Allergic Contact Dermatitis to Manganese in Metallic Implant

Abstract

Orthopedic implants are commonly made from metal alloys, and implantation of these metals can cause delayed-type (IV) hypersensitivity reactions leading to eczematous, urticarial, or vasculitic eruptions.Most documented hypersensitivity reactions to metallic implants are attributed to chromium, cobalt, or nickel, with few documented cases of cutaneous lesions due to manganese. 2Y4 Herein, we describe a case of allergic contact dermatitis to manganese after implantation of an orthopedic metal plate whose dermatitis resolved after removal of the implant.A 60-year-old man developed diffuse, pruritic, pink scaly patches covering his trunk and extremities 3 weeks after undergoing surgery for a lateral malleolus fracture with placement of a stainless steel locking fibular plate (Synthes West Chester, Pa) containing 2% manganese. A biopsy from an outside provider showed spongiotic dermatitis after which he was referred to our department for patch testing.At the time of initial presentation, patch testing could not be completed because of the extensiveness of the eruption. The patient was started on triamcinolone 0.1% cream and 10 mg of prednisone. At this time, MELISA testing (NeuroScience, Inc, Osceola, Wis) was obtained and came back negative for all tested metals including aluminum, chromium, cobalt, molybdenum, nickel, titanium calcium, and titanium dioxide.Patch testing was completed 5 weeks later while the patient remained on 10 mg of prednisone. A total of 101 allergens from the standard, cosmetic, and metal patch test series were used. Patch testing results were checked after 48 and 72 hours. The results were negative except for gold sodium thiosulfate (1+), manganese chloride 2% in petrolatum (1+) (Fig. 1), and tungsten (equivocal).The patient did not have a previous history of atopic dermatitis but did have a history of metal intolerance including pruritus and blistering to gold. Notably, he had a knee replacement with a titanium prosthesis several years before the fibular plate implantation without dermatologic complications.The patient had the steel plate removed 6 months after the initial surgery. The dermatitis was resolved at the patient's follow-up visit, 10 days after plate removal. To date, the dermatitis has not recurred.There are few documented cases of sensitivity to manganese and Santucci et al 5 suggest that manganese is not the main causal agent of these reported cases. They propose that contamination of patch test materials with small amounts of nickel or crossreactivity between metals in close proximity on the periodic table accounts for the positive manganese patch test. This theory would not be applicable to our patient because of his negative patch test to nickel. This observation and the dramatic clinical improvement in the dermatitis seen after implant removal make manganese the most likely causal agent.In conclusion, we present a case of allergic contact dermatitis, evidenced by an eczematous eruption due to implantation of a stainless steel plate containing 2% manganese. We suggest inclu...

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