Localized argyria with pseudo-ochronosis

Elastofibromatous changes in giant cell fibroma and amalgam tattoo: Unusual findings in common oral lesions

Several cases of elastofibromatous lesion affecting the oral mucosa have been reported. Clinically, these lesions may appear as small exophytic lesions or less often as white lesions. Therefore, fibrous hyperplasia and leukoplakia are not uncommonly considered in clinical differential diagnosis. Microscopically, elastic and fibrous connective tissue deposition is seen. Rarely, elastofibromatous changes can be detected when assessing intraoral lesions, including cysts, salivary gland neoplasms, and epithelial dysplasia. Here we report two oral lesions showing elastofibromatous changes, expanding their clinicopathological spectrum. The first case was a 46-year-old man with a history of asymptomatic nodular lesion on the palate 1 year ago, diagnosed as giant cell fibroma with elastofibromatous changes. The second case was a 79-year-old woman who presented a pigmented and mildly symptomatic lesion on the mandibular alveolar mucosa several months ago, diagnosed as amalgam tattoo associated with elastofibromatous changes.

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.

Effect of Different Forms of Silver on Biological Objects

Silver has been known since ancient times on account of its pronounced antiseptic properties. Currently, its antibacterial, antiviral, and fungicidal properties are highly desired in the food and cosmetic industries, in medicine, and pharmacology. Silver exhibits toxic effects not only on pathogenic organisms but also on healthy cells. Over the past 20 years, nanosilver, a new form of silver, has been introduced in various areas of industry. The transition to the nanoscale form results in the revision of standard approaches to items, including those based on this element, and the emergence of such a novel research area as nanosafety. In this review, we address the history of using different forms of silver, the mechanisms of its interaction with living cells, toxic properties, biokinetic parameters, capability for accumulation in different organs, effects on cognitive functions, and the clinically known argyrosis condition. Relevant publications are critically analyzed and conclusions are drawn. The broader incorporation of such a weakly biophilic element as silver in the biosphere and ecosphere calls for our understanding of biochemical processes underlying the interaction of this element, in its different forms, with living cells and multicellular organisms.

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.

Clinical and Forensic Aspects of the Different Subtypes of Argyria

Argyria encompasses the different cosmetic alterations that can develop if enough silver particles deposit in a specific tissue, typically in the skin, ranging from localized dark-blue macules to a generalized slate-gray/bluish tinge following systemic absorption. This work aims to fully review the state of the art regarding pathophysiology, diagnosis, treatment, and relevant clinical and forensic features of argyria. Argyria has been diagnosed in a wide range of ages, both sexes and varied ethnicities, with no known individual predisposing factors. Ultraviolet radiation with subsequence increases of melanin production aggravates the discoloration due to a reduction in the silver deposits. Physical examination and silver exposure in the anamnesis can be highly suggestive of the diagnosis, but a histopathological analysis with Energy-Dispersive X-ray Spectroscopy is required to unequivocally determine the discoloration etiology. Safe and effective treatment has only been accomplished with laser techniques, though only a few cases have been reported and with limited follow-up time. In conclusion, argyria typically has an occupational or iatrogenic etiology. It should be suspected when a patient presents with typical skin or eye lesions. A seemingly viable treatment modality, with laser technology, is finally within the horizon.

Occupational Localized Cutaneous Argyria With Pseudo-Ochronosis in a Jeweler

ABSTRACT

A case of localized argyria in a 36-year-old female jeweler is described who presented with 2 discrete and asymptomatic bluish-black pigmented macules on the pulp of her left middle finger. A skin biopsy from both lesions demonstrated deposition of brown/black pigmented granules along the basement membrane zone of eccrine glands, blood vessels, nerves, and the dermo-epidermal junction fully in keeping with silver deposition. In addition, there was yellow-brown deposition seen within the interstitial dermis mimicking an early form of ochronosis, so called "pseudo-ochronosis." This latter feature is rarely described in cases of argyria. Transmission electron microscopy and energy dispersive x-ray spectroscopy confirmed the presence of electron dense particles up to 150 nm in diameter and the presence of silver, respectively. On further questioning, the patient had a history of localized and chronic exposure to silver, which specifically involved holding and manipulating silver wires and rings over the left middle finger. This case highlights an unusual and rare presentation of localized argyria in a jeweler. In addition, our case showed preferential silver deposition on dermal elastic fibers which has not been previously described in the literature.

