What Are the Symptoms of an Allergic Reaction to Titanium?

Titanium is a known metal used widely in the medical field and can crusade allergic reactions with complications. Our case is most a 28-year-quondam female person presenting with a spectrum of intestinal symptoms with a complicated medical history. The abdominal hurting is associated with titanium allergy reaction from previously inserted titanium-based surgical clips. This patient is concurrently found to have a retained pigtail catheter in the cecum discovered incidentally through radiology. We discuss the presentation, investigations, and treatment of this unusual case. The case also unfolds rare differential diagnoses to keep in mind when encountering a patient with abdominal hurting and associated nonspecific symptoms.

1. Introduction

Metal allergies are becoming more recognized within the surgical field. Allergic responses to metals such as nickel, chromium, mercury, cobalt, and aureate are widely recognized [1]. Titanium is another type of metal that is utilized extensively in cardiac pacemakers, dental procedures, arthroplasty, trunk piercing, and spectacle frames [ii]. Titanium has also been reported as an allergen in a few studies, causing type I or type IV hypersensitivity reactions [3]. Patients can nowadays with atopic dermatitis, pruritus, edema, urticaria, impaired healing fractures, hurting, and necrosis of implants [3]. A case by Little et al. reports an 86-twelvemonth-sometime adult female who presented three years to postlaparoscopic cholecystectomy with subdiaphragmatic abscess due to titanium surgical clips used during the process [4]. Other case reports by Shi et al., Tawil et al., and Towers et al., mentioned hypersensitivity reactions due to titanium in different surgical procedures such as anterior cervical discectomy, dental implants, and spinal fixation devices. Nonetheless, all the symptoms were resolved after the removal of the offending agent [5–7].

In addition to metal allergies, retained strange surgical bodies are a potential postoperative complication. Usually retained strange bodies are found after complaints such every bit pain, infections and a palpable mass. Infrequent complications have been discussed in studies regarding pigtail catheter found on computerized tomography (CT) browse following a process. Pigtail plastic stents are used to remove the intra-intestinal drainage during procedures such as endoscopic retrograde cholangiopancreatography (ERCP) [8].

We describe a case of chronic abdominal pain, which is potentially complicated by retained titanium surgical clips and later a retained portion of a pigtail catheter.

2. Case Presentation

We present a instance of a 28-year-erstwhile female with a chronic history of intermittent abdominal pain aggravated due to titanium allergy and retained foreign surgical body. The patient'southward by medical history consists of depression, polycythemia vera, hypothyroidism, mitral valve prolapse, chronic back hurting, and deep vein thrombosis of nonextremity and acute cholecystitis. The patient'due south past surgical history includes a tonsillectomy, an appendectomy, and cholecystectomy. The patient'due south social history is insignificant, with no smoking or booze consumption. The patient has allergic symptoms reported from IV dissimilarity, nickel, titanium, iodine, metoclopramide, and oxalate. The patient did not report any screening for immunodeficiency in the by.

The patient initially presented to the dispensary with an intermittent right upper quadrant (RUQ) pain in 2016. She as well reported low-grade fever, nausea, vomiting, joint pain, bloody diarrhea, and inability to go on her food down. This resulted in approximately 75 lbs. of weight loss in only four months of duration. Xi months prior, the patient had undergone cholecystectomy due to astute cholecystitis complicated by a liver abscess. During the cholecystectomy, six titanium surgical clips were placed in the RUQ. The patient had delayed hypersensitivity reaction to nickel in the past with erythematous rash formation and severe itching. With her history of allergy to other metals in the past, a titanium allergy was suspected at this visit, and the patient promptly underwent a titanium skin patch test that turned out positive. To ostend, the patient was further ordered for retentivity lymphocyte immunostimulation assay (MELISA) that as well showed equivocal results for titanium allergy. A conclusion was fabricated to remove all the metal surgical clips laparoscopically via fluoroscopic guidance (Figure i). The patient recovered well with no significant intraoperative or postoperative complications. She reported a complete resolution of all symptoms ane-calendar month postsurgery.

