Benign lymphoplasia of the earlobes induced by gold earrings: immunohistologic study on the cellular infiltrates

Cutaneous Reactive B-cell Lymphoid Proliferations

Cutaneous lymphoid hyperplasia (CLH), also known as cutaneous pseudolymphoma, is a spectrum of benign conditions characterized by reactive B- and T-cell cutaneous lymphocytic infiltrates. B-cell lymphoid proliferations are a heterogenous group of non-neoplastic cutaneous diseases that must be histopathologically distinguished from cutaneous B-cell lymphomas. These proliferations can be observed as reactive phenomena to infections, medications, allergens, neoplasms, and more. Further, there are many inflammatory conditions that present with reactive B-cell infiltrates, including actinic prurigo, Zoon balanitis, Rosai-Dorfman, and cutaneous plasmacytosis. This review summarizes multiple cutaneous B-cell lymphoid proliferations within the major categories of reactive and disease-associated CLH. Further we discuss major discriminating features of atypical CLH and malignancy. Understanding the specific patterns of B-cell CLH is essential for the proper diagnosis and treatment of patients presenting with such lesions.

Cutaneous B-Cell Pseudolymphoma (Lymphocytoma Cutis) of the Earlobe: A Poorly Recognized Complication of Ear Piercing in Children

Background: Cutaneous pseudolymphoma (CPL) refers to a group of benign, reactive processes that mimic cutaneous lymphoma and are associated with a variety of triggering immune stimuli, including arthropod bites, drugs, and foreign bodies. In children, most cases of CPL are due to a variant of Borreliosis that is specific to Eurasia. Cutaneous pseudolymphoma secondary to ear piercing has only been documented in adults. Case Reports: We present the clinical and pathological findings of cutaneous Bcell psuedolymphoma in two adolescent patients (11-year-old female and 15-year-old male) secondary to ear piercing. Conclusion: Our report expands the clinico-pathological spectrum of CPL associated with ear piercing by documenting its occurrence in children.

Primary Cutaneous Acral CD8+ T-cell Lymphoma Induced by Persistent Delayed Hypersensitivity to Gold Earrings

Primary cutaneous CD8+ T-cell lymphoma has been included as a provisional entity within the new revised classification of lymphoid neoplasms of the World Health Organization in 20161. It was initially described as indolent CD8+ lymphoid proliferation of the ear2 and a total of 29 cases of such neoplasm have been published in the literature so far. None of them have been linked to delayed contact hypersensitivity reactions. We present a case of acral type primary cutaneous lymphoma T CD8+ involving both earlobes clearly related with the prolonged use of gold earrings, confirmed with epicutaneous tests, histopathology, immunohistochemical and molecular studies. Auricular skin lesions were induced again with a provocation test with identical histopathologycal and the same clonality, confirming both the diagnosis of lymphoma and its induction by the antigenic stimulus of gold.

Inflammatory response to therapeutic gold bead implantation in canine hip joint osteoarthritis

Inflammatory changes associated with periarticular pure gold bead implants were studied in dogs involved in a clinical trial investigating motor dysfunction and chronic pain owing to hip joint dysplasia and osteoarthritis. Gold beads were percutaneously implanted via a needle into different locations surrounding the greater trochanter of the femur. Nine dogs with implants were necropsied. In all examined animals, characteristic histologic lesions were observed in the tissue surrounding the gold implants--namely, a fibrous capsule composed of concentric fibroblasts intermixed with a variable number of inflammatory cells and a paucicellular innermost layer of collagen with a few fibrocyte-like cells in empty lacunae. Lymphocytes dominated the inflammatory infiltrate, with rarely observed macrophages present in close proximity to the implant site. No giant cells were observed. Immunohistochemistry showed mixed populations of lymphocytes, both CD3 positive (T cells) and CD79a positive (B cells), which in some cases formed lymphoid follicles. Diffuse inflammatory changes were present to a minor extent in the perimysium and surrounding fascia. The inflammation observed in dogs is similar to that observed with gold implants in humans. It is possible that the clinically beneficial effect of gold beads for chronic osteoarthritis depends on sustained localized inflammation with localized release of soluble mediators. The encapsulation of the implant by a paucicellular and poorly vascularized fibrous capsule may help prevent an exaggerated inflammatory reaction by sequestering the gold bead from the surrounding tissue.

Medical Device Regulations and Testing for Toxicologic Pathologists

Awareness of the regulatory environment is fundamental to understanding the biological assessment of biomaterials and medical devices. Medical devices are a diverse and heterogenous group of medical products and technologies defined by the lack of chemical action or requirement for metabolism. Regional activity and the Global Harmonization Task Force are now working on harmonizing the categorization and testing of medical devices. The International Organization for Standardization (ISO) has published 19 standards for biological evaluation. ISO 10993 standards are generally accepted outright or as an alternative to most national regulatory directives or acts, although Japan and the United States require more stringency in some tests. Type of materials, intended use, and risk are the basis for drafting testing programs for biomaterials and medical devices. With growth of the medical device industry and advent of new biomaterials and technologies, the need for toxicologic pathologists in safety (biocompatibility) and efficacy (conditions of use) evaluation of moderate- to high-risk devices is expanding. Preclinical evaluation of biomaterials and medical devices increasingly requires a basic understanding of materials science and bioengineering to facilitate interpretation of complex interface reactions between biomaterials, cellular and secretory factors, and vascular and tissue responses that modulate success or failure of medical devices.