Pigmented Deposits in the Skin

Pigmented deposits can occur in the skin due to many and varied causes. Some of them are systemic conditions accompanied by involvement of internal organs. Others have serious prognostic implications, and early diagnosis can help in the correct and adequate management of the diseases. In addition, some of them are quite innocuous and the correct diagnosis avoids unnecessary treatments. In this article, we review the morphologic features of some of the most common and some of the less usual pigmented deposits in skin other than tattoos.

In vivo reflectance confocal microscopy characterization of silver deposits in localized cutaneous argyria

Localized cutaneous argyria is a rare condition secondary to skin deposition of silver following exposure to substances containing this metal. The clinical appearance and dermoscopy findings require deep melanocytic lesions and particularly melanoma metastasis to be ruled out. Silver deposits are usually confirmed by scanning electron microscopy and/or energy-dispersive X-ray spectroscopy. Herein we describe the in vivo reflectance confocal microscopy (RCM) features observed in one case of localized cutaneous argyria. These features include the presence of a hyperrefractile network in the papillary dermis and a periadnexal dotted bright pattern. In vivo RCM might be a useful tool for an early diagnosis of this uncommon entity.

Alkaptonuric ochronosis

Alkaptonuria, with its sequel, ochronosis, is a rare disease, with an incidence of 1:125,000 to 1:1 million worldwide. Reported cases of ochronotic arthropathy and other orthopedic manifestations are mostly limited to a single family tree, and few cases have been reported. This study highlights 9 previously unreported patients with sporadic presentation and varied orthopedic manifestations of alkaptonuria. Patient age ranged from 34 to 50 years. One patient who had severe arthropathy of the right hip joint along with subcutaneous nodules over both knees and Achilles tendons underwent total hip replacement. Another patient had intramedullary calcification of the femur. An additional patient had associated caries of the spine at L3, L4, and L5, with resolution of symptoms after antitubercular chemotherapy. Another patient had associated features of hyperthyroidism, which was an incidental finding. A further patient had nonunion fracture of the neck of the femur and underwent total hip replacement. The remaining 4 patients had typical features of low backache and arthritis of the large joints. The parents were nonconsanguineous, and only 2 patients had affected siblings. The remaining 7 patients had sporadic nonfamilial presentation. Diagnosis was established by typical clinical and radiologic findings and biochemical analysis. At 2 years of follow-up, both patients who underwent total hip replacement were normal, with no radiologic signs of loosening or lysis. Clinicians need a high index of suspicion and awareness to make the diagnosis of ochronosis. The current study is unique because of presentation with subcutaneous nodules in 1 patient and associated caries of the spine in another patient.

Cutaneous deposits

: The cutaneous deposition disorders are a group of unrelated conditions characterized by the accumulation of either endogenous or exogenous substances within the skin. These cutaneous deposits are substances that are not normal constituents of the skin and are laid down usually in the dermis, but also in the subcutis, in a variety of different circumstances. There are 5 broad categories of cutaneous deposits. The first group includes calcium salts, bone, and cartilage. The second category includes the hyaline deposits that may be seen in the dermis in several metabolic disorders, such as amyloidosis, gout, porphyria, and lipoid proteinosis. The third category includes various pigments, heavy metals, and complex drug pigments. The fourth category, cutaneous implants, includes substances that are inserted into the skin for cosmetic purposes. The fifth category includes miscellaneous substances, such as oxalate crystals and fiberglass. In this article, the authors review the clinicopathologic characteristics of cutaneous deposition diseases, classify the different types of cutaneous deposits, and identify all the histopathologic features that may assist in diagnosing the origin of a cutaneous deposit.