In the following years, the patient went through an ERCP process multiple times due to her sphincter of Oddi dysfunction followed by laparoscopic rectopexy for a rectal prolapse. The patient started having another episode of intermittent right lower quadrant (RLQ) pain starting in Jan 2020. The pain was abrupt and stabbing in nature and radiated from the umbilicus, and the patient rated the hurting ten/10 on a scale, causing her pregnant discomfort. The patient also started having low-course fever, nausea, vomiting, articulation hurting, lengthened rash, and fatigue. She was diagnosed with pneumonia twice followed past two sinusitis episodes from January 2020 to March 2020. All of her symptoms were initially suspected due to the infections mentioned above, and she was placed on various antibiotic therapy regimens consisting of ciprofloxacin, amoxicillin/clavulanate potassium, and sulfamethoxazole/trimethoprim. In September 2020, the patient went to a walk-in clinic due to urinary tract infection (UTI) symptoms and was prescribed a form of cephalexin which resolved the infection. However, in October 2020, the patient started having new symptoms of watery, nonbloody diarrhea associated with her chronic RLQ pain. She was tested for Clostridium difficile infection and showed positive toxin B results confirming the diagnosis. The patient was referred to an communicable diseases specialist and kept on a grade of oral vancomycin and fidaxomicin. Within a few days, she started having vomiting, bloating, weakness, fatigue, and intense RLQ abdominal pain. She had to be hospitalized with strict isolation to look for her medication regimen to piece of work along with the infusion of IV fluids. Her symptoms became chronic and progressed further to abdominal distension with increasing abdominal girth, fever, and several episodes of watery diarrhea. CT scan was promptly ordered to rule out the severe complication of toxic megacolon equally a result of C. difficile infection. The CT impressions showed no signs of bowel obstruction or colitis; however, it was evident that a portion of a pigtail drainage catheter was lodged within the cecum (Figure two). The patient contacted our department the next morning, and the case and CT findings were reviewed.

On November 5, 2020, the embedded right colon strange trunk was identified with fluoroscopic guidance (Figures 3(a) and 3(b)) and removed surgically (Figure 4). The patient'south preop white blood prison cell (WBC) count was 5.2 K/μL, absolute neutrophil count was 3281 cells/μFifty, and absolute lymphocyte count was 1284 cells/μL. The surgical pathology written report for the removed catheter specified "foreign body" consisting of synthetic stent measuring 10.0 cm in length and 0.3 cm in bore (Figure 4). The patient tolerated the procedure well with no postoperative complications. By postoperative day 6, the patient'southward symptoms of abdominal distension resolved and her RLQ pain also diminished. The patient has been recommended to practice a close follow-upwards for a few months to monitor her progress.

(a)

(b)

3. Discussion

The hit features of titanium include its stability with increased resistance to corrosion and its biocompatibility to various materials [3]. This makes it an acceptable metallic of option for intraosseous employ in medical procedures. Metals including titanium can course haptenic antigens in their ionic form upon bonding with human prison cell native proteins and have the ability to potentiate degranulation of basophils and mast cells [iii]. Blazon I hypersensitivity reaction may manifest every bit anaphylaxis causing urticarial plaques or papules on the skin [3]. Moreover, titanium has been described to activate macrophages through phagocytosis to cause the release of pro- and anti-inflammatory cytokines [9]. This causes type Four hypersensitivity reaction through sensitization of T lymphocytes and macrophages. It causes delayed clinical manifestations afterward 48 to 72 hours [x]. Some symptoms include chronic dermatitis and other reactions depending on the specific organ involved [10].

Diagnosing any metal allergy, including titanium allergy, has been complicated by various tests' sensitivity and specificity. The pare patch test has not yet been adult equally the valid standardized test for titanium allergy. Okamura et al. suggested using 0.i% and 0.2% titanium sulfate solution and 0.1% and 0.2% titanium chloride as culling reagents to titanium oxide in skin-patch testing [11]. However, the peel-patch test is all the same not the best diagnostic modality due to failure in positive reaction to most titanium allergy cases [iii]. The MELISA test has been known to be a more than sensitive exam to metal allergy just lacks specificity in the proliferation of lymphocytes [3]. LTT is some other more than sensitive examination than the peel-patch test; however, there are reports of some false-positive results [3]. Finally, the blood test could be effectively used to diagnose type Four hypersensitivity allergic reactions, including contact dermatitis or eczema reported past few studies on titanium allergy [12]. The direction of any metal allergy including titanium involves removing specific offending agents and avoiding potential triggers to hypersensitivity reactions. In our case, the patient's nonspecific symptoms due to the titanium clips were quite different from the symptoms reported in other studies and may not wholly exist attributable to titanium hypersensitivity since the patient had known allergic reactions to various other allergens also. Nonetheless, it indeed seems titanium allergy had a significant office in her abdominal discomfort attributable to her positive allergy test results farther proving titanium hypersensitivity in this patient. Moreover, all her aforementioned symptoms were alleviated one time the metal surgical clips were removed surgically.

