CD06: A case of pseudoangioimmunoblastic T-cell lymphoma due to a failed shoulder replacement

C. Holden and R. Sabroe

Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

A retired metal machinist presented with extending erythematous infiltrated plaques on his right upper arm of 2 years’ duration, night sweats, fatigue, lymphadenopathy and weight loss. His symptoms had been unresponsive to three cycles of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisolone) given for presumed angioimmunoblastic T-cell lymphoma. The rash involved the scar from a right anatomical Depuy Synthes Epocca cementless total shoulder replacement (TSR) 3 years previously (titanium Ti-6-AI-7Nb eccenter, titanium press fit stem, a cobalt chromium head and polyethylene ultrahigh-molecular-weight glenoid). He reported right shoulder mechanical pain, reduced range of movement and weakness. He was patch tested to the British Society for Cutaneous Allergy standard, and a metal, acrylate and joint prosthesis series, including cobalt, potassium dichromate, aluminium, titanium oxide and components of bone cement. There was an allergic contact reaction to benzothiazolinone, possibly due to sensitization from machine oils, of no current relevance, with irritant reactions to cobalt on days 2, 4 and 7. Initial and repeat skin biopsies showed a palisaded neutrophilic and granulomatous dermatitis. The latter may be associated with connective tissue disease, haematological disorders, including lymphoma and sarcoid, or may be the result of an immune complex-mediated process. No metal or polyethylene wear particles were seen in skin or synovial tissue. A computed tomography scan showed abnormal soft tissue eroding most of the acromion, no loosening of the prosthesis, a large adjacent fluid collection, with multiple known enlarged subpectoral and axillary lymph nodes. A first-stage revision arthroplasty removed the Epocca prosthesis, inserting a temporary cement ball. There was no evidence of metallosis or prosthetic stem loosening, and the titanium components were not exposed. As a second stage, a Delta reverse cobalt and chrome TSR with a polyethylene insert was fitted. Suitable replacements all contained cobalt. The pseudolymphomatous rash started to subside soon after the TSR was removed. Three weeks after stage 2 movement and pain had improved. Fifteen months later he had a full range of movement, and the pain, rash and systemic symptoms had resolved. In a review of 238 noninfective implant-related complications, four with TSR, none of 26 with skin involvement had positive patch tests. In the others, positive tests were seen to cobalt in 2·9%, chrome 1·7%, aluminium 0·4%, titanium salts 0% and nobium 1·4% (Furrer S, Scherer Hofmeier K, Grize L, Bircher AJ. Metal hypersensitivity in patients with orthopaedic implant complications-A retrospective clinical study. Contact Dermatitis 2018; 79: 91–8). We present a case of a local pseudolymphomatous and systemic reaction to a failed shoulder prosthesis, initially imitating an angioimmunoblastic T-cell lymphoma.