Sensitization to textile dyes in Spain: Epidemiological situation (2019-2022)

BACKGROUND

Current frequency and features for positivity to textile dye mix (TDM) in Spain are unknown.

OBJECTIVES

To study the frequency, clinical features and simultaneous positivity between TDM, para-phenylenediamine (PPD) and specific disperse dyes.

MATERIALS AND METHODS

We analysed all consecutive patients patch-tested with TDM from the Spanish Contact Dermatitis Registry (REIDAC), from 1 January 2019 to 31 December 2022. Within this group, we studied all selected patients patch-tested with a textile dye series.

RESULTS

Out of 6128 patients analysed, 3.3% were positive to the TDM and in 34% of them, the sensitization was considered currently relevant. TDM positivity was associated with working as a hairdresser/beautician and scalp, neck/trunk and arm/forearm dermatitis. From TDM-positive patients, 57% were positive to PPD. One hundred and sixty-four patients were patch-tested with the textile dye series. Disperse Orange 3 was the most frequent positive dye (16%). One of every six cases positive to any dye from the textile dye series would have been missed if patch-tested with the TDM alone.

CONCLUSIONS

Positivity to TDM is common in Spain and often associated with PPD sensitization. TDM is a valuable marker of disperse dyes allergy that should be part of the Spanish and European standard series.

Indigo carmine dye for detecting urinary track damage during vaginal surgery

OBJECTIVE

Unrecognized ureteral and bladder injury increase morbidity and mortality in gynecologic surgery. The primary objective of this study is to analyze the efficiency of a systematic intra-venous (IV) injection of carmine indigo to detect bladder injury in gynecologic vaginal surgery for benign disease. The secondary objective is to analyze the cost and use of carmine indigo.

STUDY DESIGN

A retrospective, monocentric study was conducted in a tertiary hospital between January 2018 and October 2021. All patients undergoing a vaginal surgery of hysterectomy for benign disease or anterior prolapse were systematically included. Patients can be systematically included by the automatic coding of surgery. After anesthesia, during the patient's installation, an intravenous injection of 5 mL of intravenous indigo carmine (Carmyne®) diluted in 100 mL of physiological serum was systematically administered by the anesthesia team. Intraoperative cystoscopy was performed only in cases of suspected associated ureteral injury.

RESULTS

We recorded 443 vaginal hysterectomies for benign disease and 95 vaginal anterior prolapse surgeries. There were 6 (1,4%) bladder injuries during vaginal hysterectomies and 1 (1,1%) bladder injury during vaginal prolapse surgery. All bladder injuries were diagnosed intraoperatively. No ureteral injury was diagnosed in this series of patients. No complication related to IV indigo carmine injection was found. In this tertiary hospital, 1085 ampoules of carmine indigo were ordered during the same period, approximatively 270 per year. The total cost to the gynecology and obstetrics department was 19,600 euros, or about 4,900 euros per year. Half of the carmine indigo was used in vaginal surgery and half in laparotomy, caesarean section and endometriosis surgery for suspected bladder or ureteral injury.

Narrow-band imaging vs Lugol chromoendoscopy in screening for esophageal squamous cell neoplasia: a randomized trial

INTRODUCTION

To date, there is no established optimal method for endoscopic detection of esophageal squamous cell neoplasia in high‑risk individuals.

OBJECTIVES

We aimed to compare the performance of narrow‑band imaging (NBI) and Lugol chromoendoscopy in screening for esophageal neoplasia among patients with a history of treatment for head and neck squamous cell cancer (HNSCC).

PATIENTS AND METHODS

We randomly assigned 300 patients who had completed curative treatment for HNSCC at least 1 year prior to the inclusion to undergo either NBI or Lugol endoscopy (2:1 ratio). Following white‑light examination of the esophagus, the assigned imaging study was performed, and biopsies were taken from any suspicious lesions identified using NBI or Lugol chromoendoscopy. The primary end point was positive predictive value (PPV) of the biopsied lesion for a diagnosis of esophageal neoplasia (high‑grade intraepithelial neoplasia [HG‑IEN] or invasive esophageal squamous cell carcinoma [ESCC]). The secondary end points included the number of biopsied lesions, duration of esophagus examination, and endoscopy tolerance.

RESULTS

In 294 patients included in the final analysis (NBI, n = 204; Lugol chromoendoscopy, n = 90), we diagnosed 3 ESCCs (1.02%) and 2 HG‑IENs (0.68%). The PPV of NBI and Lugol chromoendoscopy in per‑lesion analysis was 7.69% (95% CI, 0.94%-25.1%) and 8.11% (95% CI, 1.7%-21.9%), respectively (P >0.99). NBI outperformed Lugol chromoendoscopy in terms of the rate of patients requiring biopsy (12.75% vs 41.11%; P = 0.003), duration of esophagus examination (3.5 min vs 5.15 min; P <0.001), and endoscopy tolerance assessed on the visual analog scale (25 mm vs 36.5 mm; P = 0.002).

CONCLUSIONS

With a PPV comparable to that of Lugol chromoendoscopy, but a lower number of biopsies required, shorter examination time, and better patient tolerance, NBI could be considered the primary screening method for ESCC in patients with HNSCC.

Investigation of Adverse Reactions in Tattooed Skin through Histological and Chemical Analysis

BACKGROUND

Just as the number of tattooed people has increased in recent years, so has the number of adverse reactions in tattooed skin. Tattoo colourants contain numerous, partly unidentified substances, which have the potential to provoke adverse skin reactions like allergies or granulomatous reactions. Identification of the triggering substances is often difficult or even impossible.

METHODS

Ten patients with typical adverse reactions in tattooed skin were enrolled in the study. Skin punch biopsies were taken and the paraffin-embedded specimens were analysed by standard haematoxylin and eosin and anti-CD3 stainings. Tattoo colourants provided by patients and punch biopsies of patients were analysed with different chromatography and mass spectrometry methods and X-ray fluorescence. Blood samples of 2 patients were screened for angiotensin-converting enzyme (ACE) and soluble interleukin-2 receptor (sIL-2R).

