Case report Cutaneous argyria after acupuncture Localized cuta,ieous argyria in fhe ear after slwrt-contact acupuncture F.J. Legat, W. Goessler, C. Schlagenhaufen and H.P. Soyer SuMMARY We report a unique case of localized cutaneous argyria in the ear of a 39-year-old woman, which developed after short-contact acupuncture. The woman presented with a blue-black macule in the skin of her left ear. The macule was 2 mm in diameter and had a smooth unaltered surface. A dermatologist suggested the diagnosis of a blue nevus and excised the lesion by punch biopsy to rule out melanoma. Histopathologic examination of the biopsy specimen revealed, in the connective tissue, a brown-black fusiform particle encapsulated by dense collagen fibres. In the surrounding dermis, numerous brown- black granules were found. The analysis of the chemical nature of the granules in an unstained paraffin section was performed by a laser microprobe mass analyzer and determined the presence of silver in the tissue section. 20 years ago, our patient had undergone five sessions of short contact acupuncture in her ears because of lumbalgia. 1 O years later, she noticed the blue-black macule in her left ear. We believe that during one of the short sessions of ear acupuncture, a small particle of a silver needle might accidentally have been deposited. This small silver particle then, over the years, could have led to the development of localized cutaneous argyria presenting as a blue-black macule in the skin of the left ear of the patient. Introduction Argyria, systemic or localized, develops after silver deposition in the tissues. White systemic argyria is caused by iatrogenic or occupational intake of silver via the gastrointestinal or the respiratory tract, localized cutaneous argyria results from localized exposure of the skin to silver. Previous reports describe localized argyria, which developed after the skin had been in long contact with silver. Thus, localized argyria has been attributed to deliberate or accidental implantatiori of acupuncture needles (1,2), silver jewellery (3,4) or silver suture material (5), or to the topical application of silver sulpha- diazine cream to burned skin (6). We describe here the case of a 39-year-old woman who noticed localized cutaneous argyria on her left ear acta dermatovenerologica A.P.A. Vol 8, 99, No 4 ------------------------------ 14J Cutaneous argyria after acupuncture ten years after she had undergone five sessions of acupuncture in her ears because of lumbalgia. Each of the five acupuncture sessions had lasted not longer than 30 minutes and no acupuncture needle had ever been left in the skin for a longer period of tirne. Part of this work has been presented in the corre- spondence section of Lancet (7). Case report A 39-year-old woman presented with a well circum- scribed, blue-black macule in the skin of her left ear. The macule was 2 mm in diameter, had a smooth unaltered surface, and was situated at the site w here the crura anthelices unite to form the anthelix (Figure 1). The blue-black colour of the macule was slightly less intense in the periphe1y of the macule. A dermatologist suggested the diagnosis of blue nevus and excised the lesion by punch biopsy to rule out melanoma. Conventional histopathologic examination of the HE-stained biopsy specimen revealed a dense, brown- black fusiform particle, about 75 pm in length, in the connective tissue near the outer surface of the auricular cartilage (Figure 2) . This particle was encapsulated by dense collagen fibres. In the surrounding dermis, numerous brown-black granules, mainly located around blood vessels, nerve fibres , and sebaceous glands, were found. At higher magnification numerous brown-black granules were detected within the wall of blood vessels (Figure 3a). In polarized light the granules had refractile properties (Figure 3b). The chemical nature of the granules was analyzed by a laser rnicroprobe mass analyzer (LAMMA 500®, Leybold Heraeus GmbH, Cologne, Germany) which ex- cites microvolumes of a sample to an ionized state by a focused laser beam (Nd:YAG-laser with a wavelength of 266 nm); the ions produced are detected by a time- to-flight mass spectrometer (8) . In an unstained paraffin section a representative area, showing brown-black granules in the HE-stained specirnen, was brought into focus of the laser beam and irradiated. The resulting mass spectrum showed clear signals for the two naturally occurring silver isotopes at m/ e (mass over electron charge) 107 and m/ e 109 thus proving that silver was present in the tissue section (Figure 4). Discussion Localized cutaneous argyria presenting clinically as a pigmented lesion resembling a b lue nevus or a malignant melanoma bas already been published in the li terature far severa! times. The embedding of the backing of silver ear-rings C 4), the usage of sil ver suture 146 Figure 1. Blue-black macule in the left ear of a 39-year-old woman. The macule was noticed 1 O years after short-contact ear acupuncture with silver needles at this site. Figure 2. Histopathology, HE-staining, 1 OOx: A brown-black, fusiform particle in the dermis adjacent to the auricular cartilage. The particle is encapsulated by dense collagen fibres. In the surrounding connective tissue numerous brown-black granules are visible. Case report acta dermatovenerologica A.PA. Vol 8, 99, No 4 Case report Figure 3. Histopathology, HE-staining, 250x: a) Numerous brown-black granules within the wall of a blood vessel. b) Refractile nature of the granules in polarized light. material (5) and the prolonged implantation of silver acupuncture needles into the skin for severa! reasons (1,2) have been reported to cause localized cutaneous argyria. In these cases localized argyria developed one to 30 years after the onset of the exposure to silver. Remarkably, in all these instances the skin had been in continuous contact with material containing silver for long periods of tirne. Our patient noticed the blue-black macule in her left ear, 10 years after she had undergone only five sessions of short-contact acupuncture in her ears be- cause of lumbalgia. Her acupuncture sessions had lasted Cutaneous argyria after acupuncture LAMMA mass spectrum , .. ,,. ... i;> ·;; " ... s.s 100 ,. Figure 4. LAMMA 5000 mass spectrum: The two naturally occurring silver isotopes at m/e {mass over electron charge) 1 07 and m/e 109 proved the irradiated specimen to contain silver. not longer than 30 minutes each. Thus, the needles had been in contact with the tissue for not longer than 3 hours, which would certainly be too short a tirne to induce localized argyria by the acupuncture needles themselves. However, the blue-black macule was loca- ted at exactly the site of acupuncture, and she did not wear silver jewellery at that site. We believe that during the short sessions of acu- puncture, a small particle of a silver needle might accidentally have been deposited. This small silver par- ticle then, over the years, could have led to the deve- lopment of localized cutaneous argyria presenting as a blue-black macule in the skin of the left ear of the woman. The brown-black fusiform particle, 75 µm in length, in the connective tissue near the outer surface of the auricular ca1tilage found by conventional histo- pathologic examination strongly underlines this hypo- thesis. Extensive exposure of the ears to natura! sunlight could have supported the development of localized argyria after deposition of the small sil ver particle in the ear following acupuncture. It bas been reported previo- usly that sunlight is a trigger for the induction of the pigment in argyria , with photo-reduction of silver com- pounds to elementa! silver as the pathway (9). In localized or generalized cutaneous argyria the refractile brown-black granules in the dermis of a biopsy specimen can be found easily by conventional micro- scopy. Asa rule, the granules are situated mainly around blood vessels, nerve fibres, hair follicles and sebaceous glands. The chemical nature of these granules, however, is more difficult to analyze ancl requires particular methods. In argyria , X-ray microanalysis (10), X-ray fluorescence spectroscopy (11) and neutron activation analysis (12) of specific granules in the dermis have previously been used to prove the granules to contain silver. acta dermatovenerologica A.P.A. Vol 8, 99, No 4 -------------------- ------------ 147 Cutaneous argyria C1fter acupuncture So far, a laser microprobe mass analyzer has not been used to determine the chemical nature of sil ver granules in paraffin-embedded sections of localized cutaneous argyria. The laser microprobe mass analyzer LAMMA 500® is a powerful tool for the qualitative analysis of exogenous inorganic deposits in thin biopsy sections. It is especially useful when these deposits are available only in very small amounts, since the absolute detection limits of the LAMMA 500® are in the range of 10·16 to 10-19 g. The analysis can be performed, without tirne consuming pre-processing, in stained or unstained tissue sections mounted on foiled electron microscopy grids made from copper. Through the microscope of the LAMMA 500® the area of interest can be focused accurately by a red He-Ne-laser before the sample is evaporated and excited by a Nd:YAG-laser beam. The smallest area, which can be analyzed, is approximately 5 pm in diameter. The disadvantage ofthe LAMMA 500® is that only semi-quantitative results can be obtained. However, the primary interest in the analysis of inorganic deposits in tissue samples mostly lies in a qualitative rather than quantitative analysis of the samples. In conclusion, we report a unique case of localized cutaneous argyria presenting as a small blue-black macule on the left ear of a 39-year-old woman 10 years after short-contact ear acupuncture. The diagnosis was suggested by conventional microscopy and was con- firmed with a laser microprobe mass analyzer by the proof of silver in this lesion. AUTHORS' ADDRESSES l. Suzuki H, Baba S, Uchigasaki S, Murase M. Localized argyria with chrysiasis caused by implanted acupuncture needles. J Am Acad Dermatol 1993; 29: 833-7. 2. Tanita Y, Kato T, Hanada K, Tagami H. Bine macules oflocalized argyria caused byimplanted acupuncture needles. Arch Dermatol 1985; 121: 1550-2. 3. Shall L, Stevens A, Millard LG. An unusual case of acquired localized argyria. Br J Dermatol 1990; 123: 403-7. 4. Van den Nieuwenhuijsen IJ, Calame JJ, Bruynzeel DP. Localized argyria caused by silver earrings. Dermatologica 1988; 177: 189-91. 5. Wolff HH, NeubertU. Ungewoehnliches Bild einer lokalisierten Argyrose. Hautarzt 1977; 28: 668-70. 6. Depuis LL, Shear NH, Zuker RM. Hyperpigmentation dne to topical application of silver sulfadiazine cream. J Am Acad Dermatol 1985; 12: 1112-4. 7. Legat FJ, Goessler W, Schlagenhaufen C, Soyer HP. Argyria after short-contact acupuncture. Lancet 1998; 352: 241. 8. Van Vaeck L, Sruyf H, Van Roy W, Adams F. Organic and inorganic analysis with laser microprobe mass spectrometry. Part I: Instrumentation and Methodology. Mass Spectrom Rev, 1994; 13: 189-208. 9. Shelley WB, Shelley ED, Burmeister V. Argyria: The intradermal "photograph", a manifestation of passive photosensitivity. J Am Acad Dermatol 1987; 16: 211-7. 10. Bleehen SS, Gould DJ, Harrington CI, Durrant TE, Slater DN, Underwood JCE. Occupational argyria; light and electron microscopic studies and X-ray microanalysis. Br J Dermatol 1981; 104: 19-26. 11. Mittag H, KnechtJ, Arnold R, Huettich C, Rupec M. Zur Frage der Argyrie. Hautarzt 1987; 38: 670-7. 12. Schroepl F, Oehlschlaegel G, Drabner J. Schwermetallnachweis in der Haut bei Argyrose mittels Neutronenaktivierungsanalyse. Arch Ciin Exp Dermatol 1968; 231: 398-407. Franz J. Legat, MD, Department oj Dermatology, Karl-Franzens-University Graz,Auenbruggerplatz 8,A-8036 Graz,Austria Walter Goessler, PhD, InstitutejorAnalytical Chemistry, Karl-Franzens- University Graz, Universiti.itsplatz 1, A-801 O Graz, Austria Claudia Schlagenhaujen, PhD, same address H Peter Soye,; MD, Department oj Dermatology, Karl-Franzens-University Graz,Auenbruggerplatz 8,A-8036 Graz,Austria Case report 148 acta dermatovenerologica A.P.A. Vol 8, 99, No 4