Elsevier

The Journal of Foot and Ankle Surgery

Volume 55, Issue 6, November–December 2016, Pages 1282-1286
The Journal of Foot and Ankle Surgery

Case Reports and Series
Long-Term Fever After Hallux Valgus Surgery Secondary to Titanium Allergy: A Case Report and Review of the Literature

https://doi.org/10.1053/j.jfas.2015.06.021Get rights and content

Abstract

We present the case of a patient who had experienced a fever of unknown cause for >7 months after surgical treatment for hallux valgus. A patch test revealed a positive reaction to a titanium alloy. All symptoms subsequently disappeared after we removed the implanted titanium screws. Histopathologic examination of the tissue surrounding the screws showed macrophage infiltration in the tissue. For >1 year after removal of the titanium screws, the patient's body temperature remained <37°C. These results support a diagnosis of titanium allergy in our patient. To the best of our knowledge, a long-term fever caused by an allergic reaction to mini-titanium screws of such a small size has not been reported. A review of 16 cases of titanium allergy reported in the published data confirmed that titanium allergy is extremely rare and that the clinical symptoms can vary. Titanium allergy should be suspected when a patient presents with a fever of unknown cause, delayed wound healing, dermatitis, or impaired fracture healing after internal fixation with titanium materials. A patch test for titanium or the lymphocyte transformation test could offer guidance for the clinical diagnosis of titanium allergy. Finally, we recommend that all patients should be asked whether they have a history of an allergy to any metal before surgery.

Section snippets

Case Report

An 18-year-old male patient presented with a prolonged low-grade fever that had lasted >7 months after surgical treatment for left hallux valgus. For transfer metatarsalgia caused by left hallux valgus, the patient had undergone Scarf and Akin osteotomy with 24-mm Extremifix cannulated screws (YZB [medical device registration product standard], standard 0105-2013, as reported by the manufacturer, Double Co., Xiamen City, China) in our hospital 22 months previously. He reported the onset of

Discussion

Metal allergy, which can be histologically described as a type of aseptic lymphocyte-dominated vascular-associated lesion, is characterized by diffuse perivascularly located lymphocyte infiltration with necrosis and a limited numbers of macrophages (6). It is a type IV allergic reaction caused by metal corrosion and a lesion resulting from the constant release of ions into the tissue environment 7, 8. The severity of the reaction depends on the material and the sensitivity of the patient (9).

Acknowledgments

The authors thank Medjaden Bioscience Limited very much for providing language help. The authors thank Drs. Tan-Hu and Linfei-Wang (Dalian Medical University, Dalian, China) for good advice and providing the photographs. The authors also thank the reviewers for their constructive and valuable comments and suggestions.

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    • Type IV Cell-Mediated Hypersensitivity Reaction Caused by Titanium Implant Following Double Calcaneal Osteotomy and First Metatarsal-Cuneiform Arthrodesis: A Case Report and Review of the Literature

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    Financial Disclosure: None reported.

    Conflict of Interest: None reported.

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