nitrate is a potential source of silver intoxication.

A swine model for the evaluation of efficacy of anti-microbial catheter coatings

A swine model was developed to investigate the efficacy of percutaneous venous catheters with anti-microbial coatings. The catheters used in the study consisted of silver-coated and uncoated catheters, both designed for percutaneous venous access. Five commercial pigs were each implanted with three venous catheters and followed for a period of 90 days. Two of the three catheters were coated and one was uncoated. To evaluate the percutaneous aspects of the catheters in the model, two venous access catheters were implanted percutaneously, parallel to the dorsal midline. These catheters were just caudal to the region that is dorsal to the scapula in each animal. In each case, the catheter to the left of the dorsal midline was silver-coated while the catheter to the right of the dorsal midline was uncoated. A silver-coated catheter was also implanted in the left external jugular vein of each animal and buried subcutaneously in order to evaluate the elution of the coating through the body under venous contact. Over the 90 day period, the concentration of silver in the blood rose to a mean peak level of 23.2 ppb following implantation of the catheters and then decreased after the second post-surgery week. The histological evaluation and macroscopic inspection at necropsy revealed minimal tissue response to both coated and uncoated materials. Data on bacterial growth indicated that bacteria were present at the terminal subcutaneous end of two of the uncoated percutaneous catheters. Based upon serum silver levels, exudate formation, histological examination, and bacterial growth information, the swine model was deemed to be suitable for testing the efficacy of catheters containing anti-microbial coatings.

Biological interaction between transition metals (Ag, Cd and Hg), selenide/sulfide and selenoprotein P

The interaction between transition metals (Ag+, Cd2+ and Hg2+) and selenium (Se) in the bloodstream was studied in vitro by means of the HPLC--inductively coupled argon plasma-mass spectrometry (ICP MS) method. Transition metal ions and selenide (produced in vitro from selenite in the presence of glutathione) or sulfide (Na2S) formed a (metal-Se/S) complex, which then bound to a plasma protein, selenoprotein P (Sel P), to form a ternary complex, (metal-Se/S)-Sel P. The molar ratios of metals to Se were 1:1 for Hg/Se and Cd/Se, but either 1:1 or 2:1 for Ag/Se, depending on the ratio of their doses. The results indicate that the interaction between transition metals and Se occurs through the general mechanism, i.e., transition metal ions and selenide form the unit complex (metal-Se)n, and then the complex binds to selenoprotein P to form the ternary complex ¿(metal-Se)n¿m--seleno-protein P in the bloodstream.

Silver modification of polyethylene terephthalate textiles for antimicrobial protection

The safety and in vitro effectiveness of applying silver to polyethylene terephthalate fabric mechanical heart valve (MHV) sewing cuffs for the prevention of prosthetic valve endocarditis (PVE) were evaluated. PVE is an infrequent but grave complication of cardiac surgery associated with mortality rates potentially exceeding 50%. A poor response to antibiotic therapy is partly responsible for the high mortality rates. Silver is a well known antimicrobial agent with broad effectiveness. Preliminary in vitro microbial challenge studies of the coated fabric using the New York State 63 bacteriostatic test and Dow Corning Shake Flask test showed a > or = 97% reduction for most organisms tested. Sheep mitral valve replacement studies suggest comparable tissue ingrowth of uncoated and coated fabric with a more organized, thinner pannus formed on silver coated fabric. Low levels of silver were present in the serum at all time periods. These results indicate MHVs with silver coated cuffs may provide additional protection against PVE.

[General argyria caused by administration of tobacco-withdrawal tablets containing silver acetate]

In a 49-year-old man generalised argyria was diagnosed, a systemic dissemination and tissue deposition of silver in the body. The clinical picture was brought about by use of a silver acetate-containing lozenge as a deterrent to smoking. Argyria is characterised by a slate blue-gray discolouration of the skin, particularly in areas exposed to light. Generally, it causes patients a great deal of anguish and embarrassment. Present understanding is that it does not entail non-cutaneous, systemic effects. There is no effective treatment--the discolouration is permanent. Currently, prevention is the only possible measure. Efforts should be made to eliminate the uncontrolled use of silver-containing preparations.

