CASE REPORT

Orthopaedic Implant Hypersensitive

Introduction Dermal hypersensitivity to metal is common, affecting about 10% to 15% of population.(1,2,4,5). Dermal contact with and ingestion of metals have been reported to cause immune reactions which most typically manifest as hives, eczema, redness, and itching.(1,6,7) All metal in contact with biological systems corrode and the released ions, while not sensitizers on their own, can activate the immune system by forming complexes with native proteins. These metal-protein complexes are considered to be candidate antigens for eliciting hypersensitivity responses. Metal known as sensitizers are beryllium(16), nickel(4,6,7,16), cobalt(16), and chromium(16), in addition, occasional responses to tantalum(17), titanium(18,19) and vanadium(17) have been reported. Nickel is most common metal sensitizer in humans, followed by cobalt and chromium (1,4,6,7). Metal hypersensitivity might be merely a clinical curiosity except for known overaggressive immune responses to haptenic antigens leading to putative clinical complications. Hypersensitivity can be either an immediate (within minutes) humeral response (initiated by an antibody or the formation of antibody-antigen complexes of type-I,II, and III reactions) or a delayed (within hours to days) cell-mediated response. (20,21) Implant-related hypersensitivity reactions are generally the latter type of response, in particular type-IV delayed-type hypersensitivity (DTH). Case report A 46 year old man presented on May 18, 2006 with dermatitis, redness, and thin scales almost over the body and very itching. Redness and itching appeared 6 weeks after implant performing at tibia fracture. At the same time he also took ciprofloxacin to cure wound at the site of operation. Because of suspected hypersensitivity to ciprofloxacin, we asked him to stop intake medicine and gave oral steroid (dexametasone 3mg/day), and antihistamine. After 5 days treatment there was no improvement and even the dermatitis became worse. Red papules with thin scale cover all the body, conjunctivitis and crustae on the lips. The therapy was changed to intravenous dexametasone without any antibiotic. Itching and redness of skin disappeared after 4 days and the wound at the side of operation was healing. A week later he got chills and redness all over the body included scalp with thick scale and also very itching. Treatment with steroid intravenous was given and the improvement was seen after 3 days of therapy but the disease relapse and more severe 4 days later. Steroid was tapering off because clinically seen likes psoriasis form, redness and very thick scale cover all the body, some skin became cracked, and all the nails change to hyperkeratotic. The therapy was changed to topical steroid only.

Histopathology was done and the result was chronic dermatitis. There was not significant to clinical appearance. The disease relapse and down, and the extremities and all the body got edema but patient denied all oral or injection treatment. Historically he always got eczema when wear metallic jewelry. So we suspect that he got metal allergic from implant. At the middle of August, we performed radiology examination, the fracture almost complete union. On September 1, 2006 implant was took out. When the operating was done we examined the tissue around implant. The muscles and soft tissue around the implant looked pale and edema. Several hours after surgery the edema had disappeared and the skin came back almost look like normal, no redness and minimal scales. Two days later all the skin became normal, no redness, no edema and smooth without scale. Another case, a 20 year old man claimed that eczema, redness and itchy around the knee 1 month after k-wire implant was performed. The symptom was reduced when he took oral steroid.

Discussion