RESULTS

Histology showed variable skin reactions such as eosinophilic infiltrate, granulomatous reactions, or pseudolymphoma. CD3+ T lymphocytes dominated the dermal cellular infiltrate. Most patients had adverse skin reactions in red tattoos (n = 7), followed by white tattoos (n = 2). The red tattooed skin areas predominantly contained Pigment Red (P.R.) 170, but also P.R. 266, Pigment Orange (P.O.) 13, P.O. 16, and Pigment Blue (P.B.) 15. The white colourant of 1 patient contained rutile titanium dioxide but also other metals like nickel and chromium and methyl dehydroabietate - known as the main ingredient of colophonium. None of the 2 patients showed increased levels of ACE and sIL-2R related to sarcoidosis. Seven of the study participants showed partial or complete remission after treatment with topical steroids, intralesional steroids, or topical tacrolimus.

CONCLUSIONS

The combination of the methods presented might be a rational approach to identify the substances that trigger adverse reactions in tattoos. Such an approach might help make tattoo colourants safer in the future if such trigger substances could be omitted.

Occupational respiratory allergy to reactive dyes

PURPOSE OF REVIEW

Reactive dyes have been shown to cause respiratory sensitization in workers with occupational exposure. The present review analyzes the current knowledge of the role of reactive dyes in promoting occupational respiratory allergy. We discuss the current classification of reactive dyes as well as the potential development of occupational respiratory diseases after exposure to these substances.

RECENT FINDINGS

Few descriptions of the role of reactive dyes in the development of occupational allergy have been published in recent years. Several reactive dyes are considered causes of occupational asthma (OA), mainly in workers in textile industries. Positive skin tests and the presence of specific serum IgE antibodies to reactive dyes suggest that respiratory symptoms provoked by reactive dyes may be immunoglobulin E (IgE)-mediated reactions. It was suggested that airborne dye molecules may act as haptens and induce IgE-mediated hypersensitivity reactions.

SUMMARY

Reactive dyes are widely used in the textile industry, owing to their ability to produce strong covalent bonds to textile fibers. These substances have been identified as potential respiratory sensitizers causing OA and occupational rhinitis. The clinical presentation and phenotype of patients with OA due to reactive dyes is very similar to those presented by patients with OA to high molecular weight agents. The extensive use of reactive dyes in industry means that it is particularly important to describe their implications for health, which in fact are probably underestimated.

Effectiveness of Vitamin C Solution in Reducing Adverse Reactions Caused by Painless Lugol Chromoendoscopy: A Multicenter Randomized Controlled Trial

GOAL

The purpose of this study was to evaluate the effectiveness of vitamin C solution (VCS) in reducing adverse reactions caused by painless Lugol chromoendoscopy.

BACKGROUND

Lugol chromoendoscopy is an effective method for screening superficial esophageal squamous cell carcinoma, although Lugol iodine solution (LIS) causes mucosal irritation.

STUDY

In 4 hospitals in China, patients were randomized and divided into a distilled water (DW) group, an sodium thiosulfate solution (STS) group and a VCS group. Patients' esophageal mucosal surfaces were stained with either 1.2% or 0.5% LIS and then sprayed with DW, STS, or VCS at various concentrations. For the current randomized study, 1610 patients were enrolled in the 1.2% LIS group and 1355 patients were enrolled in the 0.5% LIS group. In addition, 150 patients were enrolled to assess the discoloration effect. The primary outcome for evaluation was the incidence of acute or late adverse reactions after Lugol iodine staining. The secondary outcome for evaluation was the discoloration effect on esophageal iodine-stained mucosa.

RESULTS

VCS significantly reduced the occurrence of acute adverse reactions due to staining from 1.2% LIS. The effect of VCS was similar to that of STS but better than that of DW ( P <0.05). Regarding 0.5% LIS staining, VCS reduced the incidence of acute adverse reactions and heartburn within 1 week ( P <0.05). Both VCS and STS had similar effects. In addition, compared with spraying NS, VCS caused rapid decolorization of iodine-stained esophageal mucosa. After 120 seconds of deiodination, the color of the esophageal mucosa faded by 90%, which is similar to the results seen in the STS group. This contrasts with the results seen in the DW group, which showed fading by only 50.97% ( P <0.05).

CONCLUSION

VCS can effectively reduce adverse reactions caused by different concentrations of LIS, indicating its important clinical application in the screening of superficial esophageal squamous cell carcinoma.

Occurrence of Textile Dyes and Metals in Tunisian Textile Dyeing Effluent: Effects on Oxidative Stress Status and Histological Changes in Balb/c Mice

Although it is known that textile wastewater contains highly toxic contaminants whose effects in humans represent public health problems in several countries, studies involving mammal species are scarce. This study was aimed to evaluate the toxicity profile of 90-days oral administration of textile dyeing effluent (TDE) on oxidative stress status and histological changes of male mice. The TDE was collected from the textile plant of Monastir, Tunisia and evaluated for the metals, aromatic amines, and textile dyes using analytical approaches. Metal analysis by ICP-MS showed that the tested TDE exhibited very high levels of Cr, As, and Sr, which exceeded the wastewater emission limits prescribed by WHO and Tunisian authority. The screening of TDE through UPLC-MS/MS confirmed the presence of two textile dyes: a triphenylmethane dye (Crystal violet) and a disperse azo dye (Disperse yellow 3). Exposure to TDE significantly altered the malondialdehyde (MDA), Conjugated dienes (CDs), Sulfhydryl proteins (SHP) and catalase levels in the hepatic and renal tissues. Furthermore, histopathology observation showed that hepatocellular and renal lesions were induced by TDE exposure. The present study concluded that TDE may involve induction of oxidative stress which ensues in pathological lesions in several vital organs suggesting its high toxicity. Metals and textile dyes may be associated with the observed toxicological effects of the TDE. These pollutants, which may have seeped into surrounding rivers in Monastir city, can cause severe health malaise in wildlife and humans.

A retrospective analysis of rates of allergic reaction to Patent V blue dye used in sentinel lymph node biopsies for melanoma

Sentinel lymph node biopsies are a well-established component of the assessment and treatment pathway for patients with cutaneous melanoma in the UK. Commonly utilised techniques involve the use of blue dye which has an established risk of inducing allergic reactions in patients. Such reactions can be life-threatening, and this risk is important to highlight to patients. We conducted a retrospective review of all patients who had undergone this procedure at our melanoma centre in Cambridge, UK. From a group of 715 patients who received blue dye as part of the procedure, six patients suffered an allergic reaction (0.84%) with one of these treated as anaphylaxis. Our incidence of anaphylaxis is almost ten times greater than that reported in the NAP6 report led by the National Institute of Academic Anaesthesia and significantly higher than reported by others. We propose several reasons why our results differ from previous estimates. This study has focused only on patients undergoing a sentinel node procedure for melanoma, others have focused on such procedures performed on patients with breast cancer and some have combined the two. The administration technique, volume and anatomical distribution of disease all differ significantly from melanoma, possibly influencing rates and severity of allergic reactions.

