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  Case Report
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  Table of Contents 
CASE REPORT
Year : 2013  |  Volume : 17  |  Issue : 1  |  Page : 22-24
 

Cutaneous mercury granuloma


1 Department of Pathology, N. K. P. Salve Institute of Medical Sciences and Research Center, Nagpur, Maharashtra, India
2 Department of Dermatology, N. K. P. Salve Institute of Medical Sciences and Research Center, Nagpur, Maharashtra, India

Date of Web Publication12-Aug-2013

Correspondence Address:
Kalpana A Bothale
28, Shastri Layout Khamla, Nagpur - 440 025, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5278.116369

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  Abstract 

Cutaneous mercury granuloma is rarely encountered. Clinically it may pose difficulty in diagnosis. Here, we report a 23-year-old male presented with erythematous, nodular lesions over the forearm and anterior aspect of chest wall. Metallic mercury in tissue sections appear as dark black, opaque, spherical globules of varying size and number. They are surrounded by granulomatous foreign-body reaction. It is composed of foreign body giant cells and mixed inflammatory infiltrate composed of histiocytes, lymphocytes, plasma cells, and few eosinophils.


Keywords: Cutaneous, Hg granuloma, mercury granuloma


How to cite this article:
Bothale KA, Mahore SD, Pande S, Dongre T. Cutaneous mercury granuloma. Indian J Occup Environ Med 2013;17:22-4

How to cite this URL:
Bothale KA, Mahore SD, Pande S, Dongre T. Cutaneous mercury granuloma. Indian J Occup Environ Med [serial online] 2013 [cited 2019 Sep 16];17:22-4. Available from: http://www.ijoem.com/text.asp?2013/17/1/22/116369



  Introduction Top


Human contact with mercury has been ongoing for centuries and has been previously considered a legitimate means of treating different Cutaneous and systemic conditions. Toxicity from this metal may occur from exposure to elemental, inorganic, and organic forms of mercury. [1] Cutaneous mercury granuloma is a rare disorder. Clinically, it may pose difficulty in diagnosis.


  Case Report Top


A 23-year-old male patient presented to dermatology out-patient department with chief complaints of nodular, erythematous lesions over the left forearm, and anterior chest wall below the left nipple, of 4 months duration. There was a past history of injury to the chest wall and forearm 5 months back. Injury was in the form of abrasions and ulceration over the chest wall and forearm. Patient applied some ointment over the wounds. Details of the ointment were unknown to the patient. The lesions became itchy with raw ulcerated areas. The size and nodularity of the lesions increased in last 4 months. Physical examination revealed a thin built male with stable vital signs. The general examination was unremarkable. Patient did not give history of nausea, vomiting or diarrhea. On systemic examination, no abnormality was detected. On local examination, there were irregular, nodular, erythematous lesions with induration, scarring and discoloration of the overlying skin on the left forearm and anterior chest wall region below the nipple [Figure 1] and [Figure 2]. Neuropsychiatric evaluation was carried out. Neurological examination was normal except mild tremors and the clinical depression. There was no lymphadenopathy. Patient was not giving any history of self-injection or ingestion of mercury. Gold-lysis test, blood, and urine mercury levels, energy-dispersive X-ray analysis and scanning electron microscopy were not carried out in our case.
Figure 1: Clinical photograph showing irregular, nodular, and discolored lesions on the forearm

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Figure 2: Clinical photograph showing erythematous, nodular, irregular lesions on the anterior chest wall, below the left nipple

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Routine hemogram and biochemical investigations were within normal limits. X-ray showed diffuse deposition of metallic material (mercury) in the soft-tissue upto subcutaneous plane in the left forearm and chest wall [Figure 3] and [Figure 4]. The patient underwent surgical excision of the areas of skin discoloration and soft-tissue induration. The specimen was sent for the histopathological examination to pathology department.
Figure 3: X-ray elbow (Anteroposterior and lateral view) showing diffuse deposition of metal (mercury) in the subcutaneous plane

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Figure 4: X-ray chest Posteroanterior view showing irregular diffuse deposition of mercury in the subcutaneous plane

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Gross-Multiple, irregular, brownish tissue bits, total measuring 3.2 cm × 2 cm × 2 cm. Few bits were skin covered. After minute observation some shiny material was seen in the few tissue bits [Figure 5]. Microscopy-Hematoxylin and Eosin stained sections revealed stratified squamous epithelium showing hyperkeratosis and epitheliomatous hyperplasia. Subepithelial tissue showed multiple granulomas composed of central spherical dark, black colored opaque globules, surrounded by foreign-body type of multinucleate giant cells, histiocytes, and inflammatory infiltrate composed of lymphocytes, plasma cells, and few eosinophils [Figure 6]. For further confirmation of the shiny material seen on gross examination and spherical bodies seen on microscopy, small amount of tissue was sent for chemical analysis. Chemical analysis reported that material to be mercury. Histopathological diagnosis of mercury granuloma was given. Subsequently, patient has been lost to follow-up.
Figure 5: Gross photograph showing tissue bits with some shiny material on cut surface

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Figure 6: Photomicrograph showing multiple, dark black, opaque, spherical globules, surrounded by granulomatous reaction (H and E, ×100)

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  Discussion Top


This is a very rare clinical presentation. The route of entry of mercury in the skin and subcutaneous tissue was unknown in our case. Mercury could be one of the contents of the ointment that patient applied over the wounds. Other possibility was penetrating injury caused by mercury containing surface. Third possibility was patient himself injected the mercury at both sites. However, patient denied the third possibility.

Cutaneous mercury (Hg) granuloma is a rare disorder caused by the introduction of elemental Hg into skin or soft-tissue. Typically, Cutaneous elemental Hg deposits cause limited systemic effects. Prominent systemic toxicity may; however, occasionally occur. Altmeyer et al. Reported a case of Cutaneous mercury granuloma resulting in chronic painful local wounds and systemic toxicity in the form of abdominal pain, visual disturbances, and psychiatric abnormalities. [2]

Self-administration of metallic mercury through the intravenous route is rare. This event has been reported in psychiatric patients and in suicide attempts. The authors reported a single case reports of intravenous self-injections of mercury. [3],[4]

Metallic mercury in tissue sections appears as dark, opaque globules, usually spherical in shape and of varying sizes and numbers. A zone of collagen necrosis often surrounds the mercury globules. A granulomatous foreign-body-giant cell reaction and a mixed inflammatory cellular infiltrate composed of neutrophils, lymphocytes, histiocytes, plasma cells, and occasional eosinophils are usually present. Epidermal and dermal necrosis, with or without ulceration or pseudoepitheliomatous hyperplasia is also a common finding. [2],[5],[6]

Vernon provided the clinical guidelines for surgical removal of tissues and proper disposal of mercury contaminated tissues in an environmentally sound manner. [6]

Ruha et al. reported a case with a history of schizophrenia and inflammatory soft-tissue lesions after self-injection of elemental mercury presented to the Emergency Department. Multiple skin abscesses associated with fever required operative debridement. An incidental finding of oral mercury ingestion was followed clinically and did not result in complications. Exposure to elemental mercury through injection or ingestion is an uncommon event. Subcutaneous mercury injection should be managed with local wound debridement, whereas ingestions are rarely of clinical significance. [7]

In the reviewed literature, in almost all the cases similar granulomatous foreign-body reaction was observed, as seen in our case. Mercury globules were also similar, histologically.

 
  References Top

1.Boyd AS, Seger D, Vannucci S, Langley M, Abraham JL, King LE Jr. Mercury exposure and cutaneous disease. J Am Acad Dermatol 2000;43:81-90.  Back to cited text no. 1
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2.Altmeyer MD, Burgdorf MR, Newsome RE, Wang AR. Cutaneous mercury granuloma: A case report. Cutis 2011;88:189-93.  Back to cited text no. 2
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3.Givica-Pérez A, Santana-Montesdeoca JM, Díaz-Sánchez M, Martínez-Lagares FJ, Castaneda WR. Deliberate, repeated self-administration of metallic mercury injection: Case report and review of the literature. Eur Radiol 2001;11:1351-4.  Back to cited text no. 3
    
4.Kayias EH, Drosos GI, Hapsas D, Anagnostopoulou GA. Elemental mercury-induced subcutaneous granuloma. A case report and review of the literature. Acta Orthop Belg 2003;69:280-4.  Back to cited text no. 4
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5.Lupton GP, Kao GF, Johnson FB, Graham JH, Helwig EB. Cutaneous mercury granuloma. A clinicopathologic study and review of the literature. J Am Acad Dermatol 1985;12:296-303.  Back to cited text no. 5
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6.Vernon SE. Case report: Subcutaneous elemental mercury injection: Clinical observations and implications for tissue disposal from the histopathology laboratory. Ann Clin Lab Sci 2005;35:86-90.  Back to cited text no. 6
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7.Ruha AM, Tanen DA, Suchard JR, Curry SC. Combined ingestion and subcutaneous injection of elemental mercury. J Emerg Med 2001;20:39-42.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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