Total Hip Arthroplasty (THA) is a highly effective surgical treatment for severe joint involvement. However, due to the release of metal ions in the blood, the patients undergoing hip replacement with metal-on-metal (MOM) bearings may develop signs of allergic skin disease. We report a case of a 60-year-old man who had received MOM hip resurfacing (HR) five years earlier for osteoarthritis and presented with a 3-year history of diffuse dermatitis not responding to antihistamines and corticosteroids and elevated serum levels of chromium and cobalt. A patch test revealed chromium-sulfate hypersensitivity. Skin biopsy showed nonspecific perivascular lymphocytic infiltrate associated with histiocytes. Biopsy of an inguinal lymph node demonstrated large aggregates of Langerhans cells, suggesting type IV delayed-type hypersensitivity. Three months following replacement of the prosthesis using ceramic-on-ceramic bearings the dermatitis resolved. Lymph nodes decreased in volume and serum chromium normalized 24 months after revision surgery. The high levels of serum ions associated with the metal debris from MOM-THAs may induce sensitization and type IV hypersensitivity reactions. Only replacement of the prosthesis using alternative coupling surfaces may definitely solve the symptoms. Physicians who are not familiar with this issue may misdiagnose systemic symptoms and lack adequate treatment. Total hip arthroplasty (THA) is a standard successful treatment for symptomatic osteoarthritis of the hip joint.1 Metal-on-metal (MOM) hip resurfacing (HR) has been developed as an alternative to conventional THA in younger and active patients, with comparable long-termoutcomes.2 However, all MOM bearings implants corrode and cause a release of metal ions in the blood. The prevalence of metal sensitivity among the general population is approximately 10% to 15%, with sensitivity to cobalt and chromium of 3%.3 Many concerns still remain regarding the effects of prolonged exposure to increased metal ion levels: hypersensitivity, carcinogenicity, aseptic lymphocyte-dominated vasculitis-associated lesion and pseudotumor formation.3 Allergic dermatitis and reactive histiocytosis caused by orthopedic implants are well-known.4 To date, and to the best of our knowledge, diffuse dermatitis and associated lymph node involvement by Langerhans cell histiocytosis after MOM-HR have not been described.
Chromium-induced diffuse dermatitis and lymph node involvement by Langerhans cell histiocytosis after metal-on-metal hip resurfacing.
ZAMO', Alberto
2015-01-01
Abstract
Total Hip Arthroplasty (THA) is a highly effective surgical treatment for severe joint involvement. However, due to the release of metal ions in the blood, the patients undergoing hip replacement with metal-on-metal (MOM) bearings may develop signs of allergic skin disease. We report a case of a 60-year-old man who had received MOM hip resurfacing (HR) five years earlier for osteoarthritis and presented with a 3-year history of diffuse dermatitis not responding to antihistamines and corticosteroids and elevated serum levels of chromium and cobalt. A patch test revealed chromium-sulfate hypersensitivity. Skin biopsy showed nonspecific perivascular lymphocytic infiltrate associated with histiocytes. Biopsy of an inguinal lymph node demonstrated large aggregates of Langerhans cells, suggesting type IV delayed-type hypersensitivity. Three months following replacement of the prosthesis using ceramic-on-ceramic bearings the dermatitis resolved. Lymph nodes decreased in volume and serum chromium normalized 24 months after revision surgery. The high levels of serum ions associated with the metal debris from MOM-THAs may induce sensitization and type IV hypersensitivity reactions. Only replacement of the prosthesis using alternative coupling surfaces may definitely solve the symptoms. Physicians who are not familiar with this issue may misdiagnose systemic symptoms and lack adequate treatment. Total hip arthroplasty (THA) is a standard successful treatment for symptomatic osteoarthritis of the hip joint.1 Metal-on-metal (MOM) hip resurfacing (HR) has been developed as an alternative to conventional THA in younger and active patients, with comparable long-termoutcomes.2 However, all MOM bearings implants corrode and cause a release of metal ions in the blood. The prevalence of metal sensitivity among the general population is approximately 10% to 15%, with sensitivity to cobalt and chromium of 3%.3 Many concerns still remain regarding the effects of prolonged exposure to increased metal ion levels: hypersensitivity, carcinogenicity, aseptic lymphocyte-dominated vasculitis-associated lesion and pseudotumor formation.3 Allergic dermatitis and reactive histiocytosis caused by orthopedic implants are well-known.4 To date, and to the best of our knowledge, diffuse dermatitis and associated lymph node involvement by Langerhans cell histiocytosis after MOM-HR have not been described.
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