Histopathologic Spectrum of Findings Associated With Tattoos: Multicenter Study Series of 230 Cases

IMPORTANCE

Reactions to tattoo may simulate common dermatosis or skin neoplasms. Histopathology allows diagnosis and helps determining the level and degree of inflammation associated, consequently orientating treatment.

OBJECTIVE

To describe the histological features found in biopsies of cutaneous reactions to tattoo.

DESIGN

This study was designed as a multicenter case series.

SETTING

All consecutive histopathological samples of tattoos referred from 1992 to 2019 to the Hospital General de Catalunya, Hospital Germans Trias i Pujol, and a private practice, all in Barcelona, Spain, and from the Kempf und Pfaltz Histologische Diagnostik in Zurich, Switzerland were retrieved from the files.

PARTICIPANTS AND EXPOSURE

The inclusion criteria were all cosmetic/permanent makeup, artistic/professional, and traumatic tattoos associated with either inflammatory reactions alone and/or with tumors and/or infections. Exclusion criteria were cases without any associated pathologic finding in the place of the ink, amalgam tattoos, and medical or temporary tattoos.

MAIN OUTCOMES AND MEASURES

In all patients, clinical features (age, sex, location, tattoo color, and presentation) were recorded. Histological features evaluated included ink color, associated tumors or infections, and inflammatory reaction pattern. Inflammation was graded in low to moderate or severe.

RESULTS

From 477 biopsies diagnosed as tattoos, 230 cases from 226 patients met the inclusion criteria. Samples corresponded to 107 male and 120 female subjects and 3 of unknown gender. Median age was 39 years (ranging from 9 to 84 years). Fifty-three samples were referred from centers in Spain and 177 from the center in Switzerland. The series was analyzed in 2 parts: tattoos associated only with inflammatory reactions (117/230) and tattoos associated with tumors or infections (113/230). The most common form of inflammatory pattern associated with tattoo was the fibrosing reaction (79/117, 68%), followed by granulomatous reaction (56/117, 48%), lichenoid reaction (33/117, 28%), epithelial hyperplasia (28/117, 24%), pseudolymphoma (27/117, 23%) and spongiotic reaction (27/117, 23%). Combined features of 2 or more types of inflammatory patterns were seen in 64% cases.

CONCLUSIONS AND RELEVANCE

Our series confirms that cutaneous reactions to tattoos are polymorphous. Inflammation tends to present with combined patterns. Infections are tending to decline, and pathologic findings are not specific to ink color or clinical features.

Histopathology of Red Tattoo Reactions

BACKGROUND

Despite popularity of tattoos, complications may occur. In particular, red tattoo reactions due to allergic reactions are the most frequent chronic tattoo reactions. However, little is known about its histopathology and underlying pathomechanisms.

OBJECTIVE

The aim of this article is to analyze the histopathology of red tattoo reactions for diagnostic purposes and to acquire more insight into pathogenesis.

METHODS

A retrospective cross-sectional study was conducted by reviewing the histopathology of 74 skin biopsies of patients with allergic red tattoo reactions. Histopathological findings, such as inflammation patterns, inflammatory cells and pigment depth and color, were semi-quantified with an in-house validated scoring system by 2 independent senior investigators.

RESULTS

Histiocytes and lymphocytes were both present in >93%. Histiocytes were the predominant inflammatory cells in 74.3%, but well-defined granulomas were mostly absent (78.0%). Eosinophils were uncommon (8.1%) The predominantly histiocytic reaction combined with interface dermatitis was the main inflammation pattern (37.9%). Most biopsies showed more than one reaction pattern. Interface involvement was observed in 64.8%, despite the intended depth of standard tattoo procedures, in which pigment is placed deeper, in the upper- and mid-dermis. Statistical analyses showed a significant association between inflammation severity and pigment depth (P = 0.024). In 6 cases (8.1%) pigments could not be retrieved histologically.

CONCLUSIONS

In this cohort we demonstrated that cutaneous reactions to red tattoo ink are frequently characterized by the combination of dermal predominantly histiocytic infiltrates and epidermal interface dermatitis. Allergic reactions to red tattoo pigments probably represent a combination of a subtype IVa and IVc allergic reaction. Clinicians should be aware of the specific histopathology of these reactions and therefore the importance of taking a diagnostic skin biopsy.

A promising Ames battery for mutagenicity characterization of new dyes

When testing new products, potential new products, or their impurities for genotoxicity in the Ames test, the quantity available for testing can be a limiting factor. This is the case for a dye repository of around 98,000 substances the Max Weaver Dye Library (MWDL). Mutagenicity data on dyes in the literature, although vast, in several cases is not reliable, compromising the performance of the in silico models. In this report, we propose a strategy for the generation of high-quality mutagenicity data for dyes using a minimum amount of sample. We evaluated 15 dyes from different chemical classes selected from 150 representative dyes of the MWDL. The purity and molecular confirmation of each dye were determined, and the microplate agar protocol (MPA) was used. Dyes were tested at the limit of solubility in single and concentration-response experiments using seven strains without and with metabolic activation except for anthraquinone dyes which were tested with eight strains. Six dyes were mutagenic. The most sensitive was YG1041, followed by TA97a > TA98 > TA100 = TA1538 > TA102. YG7108 as well as TA1537 did not detect any mutagenic response. We concluded that the MPA was successful in identifying the mutagenicity of dyes using less than 12.5 mg of sample. We propose that dyes should be tested in a tiered approach using YG1041 followed by TA97a, TA98, and TA100 in concentration-response experiments. This work provides additional information on the dye mutagenicity database available in the literature.

