When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum



      Increasing use of implantable bars for minimally invasive pectus excavatum repair has introduced metal allergy (nickel and chromium) to pediatric surgeons. Metal allergy is a well-recognized entity in neurologic, orthopedic, and craniofacial surgery. This study was performed to evaluate metal allergy and its effects on treatment with the Nuss procedure in 862 patients.


      After institutional review board approval, we undertook a retrospective review of a prospectively gathered database of patients undergoing the Nuss procedure. Metal allergy was diagnosed either with the use of dermal patch or clinically, based on rash, fever, elevated erythrocyte sedimentation rate, cultures, and pathology specimens. Data collection included demographics, an allergy to jewelry, and history of atopy. Clinical outcomes including need for reoperation, removal of stainless steel bar, and replacement with titanium bar were evaluated.


      Over an 18-year period (1987-2005), 862 patients underwent the Nuss procedure. Nineteen (2.2%) were diagnosed with metal allergy, with an average age of 14.7 years (9-23 years). Eighteen (95%) were males. A history of atopy was present in 9 (56%) patients. Ten (63%) patients presented with rash and erythema, 1 (6%) with granuloma, 5 (32%) with pleural effusion, and 3 (15%) were diagnosed on preoperative screening. Stainless steel bars were removed because of allergic skin breakdown in 3 patients, with 2 patients requiring replacement titanium bars. In all 3 of these patients, symptoms resolved after removal of stainless steel bars. Titanium bars were placed in the 3 patients who were diagnosed preoperatively with metal allergy, without event.


      Allergy symptoms often are misdiagnosed as infection, but require different treatment. If a history of metal allergy or atopy is suggested preoperatively, the patient should be tested for metal allergy, and if positive, a titanium bar used. Because the consequences of metal allergy may include the need to replace the bar, pediatric surgeons should be aware of this occurrence.

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        • Goh C.L.
        Prevalence of contact allergy by sex, race and age.
        Contact Dermatitis. 1986; 14: 237-240
        • Kiec-Swierczynska M.
        Allergy to chromate, cobalt and nickel in Lodz 1977-1988.
        Contact Dermatitis. 1990; 22: 229-231
        • Moller H.
        Nickel dermatitis: problems solved and unsolved.
        Contact Dermatitis. 1990; 23: 217-220
      1. Liden CBM, Menne T. Metals. In: Textbook of Contact Dermatitis. 3rd ed. Berlin: Springer-Verlag.

        • Marks J.G.
        • Belsito D.V.
        • DeLeo V.A.
        • et al.
        North American Contact Dermatitis Group patch test results for the detection of delayed-type hypersensitivity to topical allergens.
        J Am Acad Dermatol. 1998; 38: 911-918
        • Albanesi C.
        • Scarponi C.
        • Sebastiani S.
        • et al.
        A cytokine-to-chemokine axis between T lymphocytes and keratinocytes can favor Th1 cell accumulation in chronic inflammatory skin diseases.
        J Leukoc Biol. 2001; 70: 617-623
        • Girolomoni G.
        • Sebastiani S.
        • Albanesi C.
        • et al.
        T-cell subpopulations in the development of atopic and contact allergy.
        Curr Opin Immunol. 2001; 13: 733-737
        • Traidl C.
        • Sebastiani S.
        • Albanesi C.
        • et al.
        Disparate cytotoxic activity of nickel-specific CD8+ and CD4+ T cell subsets against keratinocytes.
        J Immunol. 2000; 165: 3058-3064
        • Cavani A.
        • Mei D.
        • Guerra E.
        • et al.
        Patients with allergic contact dermatitis to nickel and nonallergic individuals display different nickel-specific T cell responses. Evidence for the presence of effector CD8+ and regulatory CD4+ T cells.
        J Invest Dermatol. 1998; 111: 621-628
        • Bluestone J.A.
        • Abbas A.K.
        Natural versus adaptive regulatory T cells.
        Nat Rev Immunol. 2003; 3: 253-257
        • Shevach E.M.
        CD4+ CD25+ suppressor T cells: more questions than answers.
        Nat Rev Immunol. 2002; 2: 389-400
        • Jensen C.S.
        • Lisby S.
        • Baadsgaard O.
        • et al.
        Decrease in nickel sensitization in a Danish schoolgirl population with ears pierced after implementation of a nickel-exposure regulation.
        Br J Dermatol. 2002; 146: 636-642
        • Johansen J.
        • Menne T.
        • Christophersen J.
        • et al.
        Changes in the pattern of sensitization to common contact allergens in Denmark between 1985-86 and 1997-98, with a special view to the effect of preventive strategies.
        Br J Dermatol. 2000; 142: 490-495
        • Klepesch E.
        • Baltas A.
        European Parlament and Counsil Directive 94/27/EC of 30 June 1994.
        Off J Eur Communities. 1994; 22.7.94: 1-2
        • Gawkrodger D.J.
        Metal sensitivities and orthopaedic implants revisited: the potential for metal allergy with the new metal-on-metal joint prostheses.
        Br J Dermatol. 2003; 148: 1089-1093
        • Elves M.R.W.J.
        • Scales J.T.
        • Kemp H.B.S.
        Incidence of metal sensitivity in patients with total hip replacement.
        Br Med J. 1975; 4: 376-378
        • Deutman R.M.T.
        • Brian R.
        • Nater J.P.
        Metal sensitivity before and after total hip arthroplasty.
        J Bone Joint Surg Am. 1977; 59: 862-865
        • Krob A.
        • Fleischer A.B.
        • DAgostino R.H.
        • et al.
        Prevalence and relevance of contact dermatitis allergens: a meta-analysis of 15 years of published T.R.U.E. Test data.
        J Am Acad Dermatol. 2004; 51: 349-353