Case and Research Letters
Sarcoid-type Allergic Contact Granuloma Caused by Earrings in a Boy
Granuloma alérgico de contacto tipo sarcoideo por pendientes en un niño
R. González-Pérez
, G. Ruiz-Carrillo, R. Soloeta
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Servicio de Dermatología, Hospital Santiago Apóstol, Vitoria, Spain
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Rosende, J. del Pozo, A. de Andrés, L. Pérez Varela" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Rosende" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "del Pozo" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "de Andrés" ] 3 => array:2 [ "nombre" => "L." 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González-Pérez, G. Ruiz-Carrillo, R. Soloeta" "autores" => array:3 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "González-Pérez" "email" => array:1 [ 0 => "RICARDO.GONZALEZPEREZ@osakidetza.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Ruiz-Carrillo" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Soloeta" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Santiago Apóstol, Vitoria, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Granuloma alérgico de contacto tipo sarcoideo por pendientes en un niño" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 654 "Ancho" => 949 "Tamanyo" => 75299 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sensitization to palladium, platinum, mercury, and ammonium tetrachloroplatinate.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The formation of cutaneous sarcoid-type allergic contact granuloma is rare and was first reported by Mann et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> over 20 years ago in a patient who used gold earrings. We recently studied the case of a child who developed a sarcoid-type allergic contact granuloma on the ear after wearing several earrings containing a range of metals including palladium.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient, an 11-year-old boy with no relevant medical history, visited his pediatrician in January 2008 with an asymptomatic papule on the lobe of his left ear. The papule had appeared 3 years earlier, specifically 3 months after the boy had started wearing an earring. The lesion was removed in the general surgery department and the patient was referred to our department with a histology report describing a “sarcoidal granulomatous infiltration with no evidence of refringent material in the sample” (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Physical examination revealed a papule with residual scarring on the lobe of the left ear but there were no other relevant mucocutaneous or systemic findings. A chest radiograph and laboratory tests, including angiotensin-converting enzyme and serum and urine calcium measurements, ruled out systemic sarcoidosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Skin patch tests were performed using the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) (T.R.U.E. TEST; Mekos Laboratories), additional allergens from Chemotechnique Diagnostics, and a series of 33 metal allergens provided by Marti Tor. Readings were performed at 48, 96, and 168<span class="elsevierStyleHsp" style=""></span>hours. At 168<span class="elsevierStyleHsp" style=""></span>hours (day 7), positive reactions were observed for palladium chloride (++), platinum chloride (++), ammonium tetrachloroplatinate (++), and mercury (++). In all cases, the lesions had an eczematous appearance (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Inductively coupled plasma mass spectrometry (ICP-MS) was used to determine the metal content of the 3 earrings (M1, M2, and M3) brought in by the patient (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The main component in all 3 earrings, including the one that had triggered the initial skin reaction (M1), was palladium. Based on these results, we established a diagnosis of allergic contact granuloma due to palladium.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient had 2 positive reactions on his back when examined 3 months later. The first was a persistent reaction to the palladium chloride patch. The lesion no longer had an eczematous appearance and was firm on palpation, suggesting granulomatous infiltration. Biopsy was not possible, however, as the parents withheld their consent. The second reaction was similar to the first and was located at the site of the beryllium patch, which had tested negative on day 7. The reaction was interpreted as an active sensitization. The patient had stopped wearing earrings and no recurrent lesions were identified, either on the ear lobes or at other sites. Further examination was not possible as the patient did not return for any of the scheduled follow-up visits.