Possible Adverse Effects of Food Additive E171 (Titanium Dioxide) Related to Particle Specific Human Toxicity, Including the Immune System

Titanium dioxide (TiO₂) is used as a food additive (E171) and can be found in sauces, icings, and chewing gums, as well as in personal care products such as toothpaste and pharmaceutical tablets. Along with the ubiquitous presence of TiO₂ and recent insights into its potentially hazardous properties, there are concerns about its application in commercially available products. Especially the nano-sized particle fraction (<100 nm) of TiO₂ warrants a more detailed evaluation of potential adverse health effects after ingestion. A workshop organized by the Dutch Office for Risk Assessment and Research (BuRO) identified uncertainties and knowledge gaps regarding the gastrointestinal absorption of TiO₂, its distribution, the potential for accumulation, and induction of adverse health effects such as inflammation, DNA damage, and tumor promotion. This review aims to identify and evaluate recent toxicological studies on food-grade TiO₂ and nano-sized TiO₂ in ex-vivo, in-vitro, and in-vivo experiments along the gastrointestinal route, and to postulate an Adverse Outcome Pathway (AOP) following ingestion. Additionally, this review summarizes recommendations and outcomes of the expert meeting held by the BuRO in 2018, in order to contribute to the hazard identification and risk assessment process of ingested TiO₂.

Improved filtration for dye removal using keratin-polyamide blend nanofibrous membranes

Dyes from industrial wastewaters represent one of the most hazardous pollutants as they are not effectively biodegradable. The present work is focused to study the novel properties of keratin-polyamide blend nanofibrous filtration membranes for treating wastewaters containing dye. Keratin protein was extracted from goat hair, a tannery waste through sulphitolysis process. The extracted keratin was blended with polyamide to prepare a nanofibrous membrane through the electrospinning process. The fabricated pristine polyamide and keratin-altered polyamide membranes were characterized and compared for their properties. Effects of solution pH, dye concentration, membrane flux, and membrane capacity have been examined. Very fine nanofibers and enhanced porosity drive the membrane to enhanced flux and higher filtration efficiencies. At pH 2, the dye removal efficiency of the blend membranes was 100, 99, 98, 90, and 83% for 100, 200, 250, 300, and 400 ppm concentrations of dye, respectively. The keratin-polyamide blend membrane exhibited better properties in all aspects. The results of this present investigation indicate that the presence of keratin in filtration membranes is promising for dye removal from the effluents.

Occupational mimics of rheumatoid arthritis: hair dye-induced arthritis

Hair dye (HD) and its component para-phenylenediamine (PPD) are commonly used to enhance beauty and youth. HD is associated with allergic contact reactions and the development of autoimmune phenomena. A 28-year-old woman presented to us complaining of pain and swelling affecting the small joints of the hands bilaterally lasting for 7 weeks. Laboratory evaluation was remarkable only for an increase of acute-phase reactants, while the rest of laboratory tests including serological tests for viruses, as well as immunological tests were negative or within normal limits. She noticed a close correlation between the onset of symmetrical polyarthritis and the use of HD product. Thus, after excluding other possibilities of inflammatory arthritides, the diagnosis of HD-induced arthritis was made. The patient was treated with naproxen, and after 3 weeks, she had a complete clinical response with decrease of acute-phase reactants. Thus, we review and discuss the relevant literature of cases related with the use of HD and arthritis development. This is the first described case of HD-induced arthritis. Physicians must be aware and recognize these symptoms and signs of patients exposed to HD and treat them appropriately.

Toxic effects of Red-S3B dye on soil microbial activities, wheat yield, and their alleviation by pressmud application

This study examined the effect of Red-S3B textile dye on soil microbial activities, uptake of the dye by wheat plants and growth on the dye-contaminated soil. Moreover, pressmud (PM) application was investigated for its alleviative effect on wheat yield and dye uptake by plants. Preliminarily, soil was spiked with a wide concentration range (0, 100, 250, 500, 750 and 1000 mg kg^-1 soil) of Red-S3B dye and wheat was grown for 42-days. The dye did not suppress the activities of soil enzymes and growth of wheat seedlings at 100 mg kg^-1; however, beyond this level the dye had a linear negative effect on these attributes. With 1000 mg dye kg^-1 soil, wheat seedling biomass, viable microbial count, soil respiration, dehydrogenase, phosphatase, and urease activities decreased by 84%, 33%, 45%, 69%, 24%, and 11%, respectively as compared to uncontaminated soil. Moreover, phosphorus and potassium content in wheat shoot decreased, while the nitrogen content increased in Red-S3B contaminated soil. In the subsequent pot experiment, PM application (12.5 g kg^-1 soil) was assessed to alleviate the adverse effect of moderately toxic level of Red-S3B dye (500 mg kg^-1 soil) on wheat growth and yield. Root and straw biomass, and grain yield of wheat decreased by 13, 19 and 12%, respectively in Red-S3B contaminated soil as compared to uncontaminated soil. However, PM application to dye-contaminated soil retrieved the dye-induced reduction in root and straw biomass and grain yield to become statistically (p ≤ 0.05) at par with control plants. The color of Red-S3B was clearly visible in spikes depicting that plants absorbed Red-S3B but probably could not metabolize it. Amending the dye-contaminated soil with PM decreased Red-S3B content in awns from 78 to 37 mg kg^-1. Hence, it is concluded that Red-S3B textile dye is highly toxic to soil microbes and wheat plants at levels exceeding 100 mg kg^-1 soil. Soil application of PM alleviates the adverse effect of Red-S3B dye on wheat growth through reducing its uptake by plants.

Patent blue V dye anaphylaxis: a case report and literature review

Background

Anaphylaxis is a constant perioperative concern due to the exposure to several agents capable of inducing hypersensitivity reactions. Patent blue V (PBV), also known as Sulfan Blue, a synthetic dye used in sentinel node research in breast surgery, is responsible for 0.6% of reported anaphylactic conditions. We present a case of a 49-year-old female patient who underwent left breast tumorectomy with sentinel lymph node staging using PBV and experienced an anaphylactic reaction.

Methods

We conducted a literature search through PubMed for case reports, case series, review and systematic reviews since 2005 with the keywords “anaphylaxis” and “patent blue”. We then included articles found in these publications’ reference sections.

Results

We found 12 relevant publications regarding this topic. The main findings are summarized, with information regarding the clinical presentation, management, and investigation protocol. Hypotension is the most common clinical manifestation. The presentation is usually delayed when compared with anaphylaxis from other agents and cutaneous manifestations are occasionally absent. Patients may have had previous exposure to the dye, used also as a food, clothes and drug colorant.

Conclusion

The diagnosis of anaphylaxis in patients under sedation or general anesthesia may be difficult due to particularities of the perioperative context. According to the published literature, the presentation of the reaction is similar in most cases and a heightened clinical sense is key to address the situation appropriately. Finding the agent responsible for the allergic reaction is of paramount importance to prevent future episodes.

