?VANCOMYCIN ALLERGY
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I am involved with a peculiar case.  The patient is a 70 yo male who
underwent prosthetic shoulder replacement in early 1996.  He subsequently
had a wound infection requiring surgical intervention and long term
antibiotic therapy, including vancomycin, ciprofloxacin and most recently
cindamycin.  There was a second surgical therapy involvong implantation of
vancomycin impregnated beads in the joint.
At a dermatologic evaluation in late May, he had erythema surrounding the
surgical site, suggestive clinically of allergic contact dermatitis.  All
topical therapy was stopped.  At a followup visit the erythema had
progressed to involve the anterior chest wall, deltoid, and scapular areas.
The process is described by the dermatologist as doughy with a peau d'
orange epidermal texture, sharply demarcated.  He is afebrile and is
currently taking no medicines.
A biopsy shows dermal mucin throughout with increased fibroblast and mast
cells.  Occasional multinucleated giant cell are present, containing
fragments of elastic tissue.

I have not been able to find similar cases in recent literature.
Is anyone aware of localized cutaneous reations to prostheses or the
titanium alloys in them?  Or possibly to the vancomycin beads?  References
would be appreciated.


Paul S. Gillum
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This does sound to me like a reaction to an implant, but my first choice would 
be the vancomycin beads. Check Dr. Fisher's book to see what he recommends for 
testing with vancomycin. In the absence of better information, a regular IV 
dose 
diluted 1/1000 (0.2 ml) might be injected intradermally in the contralateral 
arm 
(volar aspect, just like a TB test). If that looks like the control that you 
inject next to it after 48 hours, then I would test him against the materials 
in 
the prosthesis. 

I think that Craig Abott had a case that he thought was due to a titanium 
prosthesis; we recommended that he try and get a piece of titanium alloy to 
apply under tape occlusion to test that hypothesis (the company that makes the 
prosthesis may have test discs available). Alternatively, a piece of titanium 
bike or climbing gear might be available at a local specialty shop. 

Mark Naylor, M.D.
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