ARTICLE
Argyria is a relatively rare skin disease caused
by deposition of silver grains in the skin from industrial exposure to
silver substrate, or as a result of medication with silver salt, characterized
by blue to bluish-gray coloration of the overlying skin. It is well-known
that there are two forms of argyria: localized and generalized forms.
Localized argyria has been reported to occur through embedded acupuncture
needles, topical application of silver nitrate or other causes [1, 2].
We report a case of localized argyria caused by embedding of acupuncture
needles and describe unrecognized adverse events associated with acupuncture.
Case report
A 66-year-old woman visited our clinic with bluish macules on her right
arm. About 20 years previously, she had received acupuncture in her extremities
because of arthralgia. The needles had been embedded. Ten years later,
she noticed two bluish macules on her right arm with no symptom. The size
and color had remained unchanged before the visit. On physical examination,
two bluish-gray, ovoid macules were observed on her right arm (Fig.
1). Needles were not palpable. Biopsied specimen from the macule revealed
many tiny brownish-black granules scattered throughout the dermis, mainly
located around the sweat glands and the blood vessels (Fig.
2). The X-ray examination of the extremities revealed numerous short,
linear, needle-like fragments around her shoulder, right elbow and bilateral
knee joints. Some of these were bent (Fig.
3). By Inductively Coupled Plasma Emission Spectrometry analysis,
0.15 g of paraffin-embedded specimen contained 8.2 mug of silver respectively.
Discussion
"Embedding of Needles" is one of the traditional Japanese acupuncture
techniques originated from Chinese medicine. In Japan, it is usually applied
to control patients with refractory back pain, arthralgia, neuralgia,
migraine, or other complaints. The thin needles are inserted into the
skin, and the exposed parts of the needles are cut off for the patient's
safety. The needle fragments are retained inside the skin for a long period
of time once inserted. The needles usually contain silver, so that insoluble
silver granules induce localized argyria. The needle contains other ingredients.
Sulfur, copper, nickel, and selenium are detected with X-ray microanalysis
[3]. Matsumura et al. reported that on electron microscopic examination,
deposition of electron dense granules were found on elastic fibers and
around basal laminas of glandular portions of eccrine glands. And they
speculated that the depositing silver granules were transported through
the tissue fluid flow, and trapped at basal lamina of eccrine glands and
blood vessels [4]. In this case, the silver granules were also mainly
located around the sweat glands and the blood vessels in the dermis.
Nineteen cases of localized argyria caused by embedding of acupuncture
needles have been reported from 1983 to 2001 in Japan [5]. The bluish-gray
macules usually noticed by the patients in an average of 10 years after
embedding of the needles. The anatomical location or depth of the needles
define the severity and the period of induced argyria. As skin-deposited
silver is known to cause no serious or systemic disorders or develop malignancy,
argyria is usually left untreated.
However from 1987 to 1999, 16 serious adverse events caused by embedding
needles have been reported in Japan [6]. For example, needle fragment
migrated into the spinal cord or the upper urinary tract resulting in
severe pain and sensory disturbance or paralysis. If we find dermal lesions
near the spinal cord or internal organs corresponding to the sites needled,
we should perform X-ray analysis to find the needle fragments and remove
them surgically.
Many other adverse events after acupuncture
have been reported in Japan. Yamashita et al. reviewed 124 cases
of adverse events caused by acupuncture from 1987 to 1999 in Japan. The
most frequent ones were pneumothorax (25 cases), spinal cord injury (18
cases), acute hepatitis B (11 cases). And there were 2 fatalities from
infections. The literature included 6 other cases of acupuncture-related
dermatological problems: metal allergy or contact dermatitis (2 cases),
nodular lesions (2 cases), cutaneous chromatosis (1 case), and sarcoid
reaction (1 case) [6]. Allergic reactions were induced by zinc, chrome,
or nickel, all of those are contained in the acupuncture needles.
In recent years "Embedding of Needles" is not a common medication in
Japan, but because some cases develop argyria or serious side effects
even 30 years or more after the treatment there is also some possibility
that new cases will occur in the future. This method is not practiced
in Europe, however acupuncture is a technique that is getting popular
and we should know that accidental breakage of needles would also induce
similar serious adverse events.
The acupuncturists are planning to survey the risks of acupuncture and
to prevent these accidents [5, 7], therefore the Japan Society of Acupuncture
and Moxibustion established "The Committee for Safety of Acupuncture"
and the World Health Organization issued "Guidelines on basic training
and safety in acupuncture" in 1996. Dermatologists should know about the
adverse events induced by acupuncuture and argyria caused by acupuncture
for the safety and health of patients.
Article accepted on 19/8/01
REFERENCES
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