The effectiveness and safety of curcumin as a complementary therapy in inflammatory bowel disease: A protocol of systematic review and meta-analysis

BACKGROUND

Inflammatory bowel diseases (IBD), which include Crohn disease and ulcerative colitis, affect several million individuals worldwide. Curcumin as a complementary therapy has been used to cure the IBD, yet the efficacy and safety of curcumin remains to be assessed. In this study, we aim to draw up a protocol for systematic review to evaluate the efficacy and safety of curcumin for IBD.

METHODS

We will search the following electronic databases from inception to September 31, 2020: PubMed, Cochrane Library, EMBASE, Web of Science, Medline, the China National Knowledge Infrastructure Database, Wan Fang Database, the Chinese Scientific Journal Database, and Chinese Biomedical Literature Database. Clinical trial registrations, potential gray literatures, relevant conference abstracts and reference list of identified studies will also be searched. Relevant randomized controlled clinical trials were enrolled and analyzed. The literature selection, data extraction, and quality assessment will be completed by 2 independent authors. Either the fixed-effects or random-effects model will be used for data synthesis based on the heterogeneity test. Clinical remission will be evaluated as the primary outcome. Clinical response, endoscopic remission, inflammatory markers and adverse events will be assessed as the secondary outcomes. The RevManV.5.3.5 will be used for Meta-analysis. Subgroup analyses of doses, delivery way, frequency of treatment and the degree of IBD severity or different forms of IBD were also conducted.

RESULTS

This study will provide a synthesis of current evidence of curcumin for IBD from several aspects, such as clinical remission, clinical response, endoscopic remission, inflammatory markers, and adverse events.

CONCLUSION

The conclusion of our study will provide updated evidence to judge whether curcumin is an effective solution to IBD patients.

INPLASY REGISTRATION NUMBER

INPLASY202090065.

Tattoo Pigment within Regional Lymph Nodes Mimicking Cutaneous Melanoma Metastasis

Dear Editor, The diagnosis of malignant melanoma accounts for 1-2% of all cancer diagnoses, around 4% of all malignant skin diseases, and 80% of all skin cancer deaths (1). The prognosis depends on several factors including tumor size, Clark level, Breslow thickness, location, ulceration, and presence of metastases. Detection of lymph node metastasis is initially accomplished by clinical examination and by operative evaluation for occult metastasis using sentinel lymph node biopsy (SLNB) when indicated (2). Lymph nodes (LN) with melanoma metastasis may appear normal in early stages, but eventually they become dark, firm, and enlarged (3). In 2017, a 32-year-old female patient was referred to our ward by a dermatologist following a biopsy excision of a nevus under her right breast that tested positive for a cutaneous melanoma grade T2aNx with a Breslow thickness of 1.9 mm, with no sign of ulceration and no history of previous illnesses or chronic diseases. Based on the American Joint Committee on Cancer (AJCC) guidelines, wide excision with a sentinel lymph node (SLN) biopsy was indicated (4). The patient was injected with 0.4 mL CiTc 99m Nanocoll in all four quadrants around the primary scar. A 2 cm wide elliptical excision was performed circumferentially around the scar and to the depth of the muscular fascia of the thorax. With the aid of a gamma probe, a single radioisotope positive lymph node was located in the ipsilateral axilla, but 5 dark pigmented lymph nodes situated behind the SLN were visualized during manual dissection and thought to be consistent with metastatic disease (Figure 1). Due to this new finding, an excisional biopsy of all pigmented nodes was performed. Histology of the excised skin did not demonstrate any further cancerous cells. The size of the SLN was 15 mm, and immunohistochemistry for Melan A was negative for metastatic melanoma. Histological analysis of the darkly pigmented nodes was negative for metastatic melanoma as the pigment was demonstrated to originate from the dermal tattoo on the patient's back that had been removed by dermabrasion 3 years before melanoma development (Figure 2, Figure 3). Dermal tattooing results in initial sloughing of the overlying epidermis, variable dermal inflammation, and gradual assimilation of pigment into macrophages. Much of the pigment is rapidly carried into regional draining LN, which was shown in 2010 on a SKH-1a mouse model, and causes lymphadenopathy which is thought to be a result of local inflammation (6). Importantly, even after removal of the offending cutaneous tattoo the tattoo pigment can persist in draining or distant nodes visible to the naked eye (7). In such cases, LN can mimic metastatic malignant melanoma and may prompt the surgeon to proceed with radical lymph node dissection which may not be necessary. Despite clear guidelines for melanoma treatment in the general population, there are several questions that need to be addressed: firstly, how should a physician approach a patient with unknown history of tattoo removal, a diagnosis of melanoma, and intraoperative darkly pigmented lymph nodes? Secondly, due to the lack of scientific data and treatment protocol, if the SLN is normally colored while other regional nodes are darkly pigmented, what should the treatment plan entail?

Kounis syndrome after patent blue dye injection for sentinel lymph node biopsy

BACKGROUND

Kounis syndrome (KS) has been described as an acute coronary syndrome (ACS) associated with an anaphylactic reaction. Several triggers have been identified and the diagnostic and treatment process can be challenging.

CASE

A 58-year-old, female patient diagnosed with breast cancer and no history of allergies had subcutaneous injection of patent blue V dye for sentinel lymph node biopsy (SLNB). Intraoperatively, she developed anaphylactic shock and was transferred to the intensive care unit (ICU). A few hours later, electrocardiographic alterations and elevation of blood troponin were observed. Emergency coronary angiography revealed no occlusive lesions in coronary vessels. Further investigation in the allergy department set the diagnosis of KS.

CONCLUSION

There are just ten cases of perioperative KS in the literature so far and here we present the first one triggered by patent blue V dye for sentinel node biopsy.

[A woman with bumps in the eyebrows]

A 28-year-old woman was seen at our clinic with asymptomatic bumps in the eyebrows which arose 3 months after microblading, a cosmetic procedure to make the eyebrows appear fuller. Physical examination showed red-brown confluent papules. A skin biopsy revealed a non-necrotizing granulomatous reaction with sarcoid granulomas. Blood test and a chest X-ray showed no abnormalities and histopathological stains were negative. We diagnosed her with a granulomatous reaction in response to pigment. The skin lesions eventually disappeared spontaneously within 6 months.

