Localized Cutaneous Argyria at the Site of a Prior Melanoma Excision Confirmed by Scanning Electron Microscopy With Energy Dispersive X-ray Analysis

ABSTRACT

Localized cutaneous argyria is a rare condition caused by the accumulation of silver particles in the skin, leading to blue-gray discoloration. Argyria may mimic melanoma and lead to misdiagnosis. We present a patient with a history of melanoma that developed a blue-gray nodule at a prior melanoma graft. The diagnosis was confirmed using scanning electron microscopy and energy dispersive x-ray analysis. These techniques differentiate argyria from melanoma and can be performed on formalin-fixed, paraffin-embedded, tissue sections. Health care providers should be alert that argyria may mimic recurrent melanoma in patients unaware of silver exposure.

Localized cutaneous argyria: Review of a rare clinical mimicker of melanocytic lesions

Localized cutaneous argyria is a rare cutaneous disorder that has been associated with occupational exposure, dental procedures, topical agents, acupuncture, earrings, and nasal piercings. In this paper, we review the current literature on localized cutaneous argyria, highlight its clinical and histologic diagnostic features, and then discuss the clinical and histological differential diagnoses for blue-gray skin and black dermal pigment, respectively. We also discuss the utility of ancillary techniques, such as deeper histologic levels, special stains, darkfield microscopy, and advanced micro-analytical techniques in helping diagnose localized cutaneous argyria. Furthermore, we emphasize that a thorough clinical history and astute clinico-pathologic correlation can be the most important diagnostic techniques in correctly diagnosing this rare disorder. Our review aims serve as a reminder to clinicians and pathologists of the importance of including localized cutaneous argyria in the clinical and histological differential diagnosis of pigmented lesions.

Unsafe Deposits: Overlapping Cutaneous Manifestations of Porphyria Cutanea Tarda, Ochronosis, Hemochromatosis, and Argyria

Cutaneous deposition disorders represent an array of conditions resulting from the accumulation of endogenous and exogenous substances within the skin. Many of the deposition diseases resemble each other and can also be confused with disorders not related to deposition. Porphyria cutanea tarda (PCT) results from dysfunction particularly in the fifth enzyme of the heme synthesis pathway, leading to increased skin fragility and bullae among other abnormalities. Ochronosis develops from alkaptonuria or exogenous sources, creating deposition of ocher-colored pigment in the skin. Hemochromatosis is a systemic disorder that can be inherited or acquired, altering skin pigmentation in more than 90% of patients. PCT can be an initial manifestation of hemochromatosis. Argyria is an acquired disorder of silver deposition that can also cause pigmentation similar to ochronosis. These uncommon but not rare disorders may resemble and be confused with each other in multiple ways.

Localized cutaneous argyria: Report of two patients and literature review

BackgroundLocalized cutaneous argyria is a rare skin condition caused by direct contact with silver or silver particles. It presents as asymptomatic gray or blue-gray macules that appear similar to blue nevi. Histologic features include brown-colored or black-colored silver granules in the basement membrane and dermis, most commonly surrounding eccrine glands, elastic fibers, and collagen fibrils. The condition is most frequently observed in individuals who are regularly exposed to small silver particles, such as silversmiths and welders. However, localized cutaneous argyria has also been associated with acupuncture needles, silver earrings, and topical medications containing silver nitrate. Although the condition is benign, patients who are concerned about the cosmetic features of localized cutaneous argyria may benefit from laser therapy.PurposeWe describe the clinical and pathologic findings of two women who developed localized cutaneous argyria. We also review the characteristics of other patients with localized cutaneous argyria and summarize the differential diagnosis and treatment options for this condition.Materials and methodsThe features of two women with localized cutaneous argyria are presented. Using PubMed, the following terms were searched and relevant citations assessed: acquired localized argyria, acupuncture, argyria, argyrosis, colloidal silver, cutaneous argyria, and localized cutaneous argyria. In addition, the literature on localized cutaneous argyria is reviewed.ResultsTwo women presented with small, asymptomatic blue-gray macules appearing at sites directly adjacent to ear piercings. A punch biopsy was performed on one woman. Microscopic examination revealed a yellowish-brown colored granular material found adjacent to elastic fibers. Based on correlation of the clinical presentation and histopathologic findings, a diagnosis of localized cutaneous argyria was established. The second woman did not undergo a biopsy. However, the clinical presentation was highly suggestive of localized cutaneous argyria. Both women were reassured of the benign nature of the condition and agreed to return for clinical follow-up if they observed any changes in the appearance of the lesions.

Diagnostic methods in ocular argyrosis: case report

Purpose

The aim of this report is to present a case of a patient, metal foundry worker, who had been exposed to industrial silver salts for over 20 years. It is well established that chronic exposure to silver compounds can cause accumulation of silver deposits in various tissues. This condition is referred to as argyrosis or argyria, whereas changes related to eye tissues are defined as ocular argyrosis.

Methods

A complete eye examination, corneal confocal microscopy, kinetic and static visual field test, posterior segment optical coherent tomography, pattern visual evoked potentials (PVEP), flash visual evoked potentials, multifocal electroretinogram, pattern electroretinogram (PERG), full-field electroretinography (FERG) and electrooculogram were all performed.

Results

Eye examination revealed decreased visual acuity, corneal deposits and drusenoid changes within the macula. Although electrophysiology tests did not show changes in the function of retinal pigment epithelium, they revealed abnormal function of photoreceptors in the central and peripheral retina. PERG abnormalities and delayed latency of P100 wave in PVEP confirmed impaired function of the inner layers of the retina in the macular region.

Conclusions

Corneal confocal microscopy and electrophysiological tests may help confirm the diagnosis of ocular argyrosis.

Resident Rounds: Part III - Case Report: Argyria – A Case of Blue-Gray Skin

Argyria is an uncommon blue-gray pigmentation of the skin (increased in sun-exposed areas), nail unit, and mucous membranes caused by prolonged silver exposure. Commonly occurs in the setting of occupational exposure, silver-containing medications, or systemic absorption from use of silver sulfadiazine on extensive burns/wounds. Recently, there appears to be an increase in the practice of colloidal silver ingestion given the popularity and easy availability of alternative medicines and dietary supplements containing various silver-containing compounds. We report a case of argyria in a 72-year-old male following ingestion of colloidal silver as a supplement for over 10 years. He had a diffuse, blue-gray discoloration of his face and nails. A skin biopsy was performed and histology supported the clinical diagnosis of argyria. Our objective is to increase the awareness for this rare dermatologic entity by highlighting the clinical and histological features through a case report. Dermatologists should warn patients in regards to the use of colloidal silver for alternative health practices.

Optical coherence tomography findings in ocular argyrosis

A 68-year-old Caucasian man with a remote history of daily colloidal silver ingestion presented for ophthalmic examination in which he was noted to have a distinct slate gray skin discoloration. Funduscopy revealed confluent perimacular drusenoid deposits bilaterally, most of which localized at the level of or anterior to the inner segment ellipsoid band by optical coherence tomography (OCT) imaging. Enhanced depth imaging OCT demonstrated marked choroidal thinning. Fluorescein angiogram displayed a dark or silent choroid. Confirmatory serum silver levels were found to be markedly elevated. This report describes a unique geographic maculopathy with large drusenoid deposits anterior to the ellipsoid layer and severe choroidal thinning in association with ocular argyrosis.

Quantitative near infrared spectroscopic analysis of Q-Switched Nd:YAG treatment of generalized argyria

BACKGROUND AND OBJECTIVE

Generalized argyria is a blue-gray hyperpigmentation of the skin resulting from ingestion or application of silver compounds, such as silver colloid. Case reports have noted improvement after Q-Switched Neodymium-Yttrium Aluminum Garnet laser (1,064 nm QS Nd:YAG) laser treatment to small surface areas. No reports have objectively monitored laser treatment of generalized argyria over large areas of skin, nor have long-term outcomes been evaluated.

STUDY DESIGN/MATERIALS AND METHODS

An incremental treatment plan was developed for a subject suffering from argyria. A quantitative near infrared spectroscopic measurement technique was employed to non-invasively analyze tissue-pigment characteristics pre- and post-laser treatment. Post-treatment measurements were collected at weeks 1, 2, 3, and 4, and again at 1 year.

RESULTS

Immediate apparent removal of pigment was observed with 1 Q-switched 1,064 nm Nd:YAG laser treatment (3-6 mm spot; 0.8-2 J/cm(2) ) per area. Entire face, neck, upper chest, and arms were treated over multiple sessions. Treatments were very painful and general anesthesia was utilized in order to treat large areas. Near-infrared spectroscopy was used to characterize and quantify the concentration of silver particles in the dermis based on the absorption features of the silver particles as well as the optical scattering effects they impart. We were able to estimate that there was, on average, 0.042 mg/ml concentration of silver prior to treatment and that these levels went below the minimum detectable limit of the instrument post-treatment. There was no recurrence of discoloration over the 1-year study period.

CONCLUSION

QS 1,064 nm laser treatment of argyria is a viable method to restore normal skin pigmentation with no evidence of recurrence over study period. Quantitative spectroscopic measurements: (1) confirmed dyspigmentation was due to silver, (2) validated our clinical assessment of no recurrence up to 1-year post-treatment, and (3) indicated no collateral tissue damage with treatments.

Localized argyria secondary to acupuncture mimicking blue nevus

The typical clinical manifestation of localized cutaneous argyria is a blue-grayish asymptomatic macule, which may be caused by occupational exposure, topical treatment, dental amalgams and alternative medicine therapies. The lesions often are clinically indistinguishable from blue nevi and metastatic melanoma. The authors present a case of localized cutaneous argyria secondary to an acupuncture needle, emphasizing the importance of keeping this entity in mind in the differential diagnosis of blue-grayish pigmented lesion in a body area that could have been treated with acupuncture.

Silver-Coated Dressing Acticoat Caused Raised Liver Enzymes and Argyria-like Symptoms in Burn Patient

BACKGROUND

Treatment of acute burn wounds with silver sulfadiazine (SSD) has raised concern about potential silver toxicity. Numerous adverse reactions and side effects have been reported and an increasing resistance to SSD, especially in Pseudomonas strains, have motivated researchers to search for an alternative wound dressing.

METHODS

Recently, a silver-coated wound dressing Acticoat (Smith & Nephew, Inc.) has become available for use in burn patients. It is a three-ply dressing, consisting of an inner rayon/polyester absorptive core between two layers of silver-coated, high-density polyethylene mesh. In a moist environment, the nanocrystals of silver are released and improve the microbial control in the wound.

RESULTS

After 1 week of local treatment with Acticoat in a young, previously healthy 17-year-old boy with 30% mixed depth burns, hepatotoxicity and argyria-like symptoms, a grayish discoloration of the patient's face, appeared. The silver levels in plasma (107 microg/kg) and urine (28 microg/kg) were clearly elevated, as well as the liver enzymes. As soon as the local application of Acticoat was aborted, the clinical symptoms and liver enzymes returned to the normal values.

CONCLUSIONS

This is the first report on silver toxicity in a patient with 30% burns who received Acticoat for local treatment. Due to substantial experiences with adverse SSD reactions and side effects, it is appropriate to keep the possibility of a toxic silver effect in burn patients treated with Acticoat silver-coated wound dressing in mind. The silver levels in plasma and/or urine should be monitored.

Local argyrosis of oral mucosa or amalgam tattoo. A problem in diagnosis and treatment

The authors, basing on three cases published by different authors in the years 1995-2003, discuss the problem of diagnosis and treatment of local gingival argyrosis and amalgam tattoo. Treatment methods carried out consisted of the following procedures free gingival graft, subepithelial connective tissue graft in a two-step procedure and subepithelial connective tissue graft without flap coverage. In the authors opinion in some cases a connective tissue graft does not need flap coverage, therefore a dual blood supply is not necessary.

Silver deposition and tissue staining associated with wound dressings containing silver

Argyria is the general term used to denote a clinical condition in which excessive administration and deposition of silver causes a permanent irreversible gray-blue discoloration of the skin or mucous membranes. The amount of discoloration usually depends on the route of silver delivery (ie, oral or topical administration) along with the body's ability to absorb and excrete the administered silver compound. Argyria is accepted as a rare dermatosis but once silver particles are deposited, they remain immobile and may accumulate during the aging process. Topical application of silver salts (eg, silver nitrate solution) may lead to transient skin staining. To investigate their potential to cause skin staining, two silver-containing dressings (Hydrofiber and nanocrystalline) were applied to human skin samples taken from electively amputated lower limbs. The potential for skin discoloration was assayed using atomic absorption spectroscopy. When the dressings were hydrated with water, a significantly higher amount of silver was released from the nanocrystalline dressing compared to the Hydrofiber dressing (P <0.005), which resulted in approximately 30 times more silver deposition. In contrast, when saline was used as the hydration medium, the release rates were low for both dressings and not significantly different (silver deposition was minimal). Controlling the amount of silver released from silver-containing dressings should help reduce excessive deposition of silver into wound tissue and minimize skin staining.

[Case of membranous nephropathy associated with argyria]

We experienced a case of membranous nephropathy associated with argyria. The patient was a 78-year-old woman who had noticed blue skin of the face and azure lunulae for 8 years. She was admitted to our hospital for edema and proteinuria. She was diagnosed as membranous nephropathy by needle renal biopsy, and treated with prednisolone. Her proteinuria disappeared after 63 days. We investigated the blue skin of her face and azure lunulae. Skin biopsy was performed and black granules deposited in the upper layer of the corium were observed. The granules were identified with silver by EDS (energy-dispersive X-ray spectroscopy) analysis. Membranous nephropathy associated with gold or mercury has been reported, but association with silver has not been reported. We considered that this is a rare case of membranous nephropathy associated with silver.

The feasibility of measuring silver concentrations in vivo with x-ray fluorescence

X-ray fluorescence (XRF) has been demonstrated to be an extremely useful technique for measuring trace quantities of heavy metals in various tissues in the body. This study investigates the applicability of XRF to the measurement of silver concentrations in skin. The system chosen employs an 125I source to excite the silver K x-rays, with the source, sample and detector arranged in a 90 degrees geometry. Experiments with silver-doped skin phantoms indicate that a minimum detectable concentration of 3-4 ppm is possible in 10-20 min measurement periods. Based on estimates of silver concentrations in the skin of patients suffering from argyria, the proposed system has sufficient sensitivity to warrant further investigation into its usefulness for non-invasive monitoring of exposed populations. Specifically, such a measurement may well allow for the identification of individuals at risk of subsequently exhibiting argyria, an irreversible skin pigmentation arising from silver exposure.

Myoclonic status epilepticus following repeated oral ingestion of colloidal silver

The authors report a case of a 71-year-old man who developed myoclonic status epilepticus and coma after daily ingestion of colloidal silver for 4 months resulting in high levels of silver in plasma, erythrocytes, and CSF. Despite plasmapheresis, he remained in a persistent vegetative state until his death 5.5 months later. Silver products can cause irreversible neurologic toxicity associated with poor outcome.

[Argyria--an almost-forgotten dyschromia]

A 79-year-old woman presented with a long history of grey-blue discoloration of the light-exposed areas. Her face, forearms, and the backs of both hands were affected. The proximal parts of her fingernails were impressively discolored, but her toenails were not affected. The patient reported that she had received oral therapy with the silver-containing drug Gastrarctin in 1959. The diagnosis of argyria was confirmed by documenting high tissue levels of silver in light-exposed skin. Argyria has become uncommon as medications containing silver are no longer employed and occupational protection for those with exposure to silver salts has become more refined.

[Argyrosis in dermatologic practice]

The article covers follow-up of 7 patients suffering from occupational argyrosis and 1 patient with domestic argyrosis. Clinical signs of the disease are presented. Mainly skin and mucous membranes are involved. Conclusions concern diagnosis and treatment of the condition.

Believe it or not--silver still poisons!

For centuries, silver has been endowed with therapeutic benefits. It is still used today as a "caustic" for superficial bleeding. Within 7days, we had 3 cases of "argyria" and then 2 more over the next month. The first 2 cases involved a husband and wife with a 3-y exposure to naturopathic hydrolyzed silver treatment. The third casewas a 37-y-old male in a state psychiatric facility noted to have darkly "discolored" skin probable obtained from herbal tea. The last 2 cases were a married couple into herbal medications who developed bluish discoloration of face and hands. Current cases due to "alternative medicine" may get worse as rumor reveals its popularity as prophylaxis against anthrax. The skin's grayish discoloration, made worse by sunlight, may persist for life.

Localized argyria with pseudo-ochronosis

BACKGROUND

Localized argyria is uncommon and presents clinically as asymptomatic slate gray macules or blue macules resembling blue nevi. Its histopathologic features are usually similar to those of generalized argyria in which silver granules are found most commonly around the eccrine glands, in the walls of blood vessels, and along elastic fibers. Ochre swollen homogenized collagen bundles resembling ochronosis have not been previously described.

OBJECTIVE

The purpose of this study is to report a series of 5 patients with localized argyria with the histologic feature of "pseudo-ochronosis." In one patient, biopsy was performed on 2 distinct lesions.

METHODS

All patients underwent skin biopsies for light microscopy and darkfield microscopy. In two patients, the biopsy specimens were analyzed with a mass spectrophotometer; scanning electron microscopy and energy-dispersive x-ray analysis were performed. In one patient, the biopsy specimen was decolorized with 1% potassium ferricyanide in 20% sodium thiosulfate.

RESULTS

All 5 patients presented with the typical clinical and histologic features of localized argyria. Ochre swollen and homogenized collagen bundles were seen in all cases. In addition, light microscopy in 4 cases revealed an ellipsoid black globule within a zone of collagen degeneration.

CONCLUSION

The histologic features of localized argyria include swollen and homogenized collagen bundles resembling ochronosis, "pseudo-ochronosis," which may be more common than previously recognized.

Generalized argyria in two chronic hemodialysis patients

Silver can be absorbed through ingestion, topical administration, or inhalation. Generalized argyria results from deposition of silver in the skin, nails, mucous membranes, and internal organs and is characterized by a diffuse bluish-gray discoloration in sun-exposed areas. We report two cases of generalized argyria in patients on maintenance hemodialysis (HD) therapy for more than 15 years. They presented with diffuse hyperpigmentation of the face that was mistaken to be related to uremia and bluish-gray discoloration of all nails believed to be cyanosis. Histopathologic examination of skin biopsy specimens showed characteristic findings of argyria, which was further confirmed by radiograph microanalysis. Their serum silver levels were also elevated. No definite silver source could be determined. However, their argyria might be related to their long-term HD therapy because (1) they had been on HD therapy for more than 15 years and the discoloration appeared several years afterward, and (2) the water used for HD was not well processed in the early 1980s in TAIWAN: Argyria should be suspected in chronic HD patients presenting with a diffuse bluish-gray discoloration of the skin and nails and evaluated carefully by skin biopsy.

Argyria following the use of dietary supplements containing colloidal silver protein

The onset of argyria following the use of dietary supplements containing colloidal silver protein is presented. The patient was using a silver-containing product for cold and allergy prophylaxis. We review the past and present medicinal roles of silver and include a differential diagnosis for argyria. The hyperpigmentation of argyria is usually permanent, and it follows a sun-exposed distribution. This case report highlights the potential for toxicity following the use of dietary supplements and demonstrates the importance of physician inquiry regarding alternative medicines. Finally, we examine the limited role of the Food and Drug Administration (FDA) in regulating alternative medicines marketed as dietary supplements.

[Occupational argyria]

The article presents data on follow-up of 7 patients having occupational argyria. Signs and symptoms of the disease are shown. Skin and mucous membranes are the main sites involved. Conclusions on diagnosis and treatment of the disease are given.

Human generalized argyria: a submicroscopic and X-ray spectroscopic study

A 58-year-old man presented with a slate-gray discoloration of the skin. The patient had no medical complaint apart from the increasing cosmetic disability. He gave no drug history and denied professional exposure to chemical compounds. General medical examination was noncontributory; routine laboratory data were within the normal range. Light microscopy revealed the presence of numerous, small, pigmented particles at the dermal level. The submicroscopic investigation showed that the granules were deeply electron dense, had an irregular polycyclic contour, and varied in size between 100 and 600 nm. They were predominantly located in relation to the basal laminae of the epidermis and the cutaneous appendages, and in the dermal elastic fibers. In addition, the authors were able to document the presence of silver particles lying free in the cytoplasm of both epithelial cells of the secretory segment of eccrine sweat glands and mastcells, findings that have never been reported so far. X-ray spectroscopy documented that the electron-opaque particles contained silver, with some differences in the elemental composition of the granules, according to their location. These novel findings expand the knowledge of the various mechanisms of interaction of silver with the cellular and extracellular environment and allow some speculations about possible mechanisms of silver detoxification.

Detection of selenium in generalized and localized argyria: report of four cases with X-ray microanalysis

Electron microscopic and X-ray microanalytic studies were performed on four cases of argyria; one generalized and three localized. Deposition of electron dense granules was predominantly found on elastic fibers and around basal laminas of secretory portions of eccrine glands, although the amount of deposition was much less in the case of generalized argyria. In all four cases, X-ray microanalysis revealed that the depositions consisted mainly of silver, selenium, and sulfur. The importance of selenium in the detoxification of heavy metals was discussed.