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• W2133304606 abstract "To the Editor: A 31-year-old woman presented with a solitary, blue-gray papule on the medial aspect of her right elbow that clinically resembled a blue nevus. She had a family history of malignant melanoma in her mother, but no personal history of atypical nevi or malignancy. A punch biopsy was performed. On histologic examination, elastic and collagen fibers within the mid dermis appeared to be coated by fine, brown-black granules (Fig 1, A). Immediately deep to these fibers, histiocytes formed an ill-defined nodule. Brown-black granules were also identified within the cytoplasm of these histiocytes and coated the basement membrane of adjacent eccrine sweat glands (Fig 1, B). The histiocytes surrounded fragments of a crystalline material that resembled silica on polarized light examination (Fig 1, C). Dark-field microscopy highlighted the brown-black granules, confirming their mineral nature (Fig 2, A). Scanning electron microscopy with energy-dispersive spectroscopy demonstrated small, regular granules adherent to elastic and collagen fibers and showed that the granules were composed of silver and copper with admixed silica (Fig 2, B and C).Fig 2A, Dark field microscopy reveals small, white, refractile granules deposited on elastic and collagen fibers. B, Scanning electron microscopy demonstrates small particles on elastic and collagen fibers. C, Energy-dispersive spectroscopy identifies the particles as minute fragments of silver and copper and confirms admixed silica. (A, Hematoxylin-eosin stain; B and C, unstained slides; original magnifications: A, ×400; B, ×1500.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Scanning electron microscopy with energy-dispersive spectroscopy is a useful tool in the evaluation of chemical elements within skin biopsies; it bombards the tissue with electrons, creating an image based on electron scatter and identifying elements based on unique and characteristic patterns of emitted x-rays. This technique has been critical in identifying the relationship between gadolinium and nephrogenic systemic fibrosis.1High W.A. Ayers R.A. Chandler J. Zito G. Cowper S.E. Gadolinium is detectable within the tissue of patients with nephrogenic systemic fibrosis.J Am Acad Dermatol. 2007; 56: 21-26Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar The combination of heavy metals and silica identified in the patient's biopsy specimen is compatible with the constituents of a mirror. On further discussion, the patient reported a recent, severe motor vehicle accident with damage to the driver's side rear-view mirror and window. Although she did not recall mirror fragments entering her skin, the patient noted that window and mirror fragments surrounded her in the car and that she had close contact with both. Moreover, she had no other reasonable explanation for the clinical and histologic findings.Argyria is rare, particularly since the discontinuation of silver-containing medications. However, heavy metals including silver may be inadvertently introduced into the skin through occupational exposures, acupuncture, earrings, topical silver medications, and trauma, among other causes.2Robinson-Bostom L. Pomerantz D. Wilkel C. Mader R. Lerner L. Dufresne R. et al.Localized argyria with pseudo-ochronosis.J Am Acad Dermatol. 2002; 46: 222-227Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 3Kapur N. Landon G. Yu R.C. Localized argyria in an antique restorer.Br J Dermatol. 2001; 144: 191-192Crossref PubMed Scopus (22) Google Scholar Argyria leads to a focal, gray discoloration that clinically resembles a melanocytic proliferation.2Robinson-Bostom L. Pomerantz D. Wilkel C. Mader R. Lerner L. Dufresne R. et al.Localized argyria with pseudo-ochronosis.J Am Acad Dermatol. 2002; 46: 222-227Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 3Kapur N. Landon G. Yu R.C. Localized argyria in an antique restorer.Br J Dermatol. 2001; 144: 191-192Crossref PubMed Scopus (22) Google Scholar, 4Utikal J. Thoelke A. Becker J.C. Figl R. Goerdt S. Schadendorf D. et al.Local cutaneous argyria mimicking melanoma metastases in a patient with disseminated melanoma.J Am Acad Dermatol. 2006; 55: S92-S94Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As seen here, the collagen fibers may be prominently coated with silver granules, leading to a pseudo-ochronosis appearance.2Robinson-Bostom L. Pomerantz D. Wilkel C. Mader R. Lerner L. Dufresne R. et al.Localized argyria with pseudo-ochronosis.J Am Acad Dermatol. 