Lymphomatoid contact dermatitis induced by gold earrings

Metallic gold has long been regarded as a relatively safe material when in contact with the skin and mucosal membranes, with only sporadic reports of allergic contact dermatitis or stomatitis. This is probably due to its stability and low tendency to ionization. Lymphomatoid reactions have been described in cutaneous responses to several products. We report a patient who developed bilateral nodules on the earlobes at the sites of piercing earrings. Histologically, these lesions presented a lymphomatoid appearance, with a T-cell diffuse infiltrate. The patch test demonstrated a strong reaction to 1% gold sodium thiosulfate.

Lymphocytoma cutis due to pierced earrings

We report two cases of lymphocytoma cutis caused by pierced earrings, with the results of patch tests and X-ray microanalyses on electron microscopy. We detected zinc through scanning electron microscopy from the specimen of Case 1 and gold and titanium through transmission electron microscopy from Case 2. This is the first report to demonstrate the presence of metal fragments in the lesion, which may suggest the remanence of metal for 20 years, bringing about persistent allergic reaction.

CD30-positive T-cell-rich pseudolymphoma induced by gold acupuncture

Cases of pseudolymphoma induced by intradermal gold injection or gold piercing have previously been described. Most of these cases showed the histopathological finding of B-lymphocyte predominant lymphocytoma cutis. We describe a patient with gold acupuncture-induced T-cell-rich pseudolymphoma. Some T cells showed positive staining with CD30. The lesions responded to an intralesional injection of triamcinolone acetonide.

Body piercing medical concerns with cutting-edge fashion

OBJECTIVE

To review the current information on medical complications, psychological implications, and legislative issues related to body piercing, a largely unregulated industry in the United States.

METHODS

We conducted a MEDLINE search of English language articles from 1966 until May 1998 using the search terms "body piercing" and "ear piercing." Bibliographies of these references were reviewed for additional citations. We also conducted an Internet search for "body piercing" on the World Wide Web.

MAIN RESULTS

In this manuscript, we review the available body piercing literature. We conclude that body piercing is an increasingly common practice in the United States, that this practice carries substantial risk of morbidity, and that most body piercing in the United States is being performed by unlicensed, unregulated individuals. Primary care physicians are seeing growing numbers of patients with body pierces. Practitioners must be able to recognize, treat, and counsel patients on body piercing complications and be alert to associated psychological conditions in patients who undergo body piercing.

Cutaneous pseudolymphomas

Cutaneous pseudolymphoma refers to a heterogeneous group of benign reactive T- or B-cell lymphoproliferative processes of diverse causes that simulate cutaneous lymphomas clinically and/or histologically. The inflammatory infiltrate is bandlike, nodular, or diffuse and is composed predominantly of lymphocytes with or without other inflammatory cells. Depending on the predominant cell type in the infiltrate, cutaneous pseudolymphomas are divided into T- and B-cell pseudolymphomas. Cutaneous T-cell pseudolymphomas include idiopathic cutaneous T-cell pseudolymphoma, lymphomatoid drug reactions, lymphomatoid contact dermatitis, persistent nodular arthropod-bite reactions, nodular scabies, actinic reticuloid, and lymphomatoid papulosis. Cutaneous B-cell pseudolymphomas include idiopathic lymphocytoma cutis, borrelial lymphocytoma cutis, tattoo-induced lymphocytoma cutis, post-zoster scar lymphocytoma cutis, and some persistent nodular arthropod-bite reactions. This review attempts to discuss current aspects of the classification, pathogenesis, clinical spectrum, histopathologic and immunohistochemical diagnosis, and laboratory investigations for clonality in the various types of cutaneous pseudolymphomas.

Gold: an allergen of growing significance

Gold moved into the limelight of medical literature thanks to the anti-inflammatory activity and effectiveness of gold compounds in the treatment of rheumatoid arthritis, but more recently also because of the growing incidence of hypersensitivity induced by it which is expressed in cutaneous and mucosal reactions. This review discusses dermatotoxicity associated with gold. In some countries gold has moved into second place as allergen, following nickel. Such recognition is mainly due to improved diagnostic methods and to its inclusion in routine dermal patch testing. Some unconventional manifestations of hypersensitivity are associated with use patterns which involve intimate contact with the metal as a component of jewelry. In-depth analysis of the growing number of cases of allergy has revealed various immunological idiosyncrasies as being characteristic of this metal. These include late reactions to challenge, extraordinary persistence of clinical effects, formation of intracutaneous nodules and immunogenic granuloma unresponsive to conventional steroid therapy, the occurrence of eczema at sites distant from the site of contact, and flare-ups of eczema upon systemic provocation with allergen which are characteristic of drug induced allergy. These manifestations demand investigations at the molecular level of the unusual mechanisms of action involved.