Absence of symptoms in silver refiners with raised blood silver levels

Silver has been implicated as a cause of ill health, related largely to its use in the medical setting as a treatment for burns and in prosthetic cements. This report discusses occupational silver exposure in two workers with blood silver levels of 49 micrograms/l and 74 micrograms/l who were asymptomatic and showed no signs of argyric neuropathy which has previously been described at blood silver levels as low as 10 micrograms/l. One of the men showed non-characteristic clinical signs of argyrosis. The clinical findings, results of environmental monitoring and effects of environmental improvements on blood silver levels are discussed.

Solubility of silver sulfadiazine in physiological media and relevance to treatment of thermal burns with silver sulfadiazine cream

Silver sulfadiazine cream has been a standard treatment for burns over the past two decades. Although many studies have described the phenomenon of silver absorption from burn wounds treated with silver sulfadiazine, they failed to examine the chemistry underlying the absorption process: Silver chloride was assumed to form at the burn wound and absorption of silver was believed to be negligible. Here we have developed chemical model systems to investigate the interactions of silver sulfadiazine and silver chloride in direct contact with synthetic serum electrolyte solution (SSES), with SSES plus endogenous ligands or beef blood plasma, and with human serum. The results indicate that silver absorption from an acute burn site can be significant, because human serum is capable of solubilizing silver. This finding is of concern, given the potential for silver toxicity as a direct consequence of applying silver sulfadiazine to extensive burn wounds.

Determination of silver in blood, urine, and tissues of volunteers and burn patients

Silver sulfadiazine cream (SSD) has been used successfully in the management of burn wound sepsis. Silver deposition has been found in the skin, gingiva, cornea, liver, and kidney of patients treated with this cream, causing argyria, ocular injury, leukopenia, and toxicity in kidney, liver, and neurologic tissues. Monitoring concentrations of silver in blood and urine of patients receiving this treatment has become necessary, but sensitive and suitable methods adaptable to a clinical laboratory are still needed. We have developed a flameless thermal atomic absorption spectrophotometric method to measure silver concentrations in blood, urine, and other tissues. The detection limit is 0.4 microgram/L; the within-run precisions (CV) are 5.16%, 3.83%, and 2.79% for concentrations of 5, 13.5, and 42 micrograms/L, respectively; and the between-run precisions are 4.3% and 3.2% for concentrations of 13.5 and 42 micrograms/L. The concentrations of silver in blood, urine, liver, and kidney of subjects without industrial or medicinal exposure are less than 2.3 micrograms/L, 2 micrograms/day, 0.05 microgram/g wet tissue, and 0.05 microgram/g wet tissue, respectively. In SSD cream-treated burn patients, plasma concentrations may be as great as 50 micrograms/L within 6 h of treatment and can reach a maximum of 310 micrograms/L. Silver in urine is detectable after one day of treatment and may reach a maximum of 400 micrograms/day. After absorption, silver was found to be deposited in various tissues. Tissue silver concentrations in one burn patient who died of renal failure after eight days of treatment were 970, 14, and 0.2 micrograms/g wet tissue in cornea, liver, and kidney, respectively.

Serum sulfate concentration and the anion gap in hemodialysis patients

First-of-the-month predialysis serum sulfate (SO4) and other blood chemistry values were measured prospectively for 5 to 7 months in 14 patients undergoing single pass chronic tri-weekly maintenance hemodialysis with bicarbonate dialysate. Blood was also obtained predialysis and again immediately postdialysis from seven patients (five of whom also participated in the chronic study). As expected, the patients manifested a high anion gap (AG) metabolic acidosis. Serum SO4 was only moderately stable from month to month (the average coefficient of variation was 0.30; correlation between the serum SO4 value of month one and months two and five were r = 0.59, p = 0.026; and r = 0.38, p = 0.182, respectively). The ratio of mean serum SO4 to mean AG (5.0 +/- 0.4 [SE] mEq/L divided by 19.1 +/- 0.5 mEq/L) was 0.26. Although there was a statistically significant correlation between the serum SO4 and the blood urea nitrogen (BUN), there was no such correlation between SO4 and AG. A single hemodialysis reduced serum SO4 by 54% (from 3.5 +/- 0.5 mEq/L to 1.6 +/- 0.1 mEq/L), but there was no correlation between the change in SO4 and the change in AG. The authors concluded that SO4 contributes importantly to the elevated AG in patients receiving chronic hemodialysis. Single pass bicarbonate hemodialysis temporarily reduces, but does not normalize, both the serum SO4 and the AG of such patients.