SOX10 commonly stains scar in Mohs sections

Sox10 immunostaining is used for the diagnosis and margin evaluation of melanocytic lesions. Sox10 was initially thought not to stain fibrohistiocytic processes. Consequently, it was believed to reliably distinguish desmoplastic melanoma from scar. However, recent data from formalin sections suggest Sox10 is less specific than previously thought. In this report, we demonstrate that Sox10-stained Mohs sections commonly show strong, fractional staining of scar. When using Sox10 with frozen section immunohistochemistry, Mohs practitioners should recognize the potential of this marker to stain scar to avoid overdiagnosis of desmoplastic melanoma.

In vivo and ex vivo dermoscopy of lesions from implantation of human papillomavirus in tattoos: report of two cases

The number of individuals with tattoos has been increasing worldwide, alongside with reports of complications varying from reactions to the injected pigments to infections caused by agents inoculated in the pigmentation process. The diagnosis of such unwanted events can be obtained through complementary non-invasive methods, preserving the maximum of the tattoo design. The authors present two cases of patients with warts on tattooing, and correlate their clinical aspects to in vivo and ex vivo dermoscopy, and to the findings in the histopathological examination, aiming to determine patterns that aid the diagnosis of these lesions without performing biopsy.

Controlling the risks of nano-enabled products through the life cycle: The case of nano copper oxide paint for wood protection and nano-pigments used in the automotive industry

The widespread use of engineered nanomaterials (ENMs) in consumer products and the overwhelming uncertainties in their ecological and human health risks have raised concerns regarding their safety among industries and regulators. There has been an ongoing debate over the past few decades on ways to overcome the challenges in assessing and mitigating nano-related risks, which has reached a phase of general consensus that nanotechnology innovation should be accompanied by the application of the precautionary principle and best practice risk management, even if the risk assessment uncertainties are large. We propose a quantitative methodology for selecting the optimal risk control strategy based on information about human health and ecological risks, efficacy of risk mitigation measures, cost and other contextual factors. The risk control (RC) methodology was developed in the European FP7 research project SUN and successfully demonstrated in two case studies involving real industrial nano-enabled products (NEPs): nano-scale copper oxide (CuO) and basic copper carbonate (Cu₂(OH)₂CO₃) used as antimicrobial and antifungal coatings and impregnations for the preservation of treated wood, and two nanoscale pigments used for colouring plastic automotive parts (i.e. red organic pigment and carbon black). The application of RC for human health risks showed that although nano-related risks could easily be controlled in automotive plastics case study with modifications in production technology or specific type of engineering controls, nano-related risks due to sanding and sawing copper oxide painted wood were non-acceptable in the use lifecycle stage and would need the identification of a more effective risk control strategy.

T lymphocyte phenotype of contact-allergic patients: experience with nickel and p-phenylenediamine

BACKGROUND

There is considerable interest in understanding the immunological variables that have the greatest influence on the effectiveness of sensitization by contact allergens, particularly in the context of developing new paradigms for risk assessment of novel compounds.

OBJECTIVES

To examine the relationship between patch test score for three different contact allergens and the characteristics of T cell responses.

METHODS

A total of 192 patients with confirmed nickel, p-phenylenediamine (PPD) or methylisothiazolinone (MI) allergy were recruited from the Contact Dermatitis Investigation Unit at Salford Royal Hospital. Severity of allergy was scored by the use of patch testing, peripheral blood lymphocytes were characterized for T cell phenotype by flow cytometry, and proliferative activity was characterized by radiolabelled thymidine incorporation. Comparisons were drawn with buffy coat samples from healthy volunteers.

RESULTS

Patch test positivity for nickel, PPD and MI was associated with changes in the phenotype of peripheral blood T cells: increases in naïve cells, decreases in regulatory T cell frequency and the CD4+ /CD8hi ratio, and increased expression of the skin-homing marker cutaneous lymphocyte antigen (CLA), particularly for those patients with a +++ patch test score.

CONCLUSIONS

This increased understanding of the characteristics of the T cell responses to contact allergens may provide parameters with which to better measure health risks associated with skin sensitization.

Women and Tattoos: Fashion, Meaning, and Implications for Health

Tattooing is a type of body modification that is both ancient and modern. Tattooing is rapidly increasing in popularity and prevalence, especially among younger people. Therefore, health care providers require knowledge about this form of artistic expression, including potential health implications and psychosocial significance. Tattooing is richly laden with cultural and personal meaning, but despite the increasingly mainstream status of this art form, individuals with tattoos may experience stigma, stereotyping, and discrimination in their personal and professional lives. The legal and regulatory aspects of tattoos have lagged behind the rapid growth of this art form, causing confusion and variation in practice. Particularly concerning is the multitude of largely unregulated tattoo inks marketed for human use but untested on humans. Common and uncommon side effects and complications of this procedure include hypersensitivity, infection, and regret. More women than men are now tattooed, and tattooing is associated with important implications for women's health care, including pregnancy, childbirth, and breastfeeding. Because of the frequency of regret, many individuals wish to be rid of previously acquired body art. Therefore, health care providers also need to be conversant with tattoo removal: motivations, techniques, risks, and factors influencing success. Familiarity with the many dimensions of body art will facilitate safe, compassionate health care provision and will enhance the therapeutic relationship enjoyed by clinicians and the individuals they serve.

Dyeing but not dying: Colourful dyes as a non-lethal method of food labelling for in vitro-reared honey bee (Apis mellifera) larvae

Several environmental factors (e.g. food source, pesticides, toxins, parasites and pathogens) influence development and maturation of honey bees (Apis mellifera). Therefore, controlled experimental conditions are mandatory when studying the impact of environmental factors: particularly food quality and nutrient consumption. In vitro larval rearing is a standard approach for monitoring food intake of larvae and the labelling of food is necessary to quantify intake in controlled feeding experiments. Here, we tested the suitability of two food dyes, Allura Red and Brilliant Blue, in an experimental set up using in vitro reared honey bee larvae and freshly hatched adult workers. Absorbance of both dyes was measured, in food and dye-fed larvae, to determine the optimal dye concentrations for accurate detection and quantification. By quantifying relative dye concentrations in dye mixtures, relative concentrations of mixed dyes can be estimated independent of the total food consumed by the larvae. Survival assays were conducted to test the impact of both dyes on larval and worker bee survival. Worker bees showed no increase in adult mortality, when fed with dyed honey. Larval survival was not significantly different until the late pupal stage. The physiological impact of dye feeding was tested by measuring larval immune response. No changes in innate immune gene expression were detectable for larvae fed with dyed and non-dyed food. In conclusion, we established a non-invasive food labelling protocol for food intake quantification in in vitro reared honey bee larvae, using non-toxic, inexpensive, and easy to apply food dyes.