Localized cutaneous argyria: two case reports and clinicopathologic review

We report 2 cases of patients who presented with blue macules clinically suspicious for blue nevi. One patient had no documented history of trauma or silver exposure, and the other reported exposure to silver over 30 years ago. Microscopic examination revealed a dermal population of brown-black globules predominantly adhering to collagen fibers. In both cases, no melanocytic proliferation was identified by immunohistochemistry. Analysis of the skin biopsies with scanning electron microscopy and energy dispersive x-ray spectroscopy demonstrated the presence of silver and selenium. These findings were diagnostic of localized cutaneous argyria. Our case reports highlight the importance of including localized cutaneous argyria in the differential diagnosis of pigmented lesions.

"Pseudo" Nomenclature in Dermatology: What's in a Name?

In the bewildering array of scientific nomenclature in the medical field, it is important to use correct terminology, know their aberrations and the reason behind a specific terminology. This paper is an attempt towards compiling all the pseudo-nomenclatures coined in dermatology, in order to make it easier to retain and recollect these pseudo names, signs, morphology, diseases, and conditions. It is also imperative to know the true entities that these pseudo names masquerade as, so as to understand the explanation for assigning the term 'pseudo' to these conditions. A total of 52 pseudo-terms have been compiled here in reference to dermatology. Most of these pseudo-nomenclatures were coined due to some clinical or histopathological resemblance to the true conditions, while some were premature conclusions drawn from a flawed understanding of the basic nature of the condition. Clear understanding of each of these terms and the explanation behind them being pseudo will enable a dermatologist to avoid misdiagnosis and needless confusion.

Imipramine-induced hyperpigmentation: a case report and review of the literature

Imipramine-induced hyperpigmentation is rare with only 13 cases reported in the literature to date. We report a 64-year-old female who presented with blue-gray discoloration on her face present for 4-5 years. The patient's medications included imipramine for depression for approximately 23 years. Physical examination revealed slate-gray hyperpigmented discrete and coalescing macules of the malar cheeks and the bilateral temples and periorbitally. She also had diffuse gray pigmentation of the bilateral dorsal hands. Histologic examination revealed an unremarkable epidermis with golden-brown round globules clustered in the superficial dermis, which stained strongly positive with a Fontana-Masson stain. Prussian blue stain for hemosiderin was negative. A diagnosis of imipramine-induced hyperpigmentation was made. Imipramine-induced hyperpigmentation as well as a detailed review of drug-induced hyperpigmentation is discussed.

An amalgam tattoo on the oral mucosa related to a dental prosthesis

A 60-year-old woman presented with a pigmented lesion on the upper left gingival mucosa of 2 years duration. The lesion was in an area where a dental metallic prosthesis had been inserted into a nearby tooth several years earlier. A biopsy of the affected mucosa showed aggregates of pigmented granules varying in size in the dermis, extracellular matrix and within macrophages; these did not stain with melanin stains. The diagnosis was consistent with an amalgam tattoo.

Alkaptonuric ochronosis with aortic valve and joint replacements and femoral fracture: a case report and literature review

Alkaptonuria is a rare autosomal recessive disorder of metabolism caused by deficiency of homogentisic acid oxidase and resulting in accumulation of homogentisic acid in collagenous structures. It is characterized by homogentisic aciduria, bluish-black discoloration of connective tissues (ochronosis) and arthropathy of large joints. Less common manifestations include cardiovascular abnormalities, renal, urethral and prostate calculi. Bone fractures are unusual in ochronosis. In this report, we describe a woman, 69 years of age, with a history of dark urine since childhood and progressive pigmentation of the skin, sclera, and auricular cartilages. She had severe arthropathy requiring total joint replacement in both of her knees and right hip. She also had severe aortic stenosis requiring valve replacement, and asymptomatic nephrolithiasis. She presented with a low trauma fracture of the distal femur despite two years of alendroate therapy. We review the etiology, pathogenesis, clinical presentation, diagnosis and treatment of alkaptonuric ochronosis. Early detection is important for prevention and treatment of multiple systems. Nitisinone, a potent inhibitor of 4-hydroxyphenylpyruvate dioxygenase, dramatically reduces production and urinary excretion of homogentisic acid; however, the long-term efficacy and side effects of such therapy are unknown. Identifying the gene for alkaptonuria offers the potential for a new therapeutic approach (replacement therapy with a recombinant enzyme) in the treatment of alkaptonuric ochronosis.