[Serum and tissue silver levels after burns treated with silver compounds]

This study was performed in order to investigate serum and tissue silver levels in burns which were used 10 percent silver nitrate as a topical agent. We formed four groups of animals and pulverized 10 percent silver nitrate solution to the first group (GI) that included ten rabbits of which backs were burned by boiling water and silver sulphadiazine cream to second group (GII) with nine rabbits. We carried out 10 percent silver nitrate solution to the first control group (GIII) and silver sulphadiazine cream to the second control group (GIV) each of which had seven animals with unburned skin. We obtained blood samples from every animal before and after application of topical agent on the 1st, 3rd, 7th, 15th, 21st and 28th. We determined serum and tissue silver levels by atomic absorption spectrophotometer in kidney and liver of the animals which were sacrificed on the 28th day. In first and second groups we found that serum silver values reached on 3rd day to the maximum level and then the values decreased gradually. We also determined that diminution of the serum silver levels were prominent following on 15th day. It was shown that there was no silver in the serum on 28th day except four animals. The silver deposition in the liver was much more than in the kidney. Between these two groups there was significant difference neither in the serum on the same days nor the tissue silver levels. According to these data it was concluded that serum and tissue silver levels with 10 percent silver nitrate used in burns produced no difference from that of 1 percent silver sulphadiazine cream.

Results of a multicenter outpatient burn study on the safety and efficacy of Dimac-SSD, a new delivery system for silver sulfadiazine

Dimac with silver sulfadiazine (Dimac-SSD), a new silver sulfadiazine delivery system, was evaluated prospectively in a multicenter study for the treatment of outpatient burn injuries. The goal of this study was to evaluate the effect of Dimac-SSD on the microbiology of the burn wounds and to quantitate its clinical safety and efficacy. A total of 197 patients were evaluated. Eight (4%) of these patients did not complete the study. Six patients withdrew because of local discomfort caused by the Dimac-SSD and two patients were terminated because of technical problems. The mean +/- SD duration of treatment with Dimac-SSD was 12 +/- 8.5 days, during which time the mean number of dressing changes was 2.9 per patient. During treatment with Dimac-SSD, the burn wound bacterial flora remained stable and overgrowth with Pseudomonas species or Gram-negative bacilli did not occur. Only four (2%) patients developed clinical infections; thus the Dimac-SSD appeared to have good antimicrobial effectiveness. This dressing was not associated with any organ system or metabolic side-effects and patient discomfort during application and removal was minimal. Thus this new delivery system for silver sulfadiazine was associated with excellent wound healing, a low incidence of wound infections, reduced frequency for dressing changes, and excellent patient compliance.

Serum concentrations and accumulation of silver in skin during three months treatment with an anti-smoking chewing gum containing silver acetate

Silver acetate chewing gum was used for 12 weeks as a smoking deterrent in 21 adults. The effect of silver on serum concentrations, its accumulation in the skin and the risk of developing clinically evident argyria were investigated. Serum concentrations of silver clearly rose after chewing gum use had started, and concentrations quickly returned to normal after use had ceased. In most cases the number of silver granules in skin biopsies, observed by autometallography, increased after the gum had been used for 12 weeks. No one developed clinical signs of argyria. Silver acetate containing remedies can be used as an aid to stop smoking, but the consumption must be monitored to avoid accumulation of larger amounts of silver in the body.

[Argyria. A clinical, chemical analytic and micromorphologic study]

A 62-year-old male patient developed generalized argyria following the intake of silver-proteinacetyltannate (Targesin; approx. 60 g in 10 years) as treatment for gastric discomfort. On histological and ultrastructural examination of the skin, silver particles were found not only in the usual locations but also in the Schwann cell, the mast cell, and in smooth muscle cells. This corresponded to chemical analysis, proving the presence of this metal in the skin. In the blood, a level of 0.26 +/- 0.04 ppm silver was found. By means of an equation, attempts were made to demonstrate the reaction process involved in the formation of Ag2S as subjected to the photochemical effect of sunlight.