Comparison of the skin sensitization potential of 3 red and 2 black tattoo inks using interleukin-18 as a biomarker in a reconstructed human skin model

BACKGROUND

During the last decade, the number of people with ≥1 tattoo has increased noticeably within the European population. Despite this, limited safety information is available for tattoo inks.

OBJECTIVES

To test the skin sensitization potential of 5 tattoo inks in vitro by using reconstructed human skin (RHS) and the contact sensitization biomarker interleukin (IL)-18.

METHODS

Two red and 3 black tattoo inks, 1 additive (Hamamelis virginiana extract) and 1 irritant control (lactic acid) were tested. The culture medium of RHS (reconstructed epidermis on a fibroblast-populated collagen hydrogel) was supplemented with test substances in a dose-dependent manner for 24 hours, after which cytotoxicity (histology; thiazolyl blue tetrazolium bromide assay) and skin sensitization potential (IL-18 secretion; enzyme-linked immunosorbent assay) were assessed.

RESULTS

All but 1 ink showed cytotoxicity. Notably, 1 red ink and 1 black ink were able to cause an inflammatory response, indicated by substantial release of IL-18, suggesting that these inks may be contact sensitizers.

CONCLUSIONS

The in vitro RHS model showed that 4 tattoo inks were cytotoxic and 2 were able to cause an inflammatory IL-18 response, indicating that an individual may develop allergic contact dermatitis when exposed to these tattoo inks, as they contain contact sensitizers.

Cochineal dye-induced immediate allergy: Review of Japanese cases and proposed new diagnostic chart

BACKGROUND

Cochineal dye is used worldwide as a red coloring in foods, drinks, cosmetics, quasi-drugs, and drugs. The main component of the red color is carminic acid (CA). Carmine is an aluminum- or calcium-chelated product of CA. CA and carmine usually contain contaminating proteins, including a 38-kDa protein thought to be the primary allergen. Severe allergic reactions manifest as anaphylaxis. The aim of this study was to review all Japanese reported cases and propose useful diagnostic chart.

METHODS

All reported Japanese cases of cochineal dye-induced immediate allergy were reviewed, and newly registered cases were examined by skin prick test (SPT) with cochineal extract (CE) and measurement of CE and carmine-specific serum IgE test. Two-dimensional (2D) western blotting using patient serum was conducted to identify the antigen.

RESULTS

Twenty-two Japanese cases have been reported. SPT and the level of specific IgE test indicated that six cases should be newly registered as cochineal dye allergy. All cases were adult females, and all cases except three involved anaphylaxis; 13 cases involved past history of local symptoms associated with cosmetics use. Japanese strawberry juice and fish-meat sausage, and European processed foods (especially macarons made in France) and drinks were recent major sources of allergen. 2D western blotting showed that patient IgE reacted to the 38-kDa protein and other proteins. Serum from healthy controls also weakly reacted with these proteins.

CONCLUSIONS

SPT with CE and determination of the level of CE and carmine-specific IgE test are useful methods for the diagnosis of cochineal dye allergy.

Comparative study for degradation of industrial dyes by electrochemical advanced oxidation processes with BDD anode in a laboratory stirred tank reactor

Comparative degradation of the industrial dyes Blue BR, Violet SBL and Brown MF 50 mg L^-1 has been studied by the electrochemical oxidation (EOx), electro-Fenton (EF), photoelectro-Fenton (PEF) process based on BDD electrode. Each dye was tested in 0.05 mM Na₂SO₄ with 0.5 mM Fe²⁺ at pH 3.0, and electrolyzed in a stirred tank reactor under galvanostatic conditions with 2.0, 5.0, 7.0, 11.0 and 18.0 mA cm^-2. Dyes were oxidized via hydroxyl radicals (OH) formed at the BDD anode from water oxidation coupled with Fenton's reaction cathodically produced hydrogen peroxide (H₂O₂). Under Na₂SO₄ medium close to 100% the decolorization was achieved. Through the color abatement rate the dyes behavior was analyzed at the beginning of the oxidation process. Dissolved Organic Carbon (DOC) was tested to evaluate the degradation. From DOC removal, it was established an increasing relative oxidation power of the EOx < EF < PEF, according with their decolorization trend. This study highlights the potential of the electrochemical/BDD process for the degradation of industrial dyes found in wastewaters under appropriate experimental conditions.

Anaphylactic shock perioperative to patent blue dye

Patent blue is one of the most used dyes for the identification of sentinel lymph nodes in breast cancer. This report describes a case of an anaphylactic shock reaction to patent blue dye in a patient with cross-reactivity to methylene blue. Therefore, after allergy confirmation, the operation was repeated avoiding blue dye and an alternative labelling technique with 99mTc albumin nanocolloids was used.

Trendy Tattoos-Maybe a Serious Health Risk?

BACKGROUND

The literature reports many cases of cutaneous malignancy in the setting of skin tattoos. In this study, we review the reported incidence of and risk factors for tattoo-associated skin cancer.

METHODS

A PubMed literature review was performed for all cases of tattoo-associated skin cancer, including squamous cell carcinoma, basal cell carcinoma, malignant melanoma, keratoacanthoma, and other rare skin malignancies (source: PubMed/until June 2017).

RESULTS

The authors identified 51 publications and 63 total cases of tattoo-associated skin cancer. We also report on a single new case of tattoo-associated skin cancer observed at one of our co-authors' institutions. Among these 64 total cases, 58% were associated with black and blue inks and 34% were associated with red ink.

CONCLUSIONS

Overall, while the strength of association remains unclear, the literature reports many cases of tattoo-associated skin cancer. Among these cases, black, blue, and red inks were particularly worrisome for their carcinogenic potential.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Not Available]

La práctica de tatuajes tienen más de 8000 años de antigüedad, existiendo un incremento continuo en la sociedad occidental en las últimos 3 décadas La introducción de una sustancia exógena en la pielpuede provocar una respuesta inmunológica en su contra, estando descritas reacciones cutáneas por hipersensibilidad a una variedad de pigmentos, las que se limitan al área de un determinado color,atribuyéndose a los materiales inyectados. El color más reportado en la literatura es el rojo, que tradicionalmente se confeccionaban a base dederivados del mercurio (cinabrio). Diversos patrones histológicos de reacción están descritos, siendo el más frecuente el liquenoide. Presentamos una serie de 10 pacientes con reacción de hipersensibilidad a tatuaje rojo, con patrón histológico predominante dereacción granulomatosa y con moderada respuesta a tratamiento. Es importante cuando se está ante un patrón granulomatoso de reacción descartar sarcoidosis sistémica e infecciones por micobacterias.