2002; 46: 222-227Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar In this case, scanning electron microscopy with energy-dispersive spectroscopy helped to identify the elements within the patient's skin and explain the pigmented lesion. To our knowledge, there have been no prior reports of cutaneous argyria from traumatically induced mirror fragments, which may reflect the relatively rare use of scanning electron microscopy with energy dispersive spectroscopy in skin biopsies (per review of PubMed, Weedon [3rd edition, 2010] and Lever [10th edition, 2009]). To the Editor: A 31-year-old woman presented with a solitary, blue-gray papule on the medial aspect of her right elbow that clinically resembled a blue nevus. She had a family history of malignant melanoma in her mother, but no personal history of atypical nevi or malignancy. A punch biopsy was performed. On histologic examination, elastic and collagen fibers within the mid dermis appeared to be coated by fine, brown-black granules (Fig 1, A). Immediately deep to these fibers, histiocytes formed an ill-defined nodule. Brown-black granules were also identified within the cytoplasm of these histiocytes and coated the basement membrane of adjacent eccrine sweat glands (Fig 1, B). The histiocytes surrounded fragments of a crystalline material that resembled silica on polarized light examination (Fig 1, C). Dark-field microscopy highlighted the brown-black granules, confirming their mineral nature (Fig 2, A). Scanning electron microscopy with energy-dispersive spectroscopy demonstrated small, regular granules adherent to elastic and collagen fibers and showed that the granules were composed of silver and copper with admixed silica (Fig 2, B and C). Scanning electron microscopy with energy-dispersive spectroscopy is a useful tool in the evaluation of chemical elements within skin biopsies; it bombards the tissue with electrons, creating an image based on electron scatter and identifying elements based on unique and characteristic patterns of emitted x-rays. This technique has been critical in identifying the relationship between gadolinium and nephrogenic systemic fibrosis.1High W.A. Ayers R.A. Chandler J. Zito G. Cowper S.E. Gadolinium is detectable within the tissue of patients with nephrogenic systemic fibrosis.J Am Acad Dermatol. 2007; 56: 21-26Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar The combination of heavy metals and silica identified in the patient's biopsy specimen is compatible with the constituents of a mirror. On further discussion, the patient reported a recent, severe motor vehicle accident with damage to the driver's side rear-view mirror and window. Although she did not recall mirror fragments entering her skin, the patient noted that window and mirror fragments surrounded her in the car and that she had close contact with both. Moreover, she had no other reasonable explanation for the clinical and histologic findings. Argyria is rare, particularly since the discontinuation of silver-containing medications. However, heavy metals including silver may be inadvertently introduced into the skin through occupational exposures, acupuncture, earrings, topical silver medications, and trauma, among other causes.2Robinson-Bostom L. Pomerantz D. Wilkel C. Mader R. Lerner L. Dufresne R. et al.Localized argyria with pseudo-ochronosis.J Am Acad Dermatol. 2002; 46: 222-227Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 3Kapur N. Landon G. Yu R.C. Localized argyria in an antique restorer.Br J Dermatol. 2001; 144: 191-192Crossref PubMed Scopus (22) Google Scholar Argyria leads to a focal, gray discoloration that clinically resembles a melanocytic proliferation.2Robinson-Bostom L. Pomerantz D. Wilkel C. Mader R. Lerner L. Dufresne R. et al.Localized argyria with pseudo-ochronosis.J Am Acad Dermatol. 2002; 46: 222-227Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 3Kapur N. Landon G. Yu R.C. Localized argyria in an antique restorer.Br J Dermatol. 2001; 144: 191-192Crossref PubMed Scopus (22) Google Scholar, 4Utikal J. Thoelke A. Becker J.C. Figl R. Goerdt S. Schadendorf D. et al.Local cutaneous argyria mimicking melanoma metastases in a patient with disseminated melanoma.J Am Acad Dermatol. 2006; 55: S92-S94Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As seen here, the collagen fibers may be prominently coated with silver granules, leading to a pseudo-ochronosis appearance.2Robinson-Bostom L. Pomerantz D. Wilkel C. Mader R. Lerner L. Dufresne R. et al.Localized argyria with pseudo-ochronosis.J Am Acad Dermatol. 2002; 46: 222-227Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar In this case, scanning electron microscopy with energy-dispersive spectroscopy helped to identify the elements within the patient's skin and explain the pigmented lesion. To our knowledge, there have been no prior reports of cutaneous argyria from traumatically induced mirror fragments, which may reflect the relatively rare use of scanning electron microscopy with energy dispersive spectroscopy in skin biopsies (per review of PubMed, Weedon [3rd edition, 2010] and Lever [10th edition, 2009])." @default.
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