Foreign body reactions

Question 1

What type of tattoos are most commonly associated with delayed reactions?

Answer 1

Red tattoos (mercuric sulfide/cinnabar)

Question 2

What is the chemical in red tattoos that most commonly leads to delayed-type reactions?

Answer 2

Mercuric sulifde/cinnabar

Question 3

What are the delayed-type reactions to red tattoos?

Answer 3

Lichenoid or pseudolymphomatous papules/nodules

Question 4

What ink most often causes photoallergies in tattoos?

Answer 4

Yellow (cadmium sulfide), red ink (cadmium selenide or yellow-red (azo dyes)

Question 5

What is a way of telling pigment from tattoos from endogenous pigments on histology?

Answer 5

Tattoo pigment granules are smaller and darker than endogenous pigemnts (hemosiderin and melanin)

Question 6

What is the treatment of choice for tattoo removal?

Answer 6

Q-switched lasers (QS ruby (694), QS-alexandrite (755), QS-Nd:YAG (1064 or 532)

Question 7

What lasers should be used to remove black, blue, or dark brown tattoo pigment?

Answer 7

QS ruby (694), QS-alexandrite (755), QS-Nd:YAG (1064 or 532)

Question 8

What lasers should be used to remove green tattoo pigment?

Answer 8

Ruby or alexandrite

Question 9

What lasers should be used to remove red, yellow, light brown, violet, and white tattoo pigment?

Answer 9

Only frequency-doubled Nd:Yag (532nm)

Question 10

What treatment should be done if a tattoo is inflamed?

Answer 10

Excision rather than laser to decrease risk of systemic allergic reaction

Question 11

What type of thing may lead to a foreign body reaction with silica?

Answer 11

Penetrating injury from sand, soil, rocks, glass

Question 12

What is the incubation period for a foreign body reaction with silica?

Answer 12

Up to 25 years

Question 13

What is the presentation of silica foreign body reaction?

Answer 13

Nodules, indurated plaques within scar or disseminated papules if from a blast injury

Question 14

What is the histology of foreign body reaction with silica?

Answer 14

Sarcoidal granulomas containing colorless, birefringent crystals

Question 15

What are some things that can lead to foreign body reaction with talc (hydrous magnesium silicate)?

Answer 15

Dusting powders, surgical glove lubricants, filler for med tablets (injection of crushed tablets)

Question 16

Histology of foreign body reaction with talc (hydrous magnesium silicate)?

Answer 16

Sarcoidal or foreign body granulomas with needle-shaped or round crystals that are white and birefringent on polarized light

Question 17

What is the color on H&E of the talc crystals?

Answer 17

They are needle-shaped or round but are highly variable in color (clear, blue-green or yellow-brown)

Question 18

What is a cause of foreign body reaction with zirconium?

Answer 18

Antiperspirants

Question 19

What is the presentation of foreign body reaction with zirconium?

Answer 19

Often soft brown papules in the axilla

Question 20

Histology of a foreign body reaction with zirconium?

Answer 20

Sarcoidal granulomas, no polarizable particles seen

Question 21

Why are there no polarizable particles seen in foreign body reaction with zirconium?

Answer 21

The particles are too small to be seen w/ polarized light microscope, need X-ray or electron imaging

Question 22

What are some risk factors for foreign body reaction with beryllium?

Answer 22

Used in manufacturing fluorescent lights in the past; can result in local or systemic reactions

• Also aerospace industry

Question 23

What is the appearance of systemic berylliosis?

Answer 23

Granulomatous lung dz with rare skin involvement (<1%) [scattered sarcoidal papules]

Question 24

What is the clinical appearance of localized cutaneous berylliosis?

Answer 24

From a puncture wound with a fluorescent bulb –> slow healing nodules/ulcers

Question 25

Histology of foreign body reaction with beryllium?

Answer 25

**Caseating granulomas** (localized or cutaneous form); no polarizable particles

Question 26

What is used to make dx of systemic berylliosis?

Answer 26

Bronchoalveolar lavage

Question 27

Where can a foreign body granuloma reaction due to aluminum be seen?

Answer 27

Sites of vaccine injections (persistent subcutaneous nodules)

Question 28

How long after an injections does a foreign body granuloma reaction due to aluminum occur?

Answer 28

Several months

Question 29

What is the histology of a foreign body granuloma reaction due to aluminum?

Answer 29

Granulomas with central granular debris and palisade of surrounding histiocytes; **no polarizable particles seen**

Question 30

What effect can topical aluminum chloride cause in histology?

Answer 30

Can cause a stippled appearance to histiocytes in the healing wound

Question 31

What can cause a foreign body granuloma reaction due to zinc?

Answer 31

Some zinc-containing insulin shots

Question 32

What is the clinical presentation of a foreign body granuloma reaction due to zinc?

Answer 32

Furuncles at sight of injection, heals with atrophic scars

Question 33

Where do a foreign body granuloma reaction due to starch often come from?

Answer 33

Contamination of wounds w/ surgical gloves and the starch lubricant ## Footnote *presents w/ papules/nodules*

Question 34

What is the histology of a foreign body granuloma reaction due to starch?

Answer 34

Ovoid basophilic starch granules that stain **PAS+**

Question 35

What is the clinical appearance of a foreign body granuloma reaction due to cactus?

Answer 35

Clusters of dome-shaped skin-colored papules with a central black dot ## Footnote *happens in those who work with or handle prickly pear fruit*

Question 36

What is the histology of a foreign body granuloma reaction due to cactus?

Answer 36

Sarcoidal or foreign body granulomas with PAS+ spines

Question 37

What is the appearance of a foreign body granuloma reaction due to jellyfish, corals, or sea urchin spines?

Answer 37

Pruritic lichenoid papules and plaques ## Footnote *Often have a linear, zig-zag, or whip-like flaggellate pattern of erythema/edema aearly then hyperpigmentationor lichenoid papules later*

Question 38

How long after exposure does a foreign body granuloma reaction due to jellyfish, corals, or sea urchin spines occur?

Answer 38

Usually 2-3 weeks after

Question 39

What can be seen on histology for a foreign body granuloma reaction due to jellyfish, corals, or sea urchin spines?

Answer 39

Lichenoid reaction ## Footnote *can also see birefringent calcite crystals for sea urchin spines*

Question 40

What can cause a foreign body granuloma reaction due to keratin?

Answer 40

Ruptured epidermoid cyst, pseudofolliculitis/acne keloidalis, pyogenic granuloma-like lesions, ingrown nails, pilonidal sinus

Question 41

What is the histology of a foreign body granuloma reaction due keratin?

Answer 41

Foreign body granulomas w/ birefringent keratin debris (can see clefts)

Question 42

What is the appearence of a foreign body granuloma reaction due intralesional corticosteroids?

Answer 42

Occurs weeks to months after injection and you develop skin-colored to yellow-white papules at site of injeciton

Question 43

What is the histology of a foreign body granuloma reaction due intralesional corticosteroids?

Answer 43

Foreign body granulomas with central pale bluish material (looks like mucin) on H&E

Question 44

What is the clinical appearance of a foreign body granuloma reaction due to suture?

Answer 44

Inflamed papule in the wound that opens to form a fistula

Question 45

Histology of a foreign body granuloma reaction due to suture?

Answer 45

Foreign body granulomas with birefringent suture material