Sudden appearance of black macules on palmar aspect of two university chemistry students

Clinical and Forensic Aspects of the Different Subtypes of Argyria

“…Localized argyria (LA; Figure 3 ) is less commonly seen, being caused by local silver deposition following skin incisions or percutaneous absorption via sweat gland pores [ 3 , 8 , 28 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 ]. This results in macular lesions or spots-clusters, confined to where the silver impregnation occurred and with coherent morphology, whose color, compared to GA’s, tends to be darker, sometimes almost black [ 8 , 73 , 81 , 82 , 83 ]. Patients most commonly present with complaints of asymptomatic lesions in a site of previous trauma, cautery with silver devices, or prolonged contact with silver-containing objects, creams, or solutions, as it occurs in the hands and forearms of silver-handling workers [ 2 , 75 , 81 , 82 , 84 , 85 , 86 , 87 ].…”

“…Argyria is often overlooked as a differential diagnosis of pigmented lesions, given its rarity [ 8 , 45 , 83 , 164 ]. Any of these findings might correspond to argyria: a slate-gray/bluish change of the complexion in sun-exposed areas, localized dark-blue lesions, eye gray/brown/dark spots or conjunctival pigmentation, or the characteristic nail changes seen in azure lunula [ 34 , 46 , 48 , 61 , 73 , 82 , 115 , 165 ].…”

“…The timespan for the onset of the pigmentation might vary from days to several years, and it then becomes ever lasting, making the diagnosis of argyria not discardable regardless of the amount of time passed since exposition and first-time pigmentation observation [ 8 , 81 , 83 , 87 , 134 , 164 , 165 , 188 , 222 , 244 ]. These should prompt a thorough anamnesis to ascertain if there is any kind of pathological or toxicological justification for these alterations and to establish a differential diagnosis ( Table 2 ).…”

“…To establish an unequivocal diagnosis, an Energy-Dispersive X-ray Spectroscopy (EDXS) must be undertaken as this technique, whose apparatus is generally attached to electron microscopes, allows identification of the chemical elements found in the granules via analysis of their emitted energy spectrum, making it the gold-standard tool for argyria definite diagnosis [ 38 , 39 , 83 , 84 , 132 , 133 , 141 , 164 ]. While being non-invasive, it presents remarkable specificity and sensitivity (estimated limit of detection of 3 to 4 ppm) for silver, as well as for other chemical elements such as selenium and sulfur, and it might even allow monitoring of subclinical silver deposition in occupationally exposed workers [ 133 , 164 , 274 ].…”

“…Dermatoscopy is also often employed, particularly in the evaluation of LA, typically exhibiting a dark, dense, and homogenous pigmentation [ 82 , 83 , 87 , 89 , 133 ]. Enei et al [ 71 ] showed that dermatoscopy might allow a peek into some detail of the histopathological pattern: dermal papillary silver seemingly appears as dots, perieccrine pigment as circumferences/ellipses, and the silver along the interpapillary dermis as linear structures.…”