Relationship between ceruloplasmin and Cu status involving metallothionein induced by several heavy metals in the mouse

ICR male mice aged 5 weeks were injected subcutaneously with CdCl2, Pb(CH3COO)2, AgNO3, CuCl2, a combination of Cd and Ag compounds, or a combination of Cu and Ag compounds. These injections were carried out 3 times. Twenty-four hours after the last injection, they were sacrificed. Cd injection significantly stimulated serum ceruloplasmin (Cp) activity and Cu concentration, accompanied by an increase in hepatic Cu. Pb injection also slightly increased the Cp level. In contrast, Ag injection markedly decreased both Cp activity and Cu concentration in the serum. Hepatic Cu increased slightly after Ag injection. Using a combination of Cd and Ag, only the Ag effect on the Cp activity appeared. The Cu injection stimulated Cu binding to metallothionein (MT) and bile excretion of Cu, but not Cp release. With a Cu and Ag combination, the effect of Ag on Cp was lost, with a concomitant disappearance of Ag from the Cp fraction in the serum. Our results suggest that in the mouse, Cd and Ag, Cu antagonistic metals, influence different sites of Cp metabolism. Excess hepatic Cu is partly eliminated by excretion of bile and is partly detoxified by MT induction.

Determination of silver in biological samples using graphite furnace atomic absorption spectrometry based on Zeeman effect background correction and matrix modification

A method for the determination of silver in human body fluids and biological material is described. The silver in an acid digest of biological samples and diluted body fluids is quantified using Zeeman graphite furnace atomic absorption spectrometry (ZGFAAS). The effects of NH4H2PO4 as matrix modifier and standard addition are discussed. Atomization from the graphite tube wall and from the pyrolytical tube with platform is also discussed and the peak height and the peak area are compared. The best results were achieved by using matrix modification, stabilized temperature platform furnace, integrated absorbance and standard addition technique. The calibration was linear up to 15 micrograms X L-1; the between-run precision was 5.9% at 40 micrograms X kg-1 of silver.

Comparative study of effect of acute administration of cadmium and silver on ceruloplasmin and metallothionein: involvement of disposition of copper, iron, and zinc

Male ICR mice were subcutaneously injected with either aqueous Ag (1.5 or 5.0 mg/kg) or Cd (1.5 or 2.5 mg/kg) for 2 consecutive days. Body fluids and livers were collected 24 hr after the second dose. In the hepatic supernatant, Ag and Cd were recovered at 2 and 36-46% of the total dose, respectively. Ag-metallothionein (MT), which is associated with Ag, Cu, and Zn, and Cd-MT, which is associated with Cd, Cu, and Zn, were induced in the liver by the injection of Ag and Cd, respectively. The supernatant Ag and Cd existed in the MT fraction at 34-61 and 97% levels, respectively. Cu concentration in the hepatic supernatant was increased by the Ag and Cd injections. The increased Cu was due to the appearance of Ag-MT and Cd-MT, respectively. Microsomal concentrations of Cu increased in the Cd groups, but decreased in the Ag groups. Serum ceruloplasmin (Cp) activity was remarkably increased by the injection of Cd, but severely decreased by the injection of Ag. These opposing changes in Cp activity induced by Cd and Ag may be due not to the sequestering of Cu in MT, but to the alteration of microsomal Cu concentration and/or the difference in affinity of the induction metals to MT. Hepatic Fe concentration was increased by the Ag injection, but was decreased by the Cd injection. These changes may not be related to induction of MT, but to Cp synthesis in the liver.

Evidence for carriage of silver by sulphadimidine: haemolysis of human erythrocytes

1 Human erythrocytes suspended in isotonic saline haemolyse in the presence of both Ag+ ions and sulphadimidine. 2 Neither Ag+ ions nor sulphadimidine on their own will haemolyse erythrocytes suspended in isotonic saline. 3 At constant Ag+ ion concentration the degree of haemolysis of saline-suspended erythrocytes depends upon the concentration of sulphadimidine. 4 Human erythrocytes suspended in isotonic sucrose (chloride-free) haemolyse in the presence of Ag+ ions. 5 Sulphadimidine in chloride-free sucrose competes with erythrocytes for Ag+ ions resulting in stoichiometric protection of the erythrocytes from the haemolytic action of Ag+ ions. 6 Haemolysis occurs when each erythrocyte receives approximately 1.2 X 10(9) Ag+ ions whether suspended in saline or sucrose. 7 Sulphadimidine acts as a carrier for Ag+ ions and so prevents their precipitation as AgCl when erythrocytes are suspended in saline.