Persistent cutaneous pseudolymphoma after intradermal gold injection

After intradermal testing with goldsodiumthiomalate (GSTM), 5 out of 8 patients developed skin papules at the test sites, which persisted up to 20 months. The lesions were surgically excised. Histology revealed pseudolymphoma of B and T cell type containing follicular structures and occasional small granulomas. The amount of histiocytic cells among B and T lymphocytes was pronounced, including acid cysteine proteinase inhibitor (ACPI) positive follicular dendritic cells, CD68 positive macrophages, factor XIIIa positive dermal dendrocytes and S-100 positive cells. By electron microscopy, the macrophages contained endosomes loaded with crystalloid material which contained gold in X-ray microanalysis. Atomic absorption spectrophotometry also confirmed the presence of gold in one specimen. Thus GSTM seemed to accumulate in tissue macrophages leading to constant immunologic activation with lymphoid proliferation and histiocytic response.

Contact allergy to gold sodium thiosulfate

278 consecutive patients with suspected contact dermatitis were patch tested with the European standard series and gold sodium thiosulfate (0.5% pet.): 13 patients (4.6%) had a positive allergic response to gold sodium thiosulfate (GST). All of these patients were female, with a mean age of 37 years. The most frequent site of eczema in these patients was the head and neck (62%). A seborrhoeic distribution of eczema was common. 46% had involvement of the limbs, 15% had a perianal or perivulval rash. The mean duration of eczema in this group of patients was 15.8 months. 54% of patients allergic to gold were also allergic to nickel. Biopsy of positive patch test reactions to GST were consistent with allergic contact dermatitis.

Physiological and toxicological changes in the skin resulting from the action and interaction of metal ions

The human environment contains more than 50 metal or metalloid elements. At least 15 are recognized as trace elements, with zinc, calcium, copper, magnesium, and iron having specific roles in skin morphogenesis and function. The present review focuses on the presumed role of metal ions in the skin, their competition for carrier proteins, and membrane receptors. Evidence presented shows that the balance of trace metal ions is critical for normal skin and repair mechanisms following injury. Xenobiotic ions can impair this balance, leading to pathological change. The skin acts as an organ of elimination of excess trace metals and xenobiotic ions from the body, but mechanisms of voidance vary for different metals. Metal ions are an important cause of allergies, and evidence is presented to show that the majority of metals or metal compounds can induce allergic changes. Except for chromium and nickel, which are among the most common human allergens, animal models have provided little information. At least cadmium, thorium, lead, chromium, nickel, beryllium, and arsenic and proven or putative carcinogens in animals or humans on the basis of cytological or epidemiological evidence. However, only arsenic exhibits a clear predilection for the skin. Other metals such as gold can induce subcutaneous sarcoma following injection, but the relevance of this observation in terms of human occupational risk is discounted.

Gold dermatitis due to ear piercing: correlations between gold and mercury hypersensitivities

A case of allergic contact dermatitis due to gold pierced earrings is reported. The patient developed recurring redness and swelling on her earlobes a month after the wearing of pierced-type gold earrings, which was followed by the appearance of reddish nodules around the puncture marks. Patch tests revealed positive reactions to 0.1% mercuric chloride, 1% gold sodium thiomalate and 0.2% chloroauric acid. We also demonstrated that guinea pigs contact-sensitized with a mercuric compound developed positive patch test reactions to both mercuric and gold compounds. These results suggest that there may be correlations between gold and mercury hypersensitivities.

Iatrogenic benign lymphoplasia induced by allergic contact dermatitis from squaric acid dibutylester: immunohistologic study of cellular infiltrates

We report of a 62-year-old male patient with a dull red itchy nodule on the induction area of allergic contact dermatitis to squaric acid dibutylester, which had been used for the therapy of alopecia universalis. The excised biopsy specimen showed dense infiltration of lymphoid cells in the dermis and subcutaneous tissue, associated with the formation of lymphoid follicles. Immunohistologic analysis of the infiltrates indicated mixed proliferation of T- and B-cells. A biopsy specimen from the challenge area showed spongiosis in the epidermis and lymphoid cell infiltration in the upper dermis, while the infiltrates consisted mainly of T-cells. The following points are discussed: (i) the lesion had an iatrogenic origin and the causative agent was quite evident; (ii) the route of allergen application was only through the epidermis and not directly in the dermis; (iii) lymphoid cell infiltrates of the induction and challenge areas were different.

A case of lymphadenosis benigna cutis of the earlobe: an immunohistochemical study

We report a 38-year-old woman who developed an erythematous nodule on her earlobe after wearing pierced-type 18-carat gold earrings. Biopsy specimens revealed dense cellular infiltration predominantly composed of lymphocytes and plasma cells in the dermis and subcutaneous tissue with formation of lymph follicles. Morphological and immunohistochemical analyses were compatible with lymphadenosis benigna cutis.