Nickel Dermatitis and Associated Gastritis after Coin Ingestion

Nickel allergic contact dermatitis is an established, well-recognized entity (1) that may affect ≤5% of men and 17% of women in North America (2,3). Exposure to daily dietary nickel is unlikely to cause exacerbation of the dermatitis, but ingestions of elemental nickel (4) or nickel-containing foreign bodies (5,6) may cause dermatitis, most likely in a dose-related fashion (7,8). We present a case of severe dermatitis following ingestion of a coin and for the first time describe associated endoscopic and histologic changes in the gastroduodenal mucosa. CASE REPORT An 8-year-old girl swallowed a Canadian 25¢ piece while playing magic tricks at home. Twenty-four hours later she developed a scaly, red, papular skin rash. The rash had started initially over the nasal bridge, ear lobules, and behind both ears, areas where she previously had well-documented contact dermatitis due to nickel in the metallic frame of her spectacles and earrings. Within 12 h the rash had spread to the rest of her body and became confluent, erythematous, and pruritic in many areas; on the fourth day she developed vesicles on her fingers. She had no upper-gastrointestinal symptoms and no history of abdominal pain. Treatment with an antihistamine and topical steroids afforded some relief of itching, but the rash was unchanged on day 5 when the patient was seen by the Gastroenterology Division at B.C. Children'sHospital. Her leukocyte count was 6.47 × 109/L, her eosinophil count was 0.42 × 109/L, her hemoglobin was 131 g/L, and her platelets were 284 × 109/L. A plain radiogram of the abdomen showed the coin to be in the stomach. At endoscopy, markedly erythematous patches with mild friability and thin exudate were observed in the gastric body; the antrum was lusterless with loss of the normal vascular pattern, some friability, and patchy erythema but no ulcers or exudate. The pylorus and duodenal bulb were normal macroscopically. The coin was removed and verified to be a Canadian quarter, its usual shiny silver appearance covered with a brown tarnish. Histological examination of gastric antral and duodenal biopsies showed moderate acute duodenitis with highly reactive epithelium, an increase in the numbers of lymphocytes and plasma cells in the mucosa, and a few polymorphonuclear leukocytes and eosinophils infiltrating the epithelial mucosa (Fig. 1). The gastric antral biopsy (Fig. 2) showed a focal area of regenerative-appearing mucosa with nuclear irregularity, irregular architecture, and superficial mitotic figures, probably representing a healing erosion. Serum nickel levels, measured by atomic absorption spectrophotometry (9), were obtained on day 5 (just before endoscopy) and day 12 (7 days postendoscopy) after ingestion and were >45 μg/L and 2.1 μg/L, respectively (expected levels in nonexposed individuals are between 1 and 2 μg/L). As the history was positive for nickel dermatitis, no further skin testing was performed. Following coin removal, the girl used topical steroid ointment for another 24 h, and the rash rapidly resolved. A week later the skin had a normal appearance, except for mild scaling over the palms. DISCUSSION Although nickel contact dermatitis is common, its occurrence has been rarely reported following ingestion. This is the first description of an associated gastrointestinal mucosal inflammation. The only two other reports in the literature (5,6) were also related to Canadian coin ingestions, which is likely explained by the fact that these coins have a high nickel content combined with an absence of plating (Table 1). The treatment of an ingested foreign object is determined by its size, shape, and chemical nature and the presence or absence of symptoms (10,11). Oral intake of a single dose of elemental nickel will result in an increased serum nickel level, which peaks at ≈3 h postingestion with clearance over the following 48 h. A skin flare-up after nickel ingestion has occurred 48 h after oral ingestion in patients with known nickel dermatitis (4). The clinical course and skin reaction observed in our case were similar to those reported with Canadian quarter ingestion in the past (5,6). The vesicular and, later, the scaly dermatitis on our patient's palms were similar to symptoms of eczema of the hands described in association with nickel ingestion (pompholyx) (12). Systemic reactions to nickel are generally regarded as cell-mediated (type IV) delayed hypersensitivity (1), but the rapid onset of the reaction in our patient was more in keeping with an immune-complex-mediated response, or even with a nonimmunologic toxic reaction, as has been proposed by Gawkrodger et al. (4). Our patient's serum nickel level 5 days after the coin ingestion was higher than the peak level 72 h following ingestion of a single dose of 5.6 mg elemental nickel reported elsewhere (4), and this finding may support a toxic reaction as the underlying mechanism. Our patient did not have peripheral eosinophilia, which has not been a constant finding in accidental nickel ingestion (5,6). With regard to the gastroduodenal findings, nickel could have been released from the coin by gastric acid, similarly to nickel release that occurs from stainless steel protheses (13). We have documented gastric and duodenal mucosal inflammation, which could be explained by traumatic gastropathy, an immune response, or the local toxic effect of nickel on the mucosa. It is also possible that these mucosal changes were an unrelated incidental finding. Traumatic gastropathy is commonly seen as a result of local irritation by a foreign body (i.e., nasogastric tube) and is a well-recognized entity in adults (14) and children (15). The presence of inflammation in areas remote from direct contact with the coin (e.g., the duodenum) speaks against the etiology of trauma in our patient. The inflammatory reaction in our patient consisted mainly of eosinophils in the duodenal and gastric mucosa, while lymphocytes and polymorphonuclear cells were observed in the gingival mucosal inflammation of laboratory animals exposed to nickel (16). We speculate that the presence of antral and duodenal inflammation in our patient may signify toxicity of nickel locally or systemically or as part of a generalized immune systemic reaction. In the routine treatment of patients who have ingested coins, we usually allow ≤4 weeks for spontaneous passage of any coin ≤27 mm (i.e., the size of a Canadian dollar, or “loony”) in children >2 years of age (Table 1). Our patient and the two previously reported (5,6) all had rapid resolution of symptoms following removal of the coin, indicating that early coin removal should be recommended if a skin rash appears shortly after ingestion, particularly of those coins with high nickel content (Table 1). The problem is most likely to arise with those coins made up of a high nickel content, which are also unplated, i.e., Canadian 25¢ or 10¢ pieces. Acknowledgment: We thank Drs. G. Lockitch, Department of Clinical Biochemistry, and G. Jevon, Staff Pathologist, B.C. Children's Hospital, for their help with serum nickel levels and figures of the mucosal biopsies.FIG. 1.: Endoscopic mucosal biopsy of the duodenal bulb showing eosinophils with typical bi-lobed nuclei, absent nucleoli, and granular cytoplasm infiltrating the epithelium (arrows) (original magnification ×40; hematoxylin-eosin stain).FIG. 2.: Gastric antral mucosa evidences focal regenerative cuboidal epithelium (RC) compared with the normal columnar epithelium (NC). Note superficial mitotic figures, abnormal for the site (arrows), and focal architectural and nuclear irregularity. (original magnification ×20; hematoxylin-eosin stain).