Necrosis and Changes in Pigmentation Following Silver Nitrate Application: A Case Report.

ABSTRACT: Silver nitrate has useful antimicrobial and anti-inflammatory effects. However, there are currently no guidelines in place for its use in cauterization and the management of hemostasis. This lack of guidelines has resulted in different approaches being taken in outpatient and healthcare settings, which can lead to a higher risk of adverse effects. The authors present a case that illustrates a classic but exaggerated adverse effect following silver nitrate application.

Lesson of the month: management for aspiration of a silver nitrate pencil tip during tracheostomy care.

We present the cases of two laryngectomised patients who were treated for granulomas of the tracheostomy orifice with a silver nitrate pencil. During tracheostomy care, the tip broke off, was aspirated and fell into the bronchial tree. Necrotising ulcerative injuries of the right bronchial tree with clear delineation were found without lesions in the subsegmental division. To prevent the risk of secondary stenosis of the small airways induced by the spread of silver nitrate, we did not irrigate with saline solution as previously reported. Antibiotherapy and endoscopic monitoring were performed. Complete healing in 4-6 weeks was found without stenosis of the bronchial tree or bleeding.

A clinical mimicker of melanoma with distinctive histopathology: Topical silver nitrate exposure.

Exposure to silver-containing compounds can result in reversible discoloration of the skin, presenting as an irregular brown or black macule, which can have a clinical appearance similar to melanoma. Both the clinical scenario and the histopathology are unique. Silver nitrate darkens with exposure to light, and the area can appear to change over time. On microscopic examination, there are coarse pigmented granules dispersed throughout the corneal layer, and largely absent from the remainder of the epidermis-although the precise location may depend on the duration of topical exposure. While argyria, its irreversible counterpart, has been well-characterized, only a single source has previously reported the histopathology of transient topical silver nitrate exposure. We present two cases, review the clinical and histopathologic differentials, and detail the distinctive histopathology that enables a diagnosis to be suggested in this clinical mimicker of melanoma.

CG Demethylation Leads to Sequence Mutations in an Anther Culture of Barley Due to the Presence of Cu, Ag Ions in the Medium and Culture Time.

During plant tissue cultures the changes affecting regenerants have a broad range of genetic and epigenetic implications. These changes can be seen at the DNA methylation and sequence variation levels. In light of the latest studies, DNA methylation change plays an essential role in determining doubled haploid (DH) regenerants. The present study focuses on exploring the relationship between DNA methylation in CG and CHG contexts, and sequence variation, mediated by microelements (CuSO4 and AgNO3) supplemented during barley anther incubation on induction medium. To estimate such a relationship, a mediation analysis was used based on the results previously obtained through metAFLP method. Here, an interaction was observed between DNA demethylation in the context of CG and the time of culture. It was also noted that the reduction in DNA methylation was associated with a total decrease in the amount of Cu and Ag ions in the induction medium. Moreover, the total increase in Cu and Ag ions increased sequence variation. The importance of the time of tissue culture in the light of the observed changes resulted from the grouping of regenerants obtained after incubation on the induction medium for 28 days. The present study demonstrated that under a relatively short time of tissue culture (28 days), the multiplication of the Cu2+ and Ag+ ion concentrations ('Cu*Ag') acts as a mediator of demethylation in CG context. Change (increase) in the demethylation in CG sequence results in the decrease of 'Cu*Ag', and that change induces sequence variation equal to the value of the indirect effect. Thus, Cu and Ag ions mediate sequence variation. It seems that the observed changes at the level of methylation and DNA sequence may accompany the transition from direct to indirect embryogenesis.

Use of Silver Nitrate Application as Mini-Invasive Treatment of Pilonidal Sinus Disease.

OBJECTIVES: To investigate the cure rate and adverse effects of silver nitrate application for treatment of pilonidal sinus disease (PSD). Methods: Number of sinus pit orifices, and complications with silver nitrate application and debridement for sacrococcygeal PSD between January 2015 and July 2018 were analyzed in this retrospective study. Data were obtained from surgical, discharge, and outpatient follow-up records. Among 56 patients who were treated with silver nitrate stick, 11 patients with incomplete hospital records were excluded from the study. Demographic data including age, gender, length of follow-up, number of silver nitrate applications, number of involved sinuses and recurrence and complication rates were recorded. Results were expressed as frequencies, means, and range of values. The Mann Whitney U and chi square tests were used to evaluate significance. Results: Mean age was 24.3 +- 5.18 (range, 14 - 36) years, and recurrence occurred in 4 (8.9%) patients. Complications developed in 10 (22.2%) patients and included abscess, erythema, and necrosis in 5 (11.1%), 2 (4.4%), and 3 (6.6%) patients, respectively. The recurrence rate was significantly higher in patients who developed abscesses during the follow-up period (p = 0.001) than those who did not. There was no statistically significant correlation between the recurrence rate and number of sinuses or the number of silver nitrate applications. CONCLUSION: Low morbidity and high healing rates achieved with silver nitrate provide support for this application as a feasible and effective conservative outpatient treatment for PSD in certain patients.

Emergency Department care of childhood epistaxis.

OBJECTIVE: The aim of this review is to determine an efficient and safe primary strategy care for paediatric epistaxis. DATA SOURCES: We searched PubMed and Cochrane databases for studies referenced with key words 'epistaxis AND childhood'. This search yielded 32 research articles about primary care in childhood epistaxis (from 1989 to 2015). Bibliographic references found in these articles were also examined to identify pertinent literature. We compared our results to the specific management of adult epistaxis classically described in the literature. RESULTS: Epistaxis is one of the most common reasons for referral of children to a hospital ENT outpatient department. The bleeding usually originates from the anterior septum, as opposed to adults. Crusting, digital trauma, foreign bodies and nasal colonisation with Staphylococcus aureus have been suggested as specific nosebleed factors in children. Rare aetiologies as juvenile nasopharyngeal angiofibroma appear later during adolescence. There are different modes of management of mild epistaxis, which begin with clearing out blood clots and bidigital compression. An intranasal topical local anaesthetic and decongestant can be used over 6 years of age. In case of active bleeding, chemical cauterisation is preferred to anterior packing and electric cauterisation but is only feasible if the bleeding site is clearly visible. In case of non-active bleeding in children, and in those with recurrent idiopathic epistaxis, antiseptic cream is easy to apply and can avoid 'acrobatic' cauterisation liable to cause further nasal cavity trauma. CONCLUSIONS: Aetiologies and treatment vary with patient age and the existence or not of active bleeding at the time of the examination. Local treatments are usually easy to perform, but physicians have to ponder their indications depending on the possible complications in order to inform parents and to know paediatric epistaxis specificities.

Silver nitrate burn of the lower lip: a case report.

Silver nitrate is used in medicine to treat a number of conditions because of its cauterizing properties. This case report describes management of a silver nitrate burn of the oral mucosa that resulted in a large mass of necrotic tissue and accompanying pain in a 41-year-old man. The patient bit his lip and received silver nitrate treatment from a physician. Significant swelling and pