Confirmation of Safety of Titanium Wire in Sternotomy Closure, A Randomized Prospective Study

BACKGROUND

There are many factors that are known to increase the risk of sternal wound infection (SWI); some studies have reported that nickel is a risk factor for SWI. Titanium wires have only been used as an alternative to steel wires in patients with known allergy to nickel. However, there is a paucity of literature regarding the safety of using titanium wires compared to that on the safety of steel wires for sternum closure after cardiac surgery. Therefore, this study aimed to demonstrate the noninferiority of titanium wires, even in patients without a known allergy.

METHODS

A total of 322 patients who underwent elective full median sternotomy were randomly assigned to sternal closure either by titanium wires (n = 161) or by stainless steel wires.

RESULTS

Fourteen patients had sternal instability, six (3.7%) patients in the titanium group and eight (5%) patients in the stainless steel group (p = 0.585). There was no statistically significant difference between both groups in terms of postoperative wound infection (p = 0.147). Patients in the titanium group experienced statistically significant lower postoperative pain than those in the stainless steel group (p = 0.024). The wire type was not an independent risk factor for SI, as shown by univariate and logistic regression analyses.

CONCLUSION

Titanium wires are a good alternative and have been proven to be safe and effective for sternal closure. The surgeon should be aware of the possibility of developing an allergic reaction to the wires, especially in patients with previous multiple allergic histories.

Do Patients With Hypoallergenic Total Knee Arthroplasty Implants for Metal Allergy Do Worse? An Analysis of Health Care Utilizations and Patient-Reported Outcome Measures

BACKGROUND

Metal allergy is a rare and controversial cause of implant failure and poor outcomes following total knee arthroplasty (TKA). Few studies have investigated clinical and patient-reported outcome measures (PROMs) in patients treated with hypoallergenic implants. This investigation aimed to compare: (1) health care utilizations (eg, hospital length of stay, 90-day readmission rate, and incidence of nonhome discharge) and (2) 1-year PROMs between patients who received hypoallergenic and standard TKA implants.

METHODS

This was a retrospective review of prospectively collected data from patients who underwent primary TKA between 2018 and 2019. Propensity score matching (3:1) was used to compare standard TKA patients with those who received hypoallergenic TKA implants, respectively. Knee injury and Osteoarthritis Outcome Score (KOOS) pain, KOOS Physical function Shortform (PS), and Veterans RAND 12-Item Health Survey Mental Component Score were collected preoperatively and at 1-year. After matching, 190 hypoallergenic and 570 standard TKAs were analyzed.

RESULTS

No differences were observed in length of stay (P = .98), 90-day readmission (P = .89), and nonhome discharge (P = .82). Additionally, there was no significant difference in change from preoperative to 1-year PROMs (KOOS pain, P = .97; KOOS PS, P = .88; Veterans RAND 12-Item Health Survey Mental Component Score, P = .28). Patient-reported satisfaction was similar at 1-year (P = .23). Patients achieved similar rates of Patient Acceptable Symptom State (PASS) and minimal clinically important difference (MCID) for KOOS pain (PASS, P = .77; MCID, P = .33) and KOOS PS (PASS, P = .44; MCID, P = .65).

CONCLUSION

Patients treated with hypoallergenic TKA implants for suspected metal allergy had similar outcomes compared to patients who had standard implants and no metal allergy.

Nickel Challenge In Vitro Affects CD38 and HLA-DR Expression in T Cell Subpopulations from the Blood of Patients with Nickel Allergy

Nickel allergy is a major health problem and shows clinical manifestation of contact eczema. The response of specific lymphocyte subpopulations in sensitized patients after new challenge to nickel has until now not been studied in detail. To evaluate if nickel-based elicitation reaction could be objectively identified by multi-parametric flow cytometry, immunophenotyping of specific T cells was applied. White blood cells from 7 patients (4 positive in patch test, 3 negative) were challenged by nickel and in vitro short-term culture. Standardized antibody-dye combinations, specific for T helper(h)1, Th17 and cytotoxic T cell activation, were selected according to the recommendations of Stanford Human Immune Monitoring Center. In cytotoxic CD8+CCR7+CD45RA+ T cells from patients suffering from nickel allergy, CD38 and HLA-DR were elevated comparing to healthy donors. After challenge to nickel in vitro both markers decreased in CD8+CCR7+CD45RA+ T cells but found up-regulated in CD4+CCR7+CD45RA+CCR6-CXCR3+Th1 cells. Intracellular expression of T-bet and RORγt further indicated Th1 and Th17 cells. Finally, CD4+CD25+CCR4- T cells increased after challenge with nickel in PBMCs of patients with nickel allergy. Flow cytometry based quantification of T cell markers might be used as a specific and reliable method to detect chemical induced skin sensitization and confirm diagnostic patch testing in the clinics.

Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence

INTRODUCTION

Nickel is a principal alloying agent in the production of vascular endoprostheses, despite persisting as the most habitually identified allergen. Variable nickel-related hypersensitivity manifestations following endovascular intervention were reported, challenging established paradigms in treatment and accuracy of prognostic assessments. The objective of this review is to critically evaluate current metrics to maximise patient-related outcomes.

METHODS

A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement. Patients indicative of nickel hypersensitivity reaction following endovascular intervention were discerned. A positive reaction was defined by patch testing, histological analysis, or anamnesis indicative of nickel hypersensitivity. Morphology of implicating prostheses, adverse events and postoperative complications, clinical course, diagnostic and therapeutic strategies alongside patient prognosis were recorded.

RESULTS

Nickel-related hypersensitivity reactions following endovascular repair were identified in 36 patients with a median age of 44.5 years. 20 patients received nitinol-containing intervention. 28 (77.8%) patients are female. Multi-organ adverse reactions occurred in 21 (58.3%) patients with variable latency. 14 (38.9%) patients were presented with neurological adverse reactions manifesting mainly as unilateral hemiparesis. Dermatological reactions implicated 16 (44.4%) patients. Miscellaneous manifestations include suicidal ideation. 13 (36.1%) patients displayed previous metal intolerance and 32 (88.9%) patients had positive patch testing for nickel. Histological analysis of lesions and prostheses indicated lymphocytic infiltration. 5 (13.9%) patients experienced device-specific reactions as in-stent restenosis or auxiliary distal vessel stenosis. 11 (30.1%) patients received solely medical therapy and 5 (13.9%) patients received solely surgical therapy. 19 (52.7%) patients underwent both medical (oral corticosteroid) and surgical therapy (device retrieval). 26 (77.1%) patients achieved symptomatic cessation, 6 (16.7%) patients exhibited symptomatic persistence and 0 patients died.

CONCLUSION

Prophylactic pre-assessment for a history of metal allergy and consideration of prostheses alternatives is recommended to minimise reaction risk and severity. Despite nickel's predominant usage, information paucity urges additional studies to emphasise its implications and maximise patient outcomes.

New Insights and Evidence on "Food Intolerances": Non-Celiac Gluten Sensitivity and Nickel Allergic Contact Mucositis

The clinical examination of patients often includes the observation of the existence of a close relationship between the ingestion of certain foods and the appearance of various symptoms. Until now, the occurrence of these events has been loosely defined as food intolerance. Instead, these conditions should be more properly defined as adverse food reactions (AFRs), which can consist of the presentation of a wide variety of symptoms which are commonly identified as irritable bowel syndrome (IBS). In addition, systemic manifestations such as neurological, dermatological, joint, and respiratory disorders may also occur in affected patients. Although the etiology and pathogenesis of some of them are already known, others, such as non-celiac gluten sensitivity and adverse reactions to nickel-containing foods, are not yet fully defined. The study aimed to evaluate the relationship between the ingestion of some foods and the appearance of some symptoms and clinical improvements and detectable immunohistochemical alterations after a specific exclusion diet. One hundred and six consecutive patients suffering from meteorism, dyspepsia, and nausea following the ingestion of foods containing gluten or nickel were subjected to the GSRS questionnaire which was modified according to the "Salerno experts' criteria". All patients underwent detection of IgA antibodies to tissue transglutaminase, oral mucosal patch tests with gluten and nickel (OMPT), and EGDS, including biopsies. Our data show that GSRS and OMPT, the use of APERIO CS2 software, and the endothelial marker CD34 could be suggested as useful tools in the diagnostic procedure of these new pathologies. Larger, multi-center clinical trials could be helpful in defining these emerging clinical problems.

Allergenicity and Bioavailability of Nickel Nanoparticles Compared to Nickel Microparticles in Mice

Metal allergy is a common disease that afflicts many people. Nevertheless, the mechanism underlying metal allergy development has not been completely elucidated. Metal nanoparticles might be involved in the development of a metal allergy, but the associated details are unknown. In this study, we evaluated the pharmacokinetics and allergenicity of nickel nanoparticles (Ni-NPs) compared with those of nickel microparticles (Ni-MPs) and nickel ions. After characterizing each particle, the particles were suspended in phosphate-buffered saline and sonicated to prepare a dispersion. We assumed the presence of nickel ions for each particle dispersion and positive control and orally administered nickel chloride to BALB/c mice repeatedly for 28 days. Results showed that compared with those in the Ni-MP administration group (MP group), the Ni-NP administration group (NP group) showed intestinal epithelial tissue damage, elevated serum interleukin (IL)-17 and IL-1β levels, and higher nickel accumulation in the liver and kidney. Additionally, transmission electron microscopy confirmed the accumulation of Ni-NPs in the livers of both the NP and nickel ion administration groups. Furthermore, we intraperitoneally administered a mixed solution of each particle dispersion and lipopolysaccharide to mice and then intradermally administered nickel chloride solution to the auricle after 7 days. Swelling of the auricle was observed in both the NP and MP groups, and an allergic reaction to nickel was induced. Particularly in the NP group, significant lymphocytic infiltration into the auricular tissue was observed, and serum IL-6 and IL-17 levels were increased. The results of this study showed that in mice, Ni-NP accumulation in each tissue was increased after oral administration and toxicity was enhanced, as compared to those with Ni-MPs. Orally administered nickel ions transformed into nanoparticles with a crystalline structure and accumulated in tissues. Furthermore, Ni-NPs and Ni-MPs induced sensitization and nickel allergy reactions in the same manner as that with nickel ions, but Ni-NPs induced stronger sensitization. Additionally, the involvement of Th17 cells was suspected in Ni-NP-induced toxicity and allergic reactions. In conclusion, oral exposure to Ni-NPs results in more serious biotoxicity and accumulation in tissues than Ni-MPs, suggesting that the probability of developing an allergy might increase.

Rab44 Deficiency Induces Impaired Immune Responses to Nickel Allergy

Rab44 was recently identified as an atypical Rab GTPase that possesses EF-hand and coiled-coil domains at the N-terminus, and a Rab-GTPase domain at the C-terminus. Rab44 is highly expressed in immune-related cells such as mast cells, macrophages, osteoclasts, and granulocyte-lineage cells in the bone marrow. Therefore, it is speculated that Rab44 is involved in the inflammation and differentiation of immune cells. However, little is known about the role of Rab44 in inflammation. In this study, we showed that Rab44 was upregulated during the early phase of differentiation of M1- and M2-type macrophages. Rab44-deficient mice exhibited impaired tumor necrosis factor alpha and interleukin-10 production after lipopolysaccharide (LPS) stimulation. The number of granulocytes in Rab44-deficient mice was lower, but the lymphocyte count in Rab44-deficient mice was significantly higher than that in wild-type mice after LPS stimulation. Moreover, Rab44-deficient macrophages showed impaired nickel-induced toxicity, and Rab44-deficient mice showed impaired nickel-induced hypersensitivity. Upon nickel hypersensitivity induction, Rab44-deficient mice showed different frequencies of immune cells in the blood and ears. Thus, it is likely that Rab44 is implicated in immune cell differentiation and inflammation, and Rab44 deficiency induces impaired immune responses to nickel allergies.

Rare Metallic Allergy Reaction Presentation to Cholecystectomy Surgical Clip

Metal allergies have been a growing concern in the general population over the past several decades. Laparoscopic cholecystectomy is the standard treatment for gallbladder diseases such as cholelithiasis and cholecystitis, during which surgical clips composed of metals such as nickel or titanium are often used to clamp the arteries and ducts. These metals are documented to produce hypersensitivity reactions. Here, we present the case of a 53-year-old male patient who successfully underwent laparoscopic cholecystectomy and two weeks later reported constant right upper quadrant pain accompanied by nausea that was exacerbated by exercise and food. After several months of severe interference with the patient's lifestyle, we removed the surgical clips after ruling out all possible organic causes of the pain. A total of six surgical clips were removed during surgery, and the patient reported a substantial resolution of symptoms post-operation. Post-cholecystectomy syndrome (PCS), allergy to the metallic surgical clips, and migration or improper clip placement during surgery were all considered possible causes for the pain. Still, the clinical presentation and laboratory studies pulled focus toward metallic surgical clip allergy as the most plausible cause for the presenting symptoms. The metallic haptens released by the surgical clips activate the innate and adaptive immune response cascades and pre-sensitize the CD8 and B cells to the metallic allergens. With reexposure, these pre-sensitized CD8 and B cells trigger a hypersensitivity reaction. Standardizing allergy tests as part of the pre-operation checklist can prove to be an inexpensive way to eliminate such post-surgical complications. Furthermore, alternatives like absorbable sutures or even different hypoallergenic metal or plastic clips can be considered viable options to replace nickel or titanium-made surgical clips during surgery.

Surgical removal of atrial septal defect closure device due to systemic allergic reaction to nickel: A case report

Systemic hypersensitivity reaction to nickel-containing medical device is a rare complication after percutaneous atrial septal defect closure. The symptoms regress spontaneously or in response to medical treatment in most cases. Surgical device removal is mandatory and effective in patients whose symptoms persist despite optimal medical therapy. Herein, we report a case of systemic allergic contact dermatitis secondary to nickel allergy after atrial septal defect closure and its successful treatment with surgical removal of the device.

Corrigendum: Ni2+-assisted hydrolysis may affect the human proteome; filaggrin degradation ex vivo as an example of possible consequences

[This corrects the article DOI: 10.3389/fmolb.2022.828674.].

Ni2+-Assisted Hydrolysis May Affect the Human Proteome; Filaggrin Degradation Ex Vivo as an Example of Possible Consequences

Deficiency in a principal epidermal barrier protein, filaggrin (FLG), is associated with multiple allergic manifestations, including atopic dermatitis and contact allergy to nickel. Toxicity caused by dermal and respiratory exposures of the general population to nickel-containing objects and particles is a deleterious side effect of modern technologies. Its molecular mechanism may include the peptide bond hydrolysis in X₁-S/T-c/p-H-c-X₂ motifs by released Ni²⁺ ions. The goal of the study was to analyse the distribution of such cleavable motifs in the human proteome and examine FLG vulnerability of nickel hydrolysis. We performed a general bioinformatic study followed by biochemical and biological analysis of a single case, the FLG protein. FLG model peptides, the recombinant monomer domain human keratinocytes in vitro and human epidermis ex vivo were used. We also investigated if the products of filaggrin Ni²⁺-hydrolysis affect the activation profile of Langerhans cells. We found X₁-S/T-c/p-H-c-X₂ motifs in 40% of human proteins, with the highest abundance in those involved in the epidermal barrier function, including FLG. We confirmed the hydrolytic vulnerability and pH-dependent Ni²⁺-assisted cleavage of FLG-derived peptides and FLG monomer, using in vitro cell culture and ex-vivo epidermal sheets; the hydrolysis contributed to the pronounced reduction in FLG in all of the models studied. We also postulated that Ni-hydrolysis might dysregulate important immune responses. Ni²⁺-assisted cleavage of barrier proteins, including FLG, may contribute to clinical disease associated with nickel exposure.

New Insights into Intestinal Permeability in Irritable Bowel Syndrome-Like Disorders: Histological and Ultrastructural Findings of Duodenal Biopsies

BACKGROUND AND AIM

Diarrhea, abdominal pain, and bloating are frequent in irritable bowel syndrome (IBS)-like disorders, although little is known about their intestinal ultrastructural alterations. The aim of the present study was to study duodenal biopsies from IBS-like patients to find ultrastructural alterations.

MATERIALS AND METHODS

Study design: descriptive comparative pilot study. Thirty outpatients (9 male and 21 female; median age 37.7 years; range, 20 to 65 years) complaining of IBS-like symptoms were enrolled between January 2015 to May 2019 and were divided into 6 groups, each equally consisting of 5 patients: (A) untreated celiac disease (uCD); (B) treated celiac disease (tCD); (C) wheat allergy (WA); (D) Non-celiac gluten sensitivity (NCGS); (E) Nickel allergic contact mucositis (Ni ACM); (F) controls affected by GERD. Transmission electron microscopy (TEM) morphological characteristics were: microvilli length, intermicrovillar distance, junctional complexes (JC) gap width, autophagic bodies, apoptosis, altered mitochondria, lipid/chylomicron droplets, and mast cells. Regarding JC, we focused on tight junctions (TJ), adherens junctions (AJ), and desmosomes.

RESULTS

Major alterations in microvilli length and intermicrovillar distance have been observed in the subjects affected by uCD. Microvilli of tCD patients showed marked recovery after adequate GFD, although not comparable to controls. Intermediate microvillar alterations were instead observed in NCGS and Ni ACM, while characteristics of WA subjects appeared more similar to tCD. Regarding JC, TJ did not show significant differences between all groups studied, including controls. The AJ were significantly more dilated in all groups compared to controls, while no significant differences were found between the pathological groups. The distance between desmosomes was greater in uCD, NCGS, and Ni ACM than in tCD, WA, and controls. Finally, intracellular alterations have been detected in most of the groups studied although they seemed more unspecific.

CONCLUSIONS

TEM analysis confirmed damages to the intestinal barrier and defense mechanisms by enterocytes in IBS-like patients, probably linked to low-grade inflammation or adverse reactions triggered by food allergens, heavy metals, or other unknown. On the other hand, our study needs confirmation and further investigations with larger populations to facilitate diagnosis, therapy, and prevention of IBS-like disorders in the future.

Nickel Allergy: Epidemiology, Pathomechanism, Clinical Patterns, Treatment and Prevention Programs

Nickel is the most common cause of contact allergy in the general population and the most frequently detected allergen in patients patch tested for suspected allergic contact dermatitis (ACD). ACD from nickel is a typical type IV hypersensitivity. Nickel allergy is mostly caused by nonoccupational exposure, such as jewelry and clothing decorations, metal tools, medical devices (mainly orthopedic and orthodontic implants, cardiovascular prosthesis), eyeglasses, utensils, keys, pigment for paint, cosmetics, and food (mainly legumes, chocolate, salmon, peanuts). Occupational exposure can involve several workers (mechanics, metalworkers, platers, hairdressers, jewelers, workers in the constructions and electronic industries), classically involving hands and forearms. The classic clinical pattern of ACD caused by nickel is characterized by eczematous dermatitis involving the sites of direct contact with the metal. Non-eczematous-patterns are reported, including lichenoid dermatitis, granuloma annulare, vitiligo-like lesions, dyshidrosiform dermatitis, and vasculitis. In the case of systemic exposure to nickel, sensitized patients could develop systemic contact dermatitis. Patch testing represents the gold standard for the diagnosis of ACD from nickel. Treatment includes avoidance of contact with products containing nickel and the patient's education about the possible use of alternative products. A recent EU nickel directive, regulating the content and release of nickel from products, has caused a decrease of nickel contact allergy in some European countries. Nickel allergy is a relevant issue of public health with significant personal, social, and economic impact. This review summarizes epidemiology, pathomechanism, clinical patterns, treatment, and prevention programs.

Nickel Allergy of the Skin and Beyond

BACKGROUND

Hypersensitization to nickel is one of the most common contact allergies in the modern world and it is considered to be a major cause of contact dermatitis, especially for hand eczema.

OBJECTIVE

The aim of this paper is to describe many faces of the nickel allergy and to find out different diagnostic, potential strategies for treatment and prevention in hypersensitized patients. A personal clinical experience with practical clinical cases of contact dermatitis to nickel has also been presented.

METHODS

Electronic databases on this topic was carried out using PubMed-Medline.

RESULTS

The literature review identified many articles reporting for nickel contact allergy and pointing the metal as number one allergen in the frequency of positive skin patch test reactions in a large population worldwide. Herein, a summary of the current understanding and evidence on nickel allergy with practical approach and proposed recommendations to the dermatologist, general practitioner, and the allergist were prepared.

CONCLUSION

The prevalence of nickel allergy represents an important socio-economical and health issue. Metal is one of the most common sensitizing agents worldwide. The morbidity due to this metal represents the allergic contact dermatitis and it is constantly growing in many countries. There are also cases of systemic allergic contact dermatitis, where they could be easily misdiagnosed as adverse drug reactions, which lead to delay of the correct diagnosis and inappropriate treatment.

Suitable test concentration of cobalt and concomitant reactivity to nickel and chromium: A multicentre study from the Swedish Contact Dermatitis Research Group

BACKGROUND

In Sweden, cobalt chloride 0.5% has been included in the baseline series since the mid-1980s. A recent study from Stockholm showed that cobalt chloride 1% petrolatum (pet.) was more suitable than 0.5%. Cobalt chloride at 1.0% has been patch tested for decades in many European countries and around the world.

OBJECTIVES

To study the suitability of patch testing to cobalt 1.0% vs 0.5% and to analyze the co-occurrence of allergy to cobalt, chromium, and nickel.

RESULTS

Contact allergy to cobalt was shown in 90 patients (6.6%). Eighty (5.9%) patients tested positive to cobalt 1.0%. Thirty-seven of the 90 patients (41.1%) with cobalt allergy were missed by cobalt 0.5% and 10 (0.7%) were missed by cobalt 1.0% (P < .001). No case of patch test sensitization was reported. Allergy to chromium was seen in 2.6% and allergy to nickel in 13.3%. Solitary allergy to cobalt without nickel allergy was shown in 61.1% of cobalt-positive individuals. Female patients had larger proportions of positive reactions to cobalt (P = .036) and nickel (P < .001) than males.

CONCLUSION

The results speak in favor of replacing cobalt chloride 0.5% with cobalt chloride 1.0% pet. in the Swedish baseline series, which will be done 2021.

Beneficial Effects of a Low-Nickel Diet on Relapsing IBS-Like and Extraintestinal Symptoms of Celiac Patients during a Proper Gluten-Free Diet: Nickel Allergic Contact Mucositis in Suspected Non-Responsive Celiac Disease

Background and Aim: Nickel (Ni)-rich foods can induce allergic contact mucositis (ACM) with irritable bowel syndrome (IBS)-like symptoms in predisposed subjects. Ni ACM has a high prevalence (>30%) in the general population and can be diagnosed by a Ni oral mucosa patch test (omPT). Many celiac disease (CD) patients on a gluten-free diet (GFD) often show a recrudescence of gastrointestinal and extraintestinal symptoms, although serological and histological remission has been achieved. Since a GFD often results in higher loads of ingested alimentary Ni (e.g., corn), we hypothesized that it would lead to a consequent intestinal sensitization to Ni in predisposed subjects. We wanted to (1) study Ni ACM prevalence in still symptomatic CD patients on a GFD and (2) study the effects of a low-Ni diet (LNiD) on their recurrent symptoms. Material and Methods: We recruited 102 consecutive CD patients (74 female, 28 male; age range 18–65 years, mean age 42.3 ± 7.4) on a GFD since at least 12 months, in current serological and histological remission (Marsh–Oberhuber type 0–I) who complained of relapsing gastrointestinal and/or extraintestinal symptoms. Inclusion criteria: presence of at least three gastrointestinal symptoms with a score ≥5 on the modified Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. Exclusion criteria: IgE-mediated food allergy; history of past or current cancer; inflammatory bowel diseases; infectious diseases including Helicobacter pylori; lactose intolerance. All patients enrolled underwent Ni omPT and followed a LNiD for 3 months. A 24 symptoms questionnaire (GSRS modified according to the Salerno Experts’ Criteria, with 15 gastrointestinal and 9 extraintestinal symptoms) was administered at T0 (free diet), T1 (GFD, CD remission), T2 (recurrence of symptoms despite GFD), and T3 (GFD + LNiD) for comparisons. Comparisons were performed using Wilcoxon signed-rank test. RESULTS: Twenty patients (all female, age range 23–65 years, mean age 39.1 ± 2.9) out of 102 (19.6%) were finally included. All 20 patients enrolled (100%) showed positive Ni omPT, confirming an Ni ACM diagnosis. A correct GFD (T0 vs. T1) induced the improvement of 19 out of the total 24 (79.2%) symptoms, and 14 out of 24 (58.3%) were statistically significant (p-value < 0.0083 according to Bonferroni correction). Prolonged GFD (T1 vs. T2) revealed the worsening of 20 out of the total 24 (83.3%) symptoms, and 10 out of 24 (41.7%) were statistically significant. LNiD (T2 vs. T3) determined an improvement of 20 out of the total 24 (83.4%) symptoms, and in 10 out of 24 (41.7%) symptoms the improvement was statistically significant. Conclusions: Our data suggest that the recrudescence of gastrointestinal and extraintestinal symptoms observed in CD subjects during GFD may be due to the increase in alimentary Ni intake, once gluten contamination and persisting villous atrophy are excluded. Ni overload can induce Ni ACM, which can be diagnosed by a specific Ni omPT. Improvement of symptoms occurs after a proper LNiD. These encouraging data should be confirmed with larger studies.

A comprehensive study of nickel levels in everyday items in Brazil

BACKGROUND

Nickel is a ubiquitous element used in many everyday items. In recent decades nickel has become a leading allergen, which has become a public health problem.

OBJECTIVE

To evaluate frequently used nickel products in Brazil. We investigated if these objects release nickel that is capable of inducing sensitization or cause clinical manifestations in terms of allergic contact dermatitis (ACD).

METHODS

Dimethylglyoxime (DMG) spot tests assessed nickel release from several common utensils used in everyday life in São Paulo and Rio de Janeiro, Brazil.

RESULTS

We tested 46 coins (two denominations) and 90 common utensils. Approximately 91.1% produced nickel-positive results using the DMG spot test.

CONCLUSIONS

The DMG limit of detection was 1.67 ppm of nickel. We observed that many objects in our test series released nickel above the DMG test limit. This observation suggests that nickel-sensitive individuals may be exposed to nickel, representing a public health issue.

The effect of patient-reported metal allergies on the outcomes of shoulder arthroplasty

BACKGROUND

Although literature exists regarding hip and knee arthroplasty outcomes in patients with skin allergy to metals, there is minimal information about skin allergy implications on shoulder arthroplasty outcomes. The purpose of this study was to determine the results, complications, and failure rate among patients with a self-reported metal allergy undergoing shoulder arthroplasty.

METHODS

Fifty-two shoulder arthroplasties were performed at our Institution in 43 patients with self-reported metal allergies. Forty primary and 12 revision shoulder arthroplasties were performed using anatomic (30) and reverse (22) components. Retrospective chart review was performed to determine metal allergy history, implant composition, pain, motion, and complications. Radiographs were reviewed to determine mechanical failure rates. Average follow-up time was 65 months.

RESULTS

Allergies reported included nickel (37), cobalt chrome (4), copper (2), zinc (1), titanium (1), gold (1), and nonspecific metal allergy (8); 8 patients reported multiple metal allergies. All components implanted in patients with nickel allergies contained nickel. At most recent follow-up, pain was rated as none or mild in 88% of shoulders. Active elevation improved from 80° to 141° and external rotation from 24° to 52°. Two revisions were performed for glenoid loosening (3.8%); both were revision cases with substantial glenoid bone loss. One patient with mild pain had a radiographically loose glenoid component 12 years after anatomic shoulder arthroplasty.

CONCLUSION

Results from this study suggest that shoulder arthroplasty in patients with self-reported metal allergy provides satisfactory pain relief and improved range of motion with low revision rates.

Nickel: Human Health and Environmental Toxicology

Nickel is a transition element extensively distributed in the environment, air, water, and soil. It may derive from natural sources and anthropogenic activity. Although nickel is ubiquitous in the environment, its functional role as a trace element for animals and human beings has not been yet recognized. Environmental pollution from nickel may be due to industry, the use of liquid and solid fuels, as well as municipal and industrial waste. Nickel contact can cause a variety of side effects on human health, such as allergy, cardiovascular and kidney diseases, lung fibrosis, lung and nasal cancer. Although the molecular mechanisms of nickel-induced toxicity are not yet clear, mitochondrial dysfunctions and oxidative stress are thought to have a primary and crucial role in the toxicity of this metal. Recently, researchers, trying to characterize the capability of nickel to induce cancer, have found out that epigenetic alterations induced by nickel exposure can perturb the genome. The purpose of this review is to describe the chemical features of nickel in human beings and the mechanisms of its toxicity. Furthermore, the attention is focused on strategies to remove nickel from the environment, such as phytoremediation and phytomining.

Oral care of a patient with a SAPHO syndrome and a nickel allergy

SAPHO is an acronym for Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis. The syndrome is difficult to diagnose because it may present many different manifestations in adults and children. Its origin is still unknown, although some infectious, genetic and immune hypotheses have been put forward. We report the case of a 49-year-old woman with SAPHO syndrome, who developed a serious cutaneous allergy following the insertion of a removable partial denture (RPD). The oral care and treatment of this patient are described.

Clinical profile of recurrent vesicular palmoplantar dermatitis in children and adolescents

BACKGROUND

Previously known as dyshidrosis, recurrent vesicular palmoplantar dermatitis (RVPD) is presented as severe eruption of nonerythematous, symmetrical vesicles or bullae located along the lateral sides of fingers, on the palmar or plantar areas, and developing into a chronic and recurrent condition. Although very frequently observed on the hands, there are no specific studies about such eczema in children and adolescents.

OBJECTIVES

To report on the RVPD clinical profile in children and adolescents, and monitor the association of RVPD with seasonal variations, hyperhidrosis, atopy and nickel sulfate.

MATERIALS AND METHODS

Eighteen patients affected by RVPD were submitted to clinical and laboratory assessment through anamnesis, physical exam, mycological exam, patch test, complete blood count and serum IgE levels.

RESULTS

Seven patients (38.9%) reported increased frequency of eruptions during the summer months; 12 patients (66.7%) presented hyperhidrosis; in 14 cases (77.8%), atopic factors were determined; reaction to nickel sulfate was positive in three patients (16.7%).

CONCLUSION

RVPD onset may occur at an early age, developing into a chronic and recurrent infection. Hyperhidrosis and atopic status was established in the clinical profile and no connection between nickel sulfate and RVPD was observed.

Does clinical testing support the current guidance definition of prolonged contact for nickel allergy?

Background

The European Chemical Agency (ECHA) definition of prolonged contact was introduced in 2014 and has not been evaluated clinically.

Objectives

To assess whether nickel‐sensitized individuals react on patch testing with high nickel‐releasing metal discs for short and repetitive periods.

Materials and methods

We patch tested 45 nickel‐sensitized individuals double‐blind with 2 different types of high nickel‐releasing discs for 10, 30 and 60 minutes on 3 occasions over a period of 2 weeks, and for 1 longer period. Discs were tested for nickel release.

Results

Nickel release from both discs significantly exceeded the 0.5 μg Ni/cm²/week limit of the EU REACH nickel restriction. However, only 1 individual tested had a largely dose‐dependent allergic reaction.

Conclusions

The majority of nickel‐allergic subjects did not react to nickel discs after 2 hours or after repetitive exposures of up to 30 minutes on 3 occasions over a period of 2 weeks. The length of time needed to cause nickel allergic contact dermatitis in most nickel‐allergic individuals is longer than the ECHA guidance definition. Longer test times are needed to define the time required to cause dermatitis in most nickel‐allergic individuals. As a limitation, the test conditions did not adequately assess real‐life factors such as friction, which is relevant for some uses of nickel.

The role of nickel allergy in hand dermatitis and its impact on handling cupronickel currency coins. A comparative cohort study from Kuwait

INTRODUCTION

Contact with nickel-releasing coins as a cause of hand dermatitis has been debated.

AIM

Studying a hand dermatitis risk from handling Kuwaiti cupronickel coins among nickel-allergic and nickel non-allergic subjects.

MATERIAL AND METHODS

One hundred hand dermatitis patients (group I: nickel-allergic) and 100 matched patients (group II: nickel non-allergic) were selected from over 500 hand dermatitis cases seen between September 2014 and September 2015. Nickel released from Kuwaiti cupronickel coins immersed in a standardized artificial sweat solution was measured at 1, 24, 48, 144 and 168 h at room temperature. Subjects in both groups were exposed to nickel releasing coins. The process was repeated after 3 months using nickel coated coins as controls.

RESULTS

Nickel released from 20, 50 and 100 fils Kuwaiti cupronickel coins at 1 week was 28.64, 32.76, 35.76 μg/cm²/week, respectively. Ninety-one patients (29 males, 62 females) in group I and 87 patients (38 males, 49 females) in group II completed the study. 47.3% in group I vs. 13.8% in group II developed dermatitis on exposure to nickel releasing coins. Nickel coated coins resulted in dermatitis in 8.8% of group I vs. 5.7% in group II.

CONCLUSIONS

Nickel is released significantly from cupronickel Kuwaiti coins. Handling of coins caused dermatitis more often in patients with nickel-allergy compared to nickel non-allergic patients.

Allergic contact dermatitis pattern in Kuwait: nickel leads the pack. In-depth analysis of nickel allergy based on the results from a large prospective patch test series report

INTRODUCTION

Contact dermatitis is a relatively common dermatosis reported among several population groups from all around the globe. However, the data from Kuwait is unavailable. Patch tests are essential for the diagnosis of contact sensitization.

AIM

To determine a relative frequency and pattern of sensitizers to different allergens in patients of suspected contact dermatitis in Kuwait and, also to study the role of the commonest sensitizer in detail.

MATERIAL AND METHODS

Patch tests were performed in 2461 consecutive patients with a clinical diagnosis of contact dermatitis seen at our hospital between September 1, 2014 and August 31, 2015. Out of the total of 1381 (56.1%) patients with positive patch test results to at least one allergen, 546 (22.2%) patients with a single positive reaction to nickel only (single largest sensitizer) were selected as the study population for further detailed analysis.

RESULTS

At least one positive patch test reaction was found in 1381 (56.12%) patients. Nickel was found to be the most common sensitizer seen in 546 (40%) patients. The mean age was 37.3 ±13.8 years and the mean duration of disease was 27.3 ±13.8 months. Most (387/546) patients sensitized were females. The forearms/hands and wrists were the most prevalent sites (52.56% of the participants). In 58.91% of women, dermatitis was more often confined to other sites, mostly ears and the neck due to earrings and necklaces. Just more than half of the number (51.09%) of nickel allergic patients were found in the age group of 15-25 years. Hairdressers/beauticians were the most affected group followed by house workers (housewives, cleaners, housekeepers).

CONCLUSIONS

Nickel is the single most common sensitizer found in our patients, and female sex, young age, occupation with long hours of contact to nickel are high risk factors. We recommend that a directive, which limits the release of nickel from products with extended skin contact, be approved in Kuwait.

Life-threatening allergic vasculitis after clipping an unruptured aneurysm: Case report, weighing the risk of nickel allergy

BACKGROUND

This case report represents one of the estimated 17,000 aneurysms clipped annually in the United States, often with nickel-containing clips. The authors highlight the development of life-threatening allergic vasculitis in a 33-year-old woman after aneurysm clipping.

CASE DESCRIPTION

After suffering subarachnoid hemorrhage, the patient had coil embolization at another facility for rupture of a right internal carotid artery (ICA) aneurysm. An incidental finding, an unruptured left posterior communicating artery aneurysm unamenable to coiling, was then successfully clipped via a left pterional craniotomy. Arriving in our emergency department 11 days later, she progressively declined during the next weeks, facing deteriorating clinical status (i.e. seizures) and additional infarctions in the left frontal lobe, midline shift, and new infarctions in the bilateral frontal lobe, right sylvian, right insular regions, and posterior cerebral artery distribution. During decompressive surgery, biopsy findings raised the possibility of lymphocytic vasculitis; consultations with rheumatology, allergy, and immunology specialists identified that our patient had a nickel allergy. After reoperation to replace the nickel-containing clip with one of a titanium alloy, the patient had an uncomplicated postoperative course and was discharged 6 days later to a rehabilitation facility.

CONCLUSIONS

Nickel-related allergies are more common than appreciated, affecting up to 10% of patients. Fortunately, severe reactions are rare; nevertheless, vascular neurosurgeons should be aware of this potential complication when using cobalt alloy aneurysms clips. The use of titanium alloy clips eliminates this risk.

Nickel oral hyposensitization in patients with systemic nickel allergy syndrome

BACKGROUND

This is the first randomized, double-blind, placebo-controlled trial (EUDRACT No. 2009-013923-43) evaluating nickel oral hyposensitizing treatment (NiOHT) in patients with "systemic nickel allergy syndrome" (SNAS), characterized by Ni-allergic contact dermatitis and systemic reactions after eating Ni-rich food.

METHODS

Adults with positive Ni-patch test, who reported symptoms suggesting SNAS, which improved after Ni-poor diet, and were positive to Ni-oral challenge were eligible. Patients were randomly assigned to three treatments (1.5 μg, 0.3 μg, or 30 ng Ni/week) or placebo for a year, with progressive reintroduction of Ni-rich foods form the 5(th) month. Out of 141 patients randomized, 113 completed the trial. Endpoints were efficacy and tolerability of treatment.

RESULTS

During Ni-rich food re-introduction, the 1.5 μg Ni/week group had a mean VAS score significantly higher than placebo (p = 0.044), with significant improvement of gastrointestinal symptoms (p = 0.016;) and significantly fewer rescue medications. Cutaneous manifestations also improved but without reaching statistical significance. After the treatment, oral challenge with higher Ni doses than at baseline were needed to cause symptoms to flare-up in significantly more patients given 1.5 μg Ni/week than placebo (p = 0.05). Patients reported no side-effects.

CONCLUSIONS

NiOHT is effective in SNAS, in particular on gastrointestinal manifestations, with trend toward improvement of cutaneous symptoms.