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Since the European Nickel Directive came into force on July 2001 limiting the amount of nickel that can be used in jewelry or released during its use, the availability of so-called safe earrings has become widespread. While these earrings contain little or no nickel they do contain other metals.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> ICP-MS analysis of the earrings brought in by the patient revealed the presence of expected metals, such as palladium, but it also showed unexpected metals that could, in the future, cause unknown or potentially dangerous adverse reactions. One example is gadolinium, which was detected in all 3 earrings, and in 1 of them, in considerable concentrations.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Among other allergens, our patient was sensitized to palladium and platinum, but not to nickel. Because mass spectrometry showed that the earring that had triggered the initial reaction (M1) contained palladium as a major component and did not contain platinum, our final diagnosis was allergic contact granuloma due to palladium. The positive reaction to platinum was interpreted as a concomitant or cross-reaction with palladium, as both metals are in the same group in the periodic table.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Apart from palladium, numerous metals (and sources of exposure) have been implicated in granulomatous allergic contact dermatitis. These include beryllium (mining, fluorescent lighting tube and beryllium alloy production); aluminium (adjuvant in vaccines and hyposensitization extracts, deodorants, and tattoos); zirconium (deodorants); titanium (pacemakers); nickel (sternotomy suture material); mercury, chromium, and cobalt (mainly tattoos).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Sensitization to palladium generally manifests as eczema, but on rare occasions it can trigger the formation of sarcoid-type granulomas due to a type IV hypersensitivity reaction. Like other authors,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> we believe that this granulomatous reaction is related to individual factors rather than to the nature of the metal and is probably an indication that individuals sensitized to the metal have a genetic predisposition that eventually induces a cytokine release pattern that favors the recruitment of macrophages, thereby resulting in the formation of a granuloma rather than the appearance of eczema. Consequently, such individuals, just like patients who develop sarcoid-type granulomas and/or sarcoidosis following several tattoos, might constitute a risk group for systemic sarcoidosis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">On reviewing the literature, we found just 7 cases of contact allergic granuloma due to palladium in earrings; in 4 of these there was co-sensitization to nickel,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7–10</span></a> which was not the case with our patient. Finally, our patient was the youngest of all the patients described in these reports, reflecting perhaps the increasing influence and popularity of piercing in young children.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: González-Perez R, et al. Granuloma alérgico de contacto tipo sarcoideo por pendiente en un niño. Actas Dermosifiliogr. 2012;103:73–4.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 713 "Ancho" => 950 "Tamanyo" => 197955 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sarcoid-type granulomatous inflammation (hematoxylin–eosin staining, original magnification ×10).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 654 "Ancho" => 949 "Tamanyo" => 75299 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sensitization to palladium, platinum, mercury, and ammonium tetrachloroplatinate.