Severe hemodynamic instability after indocyanine green injection during off-pump coronary artery bypass grafting: A case report

RATIONALE

The increasingly intraoperative use of indocyanine green (ICG) means that it is necessary to be aware of both its advantages and potential adverse effects.

PATIENT CONCERNS

A 76-year-old woman developed symptoms of sudden severe hemodynamic instability while undergoing coronary artery bypass grafting with ICG injection to detect the patency of the graft. The main clinical manifestations were a sudden drop in blood pressure and increased heart rate.

DIAGNOSES

Severe side effects or allergic reaction of ICG.

INTERVENTIONS

Cardiopulmonary bypass (CPB) was established, and an intra-aortic balloon pump was implanted in the left femoral artery after intravenous epinephrine and manual cardiac compression failed.

OUTCOMES

The patient was extubated and transferred to the general ward on the third postoperative day.

LESSONS

Invasive blood pressure monitoring should be carried out in patients undergoing intraoperative ICG administration. Anesthetists should pay close attention to the patient's hemodynamic fluctuations, and effective emergency measures should be implemented immediately if severe hemodynamic instability occurs.

Effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) measurement

To retrospectively investigate the effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) in 20 patients who underwent elective gynecologic surgery under general anesthesia. The study subjects were patients who underwent elective gynecologic surgery under general anesthesia between April 2016 and January 2017, and were administered a 5-ml intravenous injection of 0.4% indigo carmine for clinical purposes during surgery with ORi monitoring. Changes in ORi within 20 min after indigo carmine injection were observed. A relevant decrease in ORi was defined as ≥ 10% reduction in ORi from pre-injection level. ORi rapidly decreased after indigo carmine intravenous injection in all patients. In 10 of 19 patients, ORi decreased to 0 after indigo carmine injection. The median lowest value of ORi was 0 (range 0-0.16) and the median time to reach the lowest value of ORi was 2 min (range 1-4 min) after injection. ORi values returned to pre-injection levels within 20 min in 13 of 19 patients, and the median time to return to pre-injection levels was 10 min (range 6-16 min) after injection. During ORi monitoring it is necessary to consider the rapid reduction in ORi after intravenous injection of indigo carmine.

Novel Cause of 'Black Thyroid': Intraoperative Use of Indocyanine Green

The antibiotic minocycline is virtually pathognomonic for brown-black discoloration of the thyroid gland referred to as 'black thyroid'. Black thyroid' is an incidental finding in patients taking the drug who undergo thyroid surgery for another indication and is not of known clinical significance. However, its recognition is important so as not to raise concern for a disease process. Here, we present the first case of 'black thyroid' attributable to the iodine-containing compound indocyanine green. Intraoperative indocyanine green was administered as part of a research protocol transoral robotic-assisted surgery for a base of tongue cancer in a 44-year-old man. Hemithyroidectomy was subsequently performed during the same operation for further evaluation of an indeterminate thyroid nodule. The resected thyroid lobe was dark, nearly black in color, and histologically showed extensive brown pigment deposition in the follicular epithelial cells and colloid, mimicking minocycline-induced 'black thyroid'. In this case, however, the patient was not taking minocycline; instead the 'black thyroid' was attributed to the iodine-containing compound indocyanine green. Indocyanine green is a hereto unreported cause of 'black thyroid' with histopathologic features that are remarkably similar to that induced by minocycline. Indocyanine green should be included the differential diagnosis of 'black thyroid'. Clinical history is important so as not to raise concern for a disease process.

Temporary Black Henna Tattoos and Sensitization to para-Phenylenediamine (PPD): Two Paediatric Case Reports and a Review of the Literature

Background: The use of temporary henna tattoos has increased dramatically in recent years, especially in children and adolescents. To obtain a darker colour and prolong the life of the tattoo, red henna, a plant-derived substance, is typically added to para-phenylenediamine (PPD). The mixture is called temporary black henna tattoo (TBHT). Because of its molecular characteristics, PPD can induce skin sensitization that may cause various clinical manifestations with successive exposures, among which the most common is allergic contact dermatitis (ACD). This report describes two paediatric cases of PPD sensitization and ACD after the exposure to TBHT and summarizes the literature on this emerging clinical problem. Case Presentation: We describe two cases of childhood-onset ACD that occurred 2 and 10 days, respectively, after the application of a TBHT during the summer holidays. Patch tests showed an evident positive response to 1% PPD in both cases. Sensitization to PPD occurred in the first case because a previous henna tattoo did not result in overt symptoms; in the second case, the reaction occurred after the same tattoo was retouched. In both cases, hypopigmentation persisted and both the patients and their families were advised to avoid further contact with PPD-containing materials and substances that could lead to cross-reactions. Conclusions: Sensitization to PPD is a growing phenomenon in children. The most common cause appears to be exposure to TBHT in which PPD might be present at unknown or high concentrations. Once sensitization occurs, patients may experience severe clinical symptoms which can present with a persistent hypopigmentation when they are re-exposed to substances that contain or cross-react with PPD. Given the widespread use of PPD, TBHT could adversely affect the daily life of paediatric patients; thus, for this reason, this practice as a fashion accessory must be discouraged. In addition, it is extremely important to provide scientific information on the risks of TBHT to consumers, especially to adolescents and to the parents of younger children to prevent PPD sensitization.

Green Urine in Traditional Persian Medicine: Differential Diagnosis and Clinical Relevance

The color of urine is an important factor in urine examination, which can help physicians differentiate various diseases. Today, it is known that certain dyes, drug intoxications, and diseases can induce green urine discoloration. In the view of traditional Persian medicine, which is based on humoral medicine, green urine discoloration is generally referred to the dominance of coldness in the body. In fact, it is considered to be a result of a special kind of humoral imbalance and fluid depletion or retention in the human body. Persian scholars believed that green urine could be an indicator of intoxication or a predictor of an imminent spasm or convulsion in pediatric patients. Further investigations could result in finding new diagnostic scales of urine color based on the teachings of traditional Persian medicine.