Evidence for the carriage of silver by sulphadimidine: inhibition of proteolytic enzymes

1 Trypsin in free solution and trypsin-sepharose were shown to be inhibited by Ag+ in the absence of Cl-. 2 In the presence of Cl- and absence of a suitable carrier, Ag+ has no inhibitory action on trypsin or chymotrypsin. 3 Sulphadimidine bound Ag+ in the presence of Cl-, and carried the Ag+ to both trypsin and chymotrypsin in free solution as well as to trypsin-sepharose leading to the inhibition of all these enzyme systems. 4 The neutral protease of tumour cell surfaces was inhibited by Ag+ transported by sulphadimidine in the presence of Cl-. 5 Kinetic data demonstrated the requirements for both Ag+ and carrier to effect inhibition, the degree of inhibition being directly related to the molarity of each of these reagents. 6 The known inhibition of trypsin by Ag+ binding to histidine in the active site has been defined in mechanistic terms employing the sulphonamide drug, sulphadimidine, to illustrate this exchange mechanism.

Serum levels of certain trace elements (Ag, Co, Cr) in healthy subjects (part II)

In 95 healthy subjects including 55 women and 40 men the serum levels of Ag, Co and Cr were determined by means of neutron activation analysis using the method of gamma spectrometry without separation of different elements from the sample. It was found that people aged over 60 years had higher serum silver levels than younger subjects. In women a statistically significantly higher serum cobalt level was demonstrated in relation to men. Men and women aged over 60 years had serum chromium levels very similar while women aged below 60 years had lower serum chromium levels.

Control of experimental burn wound infections: comparative delivery of the antimicrobial agent (silver sulfadiazine) either from a cream base or from a solid synthetic dressing

This report demonstrates prolonged effective release of silver sulfadiazine (AgSD) to experimental burns in rats from a solid dressing by mixtures of polyethylene glycol-400 and poly-2-hydroxyethyl methacrylate. The synthetic dressing, incorporating the antimicrobial drug, may be formed either directly on the burn wound or prepared as a preformed sheet and applied to the wound after it was contaminated with bacteria. The level of silver in the blood following treatment of the burn wound with topical AgSD (Silvadene, Marion Labs) is significantly less when the drug is presented in the dressing than when the drug is applied in a cream base; the concentration of the sulfadiazine moiety in the blood is similar for the two drug preparations. Improved survival of the burned and contaminated rats and reduced nursing care were observed in the burned animals when the synthetic dressing was used to deliver the drug relative to the results when the AgSD was applied in a cream base by standard procedures.

The ocular manifestations and functional effects of occupational argyrosis

Thirty employees of an industrial plant involved in the manufacture of silver nitrate and silver oxide underwent ophthalmologic evaluation in an effort to evaluate the frequency and extent of ocular argyrosis. The most frequently noted ocular abnormality was pigmentation of the conjunctiva, present in 20 workers; corneal pigmentation occurred in 15 workers. A direct relationship existed between the levels of pigmentation and duration of employment. Ocular pigmentation was seen more frequently than cutaneous pigmentation. Ten workers noted decreased night vision, but electrophysiologic and psychophysiologic studies of seven of these ten workers demonstrated no functional deficits.

Elemental composition of platelets. Part III. Determination of Ag, Au, Cd, Co, Cr, Cs, Mo, Rb, Sb, and Se in normal human platelets by neutron activation analysis

The elements Ag, Au, Cd, Co, Cr, Cs, Mo, Rb, Sb, and Se were determined in platelets from seven normal donors. The results, in ng/g wet weight, for plasma-free platelets follow: "Pure" platelets: Ag = 29 +/- (18), au = 0.22 +/- (0.22), Cd = 6.2 +/- 3.4, Cs = 54.8 +/- 19.2, Cr = 6.1 +/- 2.5, Co = 7.5 +/- (5.0), Mo = 3.4 +/- 1.3, Rb = 10400 +/- 3000, Sb = 18 +/- (26), and Se = 782 +/- 127. "Impure" platelets: Au = 0.23 +/- (0.28), Cd = 6.4 +/- 2.6, Cs = 35.2 +/- 13.8, Cr = 8.2 +/- 2.9, Co = 2.9 +/- (3.0), Mo = 3.2 +/- 0.8, Rb = 8700 +/- 1700, Sb = 13.2 +/- (8.7), and Se = 679 +/- 57. To our knowledge, none of these 10 trace elements has been determined in platelets before. The selenium concentration in platelets exceeds that in other tissues (e.g., liver). We suggest that glutathione peroxidase or other unknown selenoenzymes are particularly important in platelet metabolism. Platelets are crucial for triggering thrombosis, and so may be involved as links between selenium deficiency and the concomitant increased death rate from cardiovascular disease.