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Earrings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Major Components \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Minor Components \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cu, Pb, Zn, Na, K, Fe, Al, Gd, Pd, Sn, Se, Au \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cr, Ni, W \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Au, Cu, Na, K, Ca, Fe, Al, Gd \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mg, Cr, Ni, Zn, Pd, Pb, Cd, W, Pt \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Au, Cu, Na, K, Ca, Fe, Al, Gd \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mg, Cr, Ni, Zn, Pd, Pb, Cd, W, Pt \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab181977.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara">Earring that triggered the initial reaction.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Metal Composition of Earrings Brought in by the Patient (Semiquantitative Analysis).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sarcoidal tissue reaction—another complication of ear piercing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.J. 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| año/Mes | Html | Total | |
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| 2021 Octubre | 69 | 58 | 127 |
| 2021 Septiembre | 55 | 43 | 98 |
| 2021 Agosto | 39 | 34 | 73 |
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| 2021 Marzo | 60 | 52 | 112 |
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| 2021 Enero | 25 | 26 | 51 |
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| 2020 Octubre | 18 | 20 | 38 |
| 2020 Septiembre | 30 | 20 | 50 |
| 2020 Agosto | 25 | 19 | 44 |
| 2020 Julio | 28 | 21 | 49 |
| 2020 Junio | 32 | 24 | 56 |
| 2020 Mayo | 14 | 22 | 36 |
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| 2020 Marzo | 32 | 18 | 50 |
| 2020 Febrero | 9 | 11 | 20 |
| 2020 Enero | 0 | 3 | 3 |
| 2019 Diciembre | 2 | 3 | 5 |
| 2019 Noviembre | 0 | 2 | 2 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 4 | 1 | 5 |
| 2019 Agosto | 0 | 1 | 1 |
| 2019 Julio | 0 | 3 | 3 |
| 2019 Junio | 2 | 15 | 17 |
| 2019 Mayo | 0 | 32 | 32 |
| 2019 Abril | 0 | 2 | 2 |
| 2019 Marzo | 2 | 7 | 9 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 0 | 3 | 3 |
| 2018 Agosto | 0 | 4 | 4 |
| 2018 Julio | 0 | 4 | 4 |
| 2018 Junio | 0 | 6 | 6 |
| 2018 Mayo | 0 | 7 | 7 |
| 2018 Abril | 0 | 4 | 4 |
| 2018 Marzo | 2 | 3 | 5 |
| 2018 Febrero | 70 | 3 | 73 |
| 2018 Enero | 66 | 14 | 80 |
| 2017 Diciembre | 72 | 11 | 83 |
| 2017 Noviembre | 45 | 18 | 63 |
| 2017 Octubre | 64 | 11 | 75 |
| 2017 Septiembre | 84 | 18 | 102 |
| 2017 Agosto | 108 | 12 | 120 |
| 2017 Julio | 110 | 11 | 121 |
| 2017 Junio | 114 | 15 | 129 |
| 2017 Mayo | 109 | 13 | 122 |
| 2017 Abril | 99 | 22 | 121 |
| 2017 Marzo | 85 | 9 | 94 |
| 2017 Febrero | 47 | 11 | 58 |
| 2017 Enero | 50 | 17 | 67 |
| 2016 Diciembre | 65 | 16 | 81 |
| 2016 Noviembre | 114 | 14 | 128 |
| 2016 Octubre | 100 | 18 | 118 |
| 2016 Septiembre | 143 | 22 | 165 |
| 2016 Agosto | 147 | 7 | 154 |
| 2016 Julio | 51 | 16 | 67 |
| 2016 Junio | 10 | 12 | 22 |
| 2016 Mayo | 5 | 9 | 14 |
| 2016 Abril | 7 | 17 | 24 |
| 2016 Marzo | 9 | 17 | 26 |
| 2016 Febrero | 3 | 19 | 22 |
| 2016 Enero | 7 | 1 | 8 |
| 2015 Diciembre | 5 | 3 | 8 |
| 2015 Noviembre | 21 | 10 | 31 |
| 2015 Octubre | 12 | 3 | 15 |
| 2015 Septiembre | 9 | 1 | 10 |
| 2015 Agosto | 9 | 2 | 11 |
| 2015 Julio | 101 | 12 | 113 |
| 2015 Junio | 81 | 8 | 89 |
| 2015 Mayo | 115 | 13 | 128 |
| 2015 Abril | 113 | 8 | 121 |
| 2015 Marzo | 67 | 7 | 74 |
| 2015 Febrero | 67 | 11 | 78 |
| 2015 Enero | 74 | 16 | 90 |
| 2014 Diciembre | 94 | 10 | 104 |
| 2014 Noviembre | 58 | 13 | 71 |
| 2014 Octubre | 90 | 18 | 108 |
| 2014 Septiembre | 74 | 21 | 95 |
| 2014 Agosto | 70 | 15 | 85 |
| 2014 Julio | 79 | 20 | 99 |
| 2014 Junio | 70 | 11 | 81 |
| 2014 Mayo | 78 | 18 | 96 |
| 2014 Abril | 61 | 11 | 72 |
| 2014 Marzo | 71 | 20 | 91 |
| 2014 Febrero | 54 | 18 | 72 |
| 2014 Enero | 61 | 16 | 77 |
| 2013 Diciembre | 28 | 5 | 33 |
| 2013 Noviembre | 17 | 12 | 29 |
| 2013 Octubre | 16 | 11 | 27 |
| 2013 Septiembre | 13 | 9 | 22 |
| 2013 Agosto | 11 | 35 | 46 |
| 2013 Julio | 13 | 16 | 29 |
| 2013 Junio | 8 | 13 | 21 |
| 2013 Mayo | 14 | 9 | 23 |
| 2013 Abril | 17 | 10 | 27 |
| 2013 Marzo | 16 | 16 | 32 |
| 2013 Febrero | 28 | 7 | 35 |
| 2013 Enero | 45 | 6 | 51 |
| 2012 Diciembre | 20 | 5 | 25 |
| 2012 Noviembre | 0 | 1 | 1 |
| 2012 Octubre | 0 | 1 | 1 |
| 2012 Agosto | 2 | 0 | 2 |
| 2012 Julio | 1 | 0 | 1 |
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