Cutaneous mercury granuloma
A 23-year-old male patient presented to dermatology out-patient department with chief complaints of nodular, erythematous lesions over the left forearm, and anterior chest wall below the left nipple, of 4 months duration. There was a past history of injury to the chest wall and forearm 5 months back. Injury was in the form of abrasions and ulceration over the chest wall and forearm. Patient applied some ointment over the wounds. Details of the ointment were unknown to the patient. The lesions became itchy with raw ulcerated areas. The size and nodularity of the lesions increased in last 4 months. Physical examination revealed a thin built male with stable vital signs. The general examination was unremarkable. Patient did not give history of nausea, vomiting or diarrhea. On systemic examination, no abnormality was detected. On local examination, there were irregular, nodular, erythematous lesions with induration, scarring and discoloration of the overlying skin on the left forearm and anterior chest wall region below the nipple [Figures and ]. Neuropsychiatric evaluation was carried out. Neurological examination was normal except mild tremors and the clinical depression. There was no lymphadenopathy. Patient was not giving any history of self-injection or ingestion of mercury. Gold-lysis test, blood, and urine mercury levels, energy-dispersive X-ray analysis and scanning electron microscopy were not carried out in our case.\nRoutine hemogram and biochemical investigations were within normal limits. X-ray showed diffuse deposition of metallic material (mercury) in the soft-tissue upto subcutaneous plane in the left forearm and chest wall [Figures and ]. The patient underwent surgical excision of the areas of skin discoloration and soft-tissue induration. The specimen was sent for the histopathological examination to pathology department.\nGross–Multiple, irregular, brownish tissue bits, total measuring 3.2 cm × 2 cm × 2 cm. Few bits were skin covered. After minute observation some shiny material was seen in the few tissue bits []. Microscopy-Hematoxylin and Eosin stained sections revealed stratified squamous epithelium showing hyperkeratosis and epitheliomatous hyperplasia. Subepithelial tissue showed multiple granulomas composed of central spherical dark, black colored opaque globules, surrounded by foreign-body type of multinucleate giant cells, histiocytes, and inflammatory infiltrate composed of lymphocytes, plasma cells, and few eosinophils []. For further confirmation of the shiny material seen on gross examination and spherical bodies seen on microscopy, small amount of tissue was sent for chemical analysis. Chemical analysis reported that material to be mercury. Histopathological diagnosis of mercury granuloma was given. Subsequently, patient has been lost to follow-up.