PEARLS & ZEBRAS
Bullet Dermatitis: A Localized Cutaneous Hypersensitivity Reaction Michael Raisch, MD and Heather P. Lampel, MD, MPH PRECI´S There is a potential role for epicutaneous patch testing in patients with concomitant dermatitis and traumatically implanted foreign bodies.
DISCUSSION A 42-year-old woman presented with a recently developed rash on the back localized around a 20-year-old gunshot scar. Her only symptom was musculoskeletal pain in the general area of the eruption. In addition to reporting a retained bullet at her gunshot site, she noted a decades-long history of rash to ‘‘cheap jewelry.’’ On examination was a 5 7-cm annular, erythematous, indurated plaque on the left midback. Two well-healed scars were conspicuously located in the center of this lesion (Fig. 1). Potassium hydroxide preparation for dermatophytes was negative. Skin biopsy revealed an unremarkable epidermis overlying a superficial and deep lymphoplasmacytic dermal infiltrate. Giant cells, foci of calcification, and bone formation were also present. Given the patient’s reported allergy to metals, the location of the eruption at the gunshot site, and the histopathologic findings consistent with a foreign body reaction, a type IV hypersensitivity reaction was considered. Epicutaneous patch testing was performed with 128 allergens, including 42 metals. Of these, only nickel sulfate 2.5% petrolatum (pet), manganese (II) chloride 2% pet, gold sodium thiosulfate 0.5% pet, and vanadium (III) chloride 1% pet were positive. Lead acetate trihydrate 0.5% aqueous (aq) and lead chloride 0.2% aq were negative. Chest radiograph confirmed a metallic object in the soft tissues of the back adjacent to the eruption (Fig. 2). The bullet was excised without complication and sent for metallurgical analysis (Analytical Sciences, Petaluma, Calif ). It was composed of lead (81%), antimony (0.42%), copper (0.046%), and calcium (0.028%). No gold, nickel, manganese, or vanadium was detected. Three months thereafter, the patient reported the area of the rash was no longer erythematous or palpable, and her musculoskeletal pain had resolved. This case describes a localized reaction to a retained bullet with reported resolution after surgical excision. Patch testing revealed allergy to 4 metals, 2 of which (nickel and manganese) are plausible bullet components. A limitation of our study is the discordance between patch test results and metallic composition of the bullet. Address reprint requests to Michael Raisch, MD, Department of Dermatology, 40 Duke Medicine Circle #3K, Durham, NC 27701. E-mail: [email protected]. The authors have no funding or conflicts to declare. DOI: 10.1097/DER.0000000000000123 * 2015 American Contact Dermatitis Society. All Rights Reserved. 190
Figure 1. Two well-healed gunshot scars are located within the center of a 5 7-cm erythematous, indurated plaque located on the left midback.
Possible explanations include the absence of antimony in our allergen panel, failure of the lead-salt allergens of our panel to evoke an immune response, or sampling error of the bullet. In addition, it is unclear how accurately epicutaneous patch testing detects type IV sensitivity when the suspected hapten reaction is located in an extracutaneous site. Finally, a nonspecific foreign body reaction could have been generated, rather than a hypersensitivity reaction. Clinically, foreign body reactions are frequently erythematous, indurated, and located near the offending object. Histologically, a variety of inflammatory responses can develop. Our case displayed a granulomatous foreign body reaction, the commonest type of foreign body reaction. Similar findings have been reported in response to traumatically implanted metals.1,2 In addition, lichenoid and pseudolymphomatous reactions have developed to metalbased pigments in tattoos.1 Finally, eczematous reactions can
Figure 2. Posteroanterior and lateral chest radiographs showing colocalization of the patient’s dermatitis with the retained bullet. The yellow arrows mark the location of a skin marker used to locate the patient’s eruption. DERMATITIS, Vol 26 ¡ No 4 ¡ July/August, 2015
Copyright © 2015 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Pearls and Zebras ¡ Pearls and Zebras
occur, as illustrated by a case of a World War II veteran who developed swelling and erythema on the dorsum of the foot after being struck by shrapnel in 1944 (43 years prior to presentation).3
PEARL When evaluating patients with dermatitis and metallic foreign bodies, an extended metal panel is recommended; commercially available panels contain only nickel, cobalt, gold, and chromate.4
191
REFERENCES 1. Requena L, Cerroni L, Kutzner H. Histopathologic patterns associated with external agents. Dermatol Clin 2012;30(4):731Y748, vii. 2. Osawa R, Abe R, Inokuma D, et al. Chain saw blade granuloma: reaction to a deeply embedded metal fragment. Arch Dermatol 2006;142(8):1079Y1080. 3. Bruynzeel DP. Dermatitis from shell splinters after 43 years. Contact Dermatitis 1988;19(3):233Y235. 4. Davis MD, Wang MZ, Yiannias JA, et al. Patch testing with a large series of metal allergens: findings from more than 1,000 patients in one decade at Mayo Clinic. Dermatitis 2011;22(5):256Y271.
Copyright © 2015 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Bullet Dermatitis: A Localized Cutaneous Hypersensitivity Reaction Michael Raisch, MD and Heather P. Lampel, MD, MPH PRECI´S There is a potential role for epicutaneous patch testing in patients with concomitant dermatitis and traumatically implanted foreign bodies.
DISCUSSION A 42-year-old woman presented with a recently developed rash on the back localized around a 20-year-old gunshot scar. Her only symptom was musculoskeletal pain in the general area of the eruption. In addition to reporting a retained bullet at her gunshot site, she noted a decades-long history of rash to ‘‘cheap jewelry.’’ On examination was a 5 7-cm annular, erythematous, indurated plaque on the left midback. Two well-healed scars were conspicuously located in the center of this lesion (Fig. 1). Potassium hydroxide preparation for dermatophytes was negative. Skin biopsy revealed an unremarkable epidermis overlying a superficial and deep lymphoplasmacytic dermal infiltrate. Giant cells, foci of calcification, and bone formation were also present. Given the patient’s reported allergy to metals, the location of the eruption at the gunshot site, and the histopathologic findings consistent with a foreign body reaction, a type IV hypersensitivity reaction was considered. Epicutaneous patch testing was performed with 128 allergens, including 42 metals. Of these, only nickel sulfate 2.5% petrolatum (pet), manganese (II) chloride 2% pet, gold sodium thiosulfate 0.5% pet, and vanadium (III) chloride 1% pet were positive. Lead acetate trihydrate 0.5% aqueous (aq) and lead chloride 0.2% aq were negative. Chest radiograph confirmed a metallic object in the soft tissues of the back adjacent to the eruption (Fig. 2). The bullet was excised without complication and sent for metallurgical analysis (Analytical Sciences, Petaluma, Calif ). It was composed of lead (81%), antimony (0.42%), copper (0.046%), and calcium (0.028%). No gold, nickel, manganese, or vanadium was detected. Three months thereafter, the patient reported the area of the rash was no longer erythematous or palpable, and her musculoskeletal pain had resolved. This case describes a localized reaction to a retained bullet with reported resolution after surgical excision. Patch testing revealed allergy to 4 metals, 2 of which (nickel and manganese) are plausible bullet components. A limitation of our study is the discordance between patch test results and metallic composition of the bullet. Address reprint requests to Michael Raisch, MD, Department of Dermatology, 40 Duke Medicine Circle #3K, Durham, NC 27701. E-mail: [email protected]. The authors have no funding or conflicts to declare. DOI: 10.1097/DER.0000000000000123 * 2015 American Contact Dermatitis Society. All Rights Reserved. 190
Figure 1. Two well-healed gunshot scars are located within the center of a 5 7-cm erythematous, indurated plaque located on the left midback.
Possible explanations include the absence of antimony in our allergen panel, failure of the lead-salt allergens of our panel to evoke an immune response, or sampling error of the bullet. In addition, it is unclear how accurately epicutaneous patch testing detects type IV sensitivity when the suspected hapten reaction is located in an extracutaneous site. Finally, a nonspecific foreign body reaction could have been generated, rather than a hypersensitivity reaction. Clinically, foreign body reactions are frequently erythematous, indurated, and located near the offending object. Histologically, a variety of inflammatory responses can develop. Our case displayed a granulomatous foreign body reaction, the commonest type of foreign body reaction. Similar findings have been reported in response to traumatically implanted metals.1,2 In addition, lichenoid and pseudolymphomatous reactions have developed to metalbased pigments in tattoos.1 Finally, eczematous reactions can
Figure 2. Posteroanterior and lateral chest radiographs showing colocalization of the patient’s dermatitis with the retained bullet. The yellow arrows mark the location of a skin marker used to locate the patient’s eruption. DERMATITIS, Vol 26 ¡ No 4 ¡ July/August, 2015
Copyright © 2015 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Pearls and Zebras ¡ Pearls and Zebras
occur, as illustrated by a case of a World War II veteran who developed swelling and erythema on the dorsum of the foot after being struck by shrapnel in 1944 (43 years prior to presentation).3
PEARL When evaluating patients with dermatitis and metallic foreign bodies, an extended metal panel is recommended; commercially available panels contain only nickel, cobalt, gold, and chromate.4
191
REFERENCES 1. Requena L, Cerroni L, Kutzner H. Histopathologic patterns associated with external agents. Dermatol Clin 2012;30(4):731Y748, vii. 2. Osawa R, Abe R, Inokuma D, et al. Chain saw blade granuloma: reaction to a deeply embedded metal fragment. Arch Dermatol 2006;142(8):1079Y1080. 3. Bruynzeel DP. Dermatitis from shell splinters after 43 years. Contact Dermatitis 1988;19(3):233Y235. 4. Davis MD, Wang MZ, Yiannias JA, et al. Patch testing with a large series of metal allergens: findings from more than 1,000 patients in one decade at Mayo Clinic. Dermatitis 2011;22(5):256Y271.
Copyright © 2015 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