Retained foreign bodies (RFB) are too possible complications of any surgical procedure. There are more than than 28 one thousand thousand surgical procedures with up to 1500 cases of retained foreign bodies estimated in the United States per year [xiii]. Symptoms can ascend as astute inflammatory response, infection, abscess, or aseptic inflammation and exudative without infection in the body cavities [xiii]. Amid unlike RFB, sponges are one of the almost common retained foreign bodies in the abdomen, pelvis, and retroperitoneal cavities [xiii]. Additionally, standard surgical instruments such every bit electrodes, drains/catheters, retractors, or clamps tin can be left unrecognized afterwards operations, particularly in the abdominal infinite [xiii].

A pigtail catheter is a universal drain used to remove fluids or abscesses from organs, ducts, or body cavities. Some of the reported complications of pigtail catheter insertion include lung penetration during pleural effusion removal and entrapment of the catheter in the tricuspid valve leaflet during middle catheterization [8, fourteen, fifteen].

In our case, the pigtail catheter was found as a retained surgical trunk lodged in the patient'southward cecum. The patient initially had intermittent RLQ abdominal pain accompanied past nonspecific symptoms. Due to ongoing chronic symptoms, CT browse incidentally revealed a portion of a lodged pigtail catheter in the cecum. The catheter was removed surgically which resolved the patient'south RLQ abdominal hurting and accompanying symptoms.

It is important to diagnose RFB promptly and remove it as soon equally possible due to life-threatening complications such as gastrointestinal bleeding, intestinal obstruction, and perforation [13]. RFB should be included in the differential diagnoses when the patient presents with acute reactions after surgical procedures. This requires immediate attention and an X-ray for farther investigation. After the diagnosis of RFB, the preferred approach is to remove the RFB laparoscopically [13]. Nonetheless, in chronic cases of months to years after the operation, a CT scan is usually performed to dominion out cancerous tumors and possible fistula formations [13].

It tin be challenging to diagnose and discover RFB due to the unlike manifestations of each case and nonspecific symptoms. Especially, in our case, the patient's all-encompassing past medical history and multiple overlapping medical conditions delayed her diagnosis of RFB and acquired her pregnant life distress. Moreover, the patient was under multiple specialists' intendance and had many hospitalizations and a history of diverse medication intake, including antibiotics and painkillers. Regardless of all these factors, surgeons and clinicians must have a loftier clinical suspicion of RFB and appropriate diagnostic imaging for diagnosis and removal of the RFB. This volition improve the patient'south quality of life and forestall serious complications.

4. Conclusion

This instance highlights the variable presentation of titanium allergy that clinicians should be vigilant for. Metals and their alloys could lead to immediate or delayed hypersensitivity reactions. Moreover, metal allergy screening should exist considered for patients with past hypersensitivity reactions before any surgery. It also sheds light on retained foreign bodies as a possible crusade of abdominal hurting in patients who accept gone through various surgical procedures in the past. Proper history taking, appropriate physical exams, and specific diagnostic modalities tin identify rare causes of chronic abdominal hurting.

Abbreviations

LTT:	Lymphocyte transformation examination
MELISA:	Memory lymphocyte immunostimulation analysis
CT:	Computerized tomography
ERCP:	Endoscopic retrograde cholangiopancreatography
RUQ:	Right upper quadrant
RLQ:	Right lower quadrant
UTI:	Urinary tract infection
PCR:	Polymerase chain reaction
WBC:	White claret cell
RFB:	Retained foreign body.

Data Availability

No data were used during this study.

Consent

We obtained written informed consent from the patient for the publication of this case study and accompanying images. The Editor-in-Chief of this journal has a copy of the written consent available for review.

Conflicts of Interest

The authors declare that they accept no competing interests.

Acknowledgments

We thank Dr. Guirguis, Section of Radiology, and Williamson Medical Center for their contributions in this case report.

Copyright

Copyright © 2021 Molly S. Jain et al. This is an open access article distributed nether the Creative Commons Attribution License, which permits unrestricted utilise, distribution, and reproduction in any medium, provided the original piece of work is properly cited.

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Source: https://www.hindawi.com/journals/cris/2021/5515401/

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