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E-IJD CASE REPORT
Year : 2015  |  Volume : 60  |  Issue : 5  |  Page : 520
Argyria after silver nitrate intake: Case report and brief review of literature


1 Department of Dermatology, National Institut of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, DF, Mexico
2 Department of Dermatopathology, National Institut of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, DF, Mexico

Date of Web Publication4-Sep-2015

Correspondence Address:
Alma Ileana Molina-Hernandez
National Institute of Medical Sciences and Nutrition Salvador Zubiran, México City, DF
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.164427

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   Abstract 

Argyria is a condition characterized by pigmentary changes secondary to exposure to silver salts and its accumulation in skin, mucous membranes and annexes, which typically produces blue or gray-blue spots. A case of a male patient 62 years old, previously healthy, who has a blue-gray hyperpigmentation on the face, trunk and upper extremity, affecting sun-exposed areas is presented. He admitted having ingested silver nitrate for 5 years at a rate of 1 bottle per week, with the intent to kill microorganisms in his body.


Keywords: Argyria, blue-gray pigmentation, silver


How to cite this article:
Molina-Hernandez AI, Diaz-Gonzalez JM, Saeb-Lima M, Dominguez-Cherit J. Argyria after silver nitrate intake: Case report and brief review of literature. Indian J Dermatol 2015;60:520

How to cite this URL:
Molina-Hernandez AI, Diaz-Gonzalez JM, Saeb-Lima M, Dominguez-Cherit J. Argyria after silver nitrate intake: Case report and brief review of literature. Indian J Dermatol [serial online] 2015 [cited 2021 Aug 5];60:520. Available from: https://www.e-ijd.org/text.asp?2015/60/5/520/164427

What was known?
Except for cases involving heavy metals, the skin biopsy may not always allow drug-induced pigmentation to be distinguished from other causes which may be equally responsible for an increase in melanogenesis.



   Introduction Top


Argyria is an extremely rare condition first detailed by Hill and Pillsbury in 1939, that is thought to have disappeared due to the suspension of the use of silver in drugs orally, [1],[2],[3] However, silver is in local antiseptics such as nitrate and sulfadiazine, nasal drops, dental and photographic material, absorbable sutures, powders used in jewellery, acupuncture needles, and supplements, therefore, may also penetrate through the skin or respiratory tract, in addition to digestive. [1],[4],[5]

Generalized argyria results from an increase in serum silver levels, secondary to prolonged ingestion of it in its various forms. To be present, it requires a total dose of 6 g orally or 1 g intravenously. [3]

Clinically, argyria characteristically presents with a blue or blue-gray uniform pigmentation of the skin (the sunlight intensifies it), mucous membranes, and nails. From nail, lunula is affected, and the hair take on a metallic look. The gums take a blue coloration. The conjunctival pigmentation is bluish gray or dark brown. It can also affect eyelids, lacrimal caruncle, semilunar fold, cornea, lens, vitreous humor, retina, and optic dis. It can manifest as localized with involvement of the cheek mucosa for amalgam tattoos and in the systemic form affects internal organs and accumulates in the liver, kidneys, and spleen. [4] It can be detected in blood and urine, and cause kidney failure.


   Case Report Top


Male patient of 62-year-old, who presented with disseminated dermatosis affecting head, neck, chest and limbs, in sun-exposed region, conjunctiva, caruncle; nails at lunula and the proximal half of the nail bed, consisting uniform blue-gray pigmentation. Lesions were five years in evolution and asymptomatic [Figure 1], [Figure 2] and [Figure 3].
Figure 1: Dermatosis disseminated to the head, neck, thoracic limbs

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Figure 2: Dermatosis comprising a uniform blue-gray color

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Figure 3: Blue-gray coloring of the sclera

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The patient reported having started consuming silver nitrate in 2006, after reading a publication on the use of silver nitrate "to kill microorganisms." He drank a bottle of it a week. He was being evaluated for Addison's disease and later for polycythemia. He was sent to dermatology for evaluation.

With these data, the presumptive clinical diagnosis of argyria was made, so it was decided to perform an incisional biopsy.

The histopathological diagnosis was argyria, confirmed by electronic microscopy [Figure 4] and [Figure 5]. No systemic involvement was found. It was explained to the patient the origin of his illness, the regular use of sun protection, and he was told to suspend silver nitrate intake.
Figure 4: Black granules scattered extracelullar among collagen fibers, (H and E)

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Figure 5: Electronic microscopy shows the same dark brown pigment

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   Discussion Top


The body accumulates a small amount of natural silver, so the total content in the body increases with age. The reservoir may contain a binding protein, is present in many tissues, without clinical effect. When a large amount of silver is present, the photoactivation and metal reduction cause bluish gray skin in areas exposed to light discoloration and has also been reported to lead to a generalized stimulation of melanin production. [5]

Clinically, the main differential diagnosis is with Addison's disease, hemochromatosis, methemoglobinemia; pigmentation due to other chemicals such as gold, mercury, arsenic, bismuth; drugs such as minocycline, antimalarials, amiodarone, chlorpromazine, quinacrine or chemotherapy. [1],[6]

Histologically, silver particles have a granular appearance of dark brown to black, scattered extracellularly in the dermis and are concentrated in the basement membrane of sweat glands, perifollicular sheath, nerve, capillary walls, and elastic fibers. [6]

By the technique of scanning electron microscopy, electron-dense granules are observed in the lysosomes of macrophages or extracellularly in old lesions. [1],[6] The chemical composition can be determined by dark field microscopy, immunohistochemistry, neutron activation analysis spectrophotometry, and X-ray energy dispersive spectroscopy.

Argyria treatment is a challenge for its poor response. Although it is a benign condition, it can cause psychological stress. [7] Hydroquinone and dermabrasion have shown disappointing results, so has oral D-penicillamine. [8]

Q-switched frequency doubled Nd-Yag laser can be effective in the treatment of localized argyria, and there is a report of successful treatment for generalized argyria. [7],[9]

There are recent reports of argyria resulting from the use of colloidal silver products that are readily available via the internet. [7] Many consumers use the internet to obtain health information and make decisions about their treatment, including traditional medical treatments.

Most reports of generalized argyria are related to colloidal silver intake, counting 15 reports in the literature. [10]


   Conclusions Top


Uncertainty about the safe dosage of silver, together with the lack of insight of dietary supplements exacerbates the problem and, therefore, we can expect more cases of argyria.

Since this condition is rare, associated with self-medication, without specific treatment, we consider it interesting to present this case.

 
   References Top

1.
Brandt D, Park B, Hoang M, Jacobe HT. Argyria secondary to ingestion of homemade silver solution. J Am Acad Dermatol 2005;53:S105-7.  Back to cited text no. 1
    
2.
Arenas R. Argyria. Case report and review of the topic. Rev Mex Dermatol 1986;30:24-35.  Back to cited text no. 2
    
3.
Chang AL, Khosravi V, Egbert B. A case of argyria after colloidal silver ingestion. J Cutan Pathol 2006;33:809-11.  Back to cited text no. 3
    
4.
Cho EA, Lee WS, Kim KM, Kim SY. Occupational generalized argyria after exposure to aerosolized silver. J Dermatol 2008;35:759-60.  Back to cited text no. 4
    
5.
East BW, Boddy K, Williams ED, Macintyre D, Mclay AL. Silver retention, total body silver and tissue silver concentrations in argyria associated with exposure to an anti-smoking remedy containing silver acetate. Clin Exp Dermatol. 1980;5:305-11.  Back to cited text no. 5
    
6.
Barnhill R, Crowson N, Magro C, Piepkorn M. Hyperpigmentation disorders. Dermatopathology. 3rd edition. 2010;15:355.   Back to cited text no. 6
    
7.
Rhee DY, Chang SE, Lee MW, Choi JH, Moon KC, Koh JK. Treatment of argyria after colloidal silver ingestion using Q-switched 1,064-nm Nd:YAG laser. Dermatol Surg 2008;34:1427-30.  Back to cited text no. 7
    
8.
Johansson EA, Kanerva L, Niemi KM, Lakomaa EL. Generalized argyria with low ceruloplasmin and copper levels in the serum. A case report with clinical and microscopical findings and a trial of penicillamine treatment. Clin Exp Dermatol 1982;7:169-76  Back to cited text no. 8
    
9.
Sakai N, Aoki M, Miyazawa S, Akita M, Takezaki S, Kawana S. A case of generalized argyria caused by the use of silver protein as a disinfection medicine. Acta Derm Venereol. 2007;87:186-7.  Back to cited text no. 9
    
10.
Bowden LP, Royer MC, Hallman JR, Lewin-Smith M, Lupton GP. Rapid onset of argyria induced by a silver-containing dietary supplement. J Cutan Pathol 2011;38:832-5.  Back to cited text no. 10
    

What is new?
This is a case where we identified extracellular clusters of granules disposed between collagen fibers, confirmed by electronic microscopy.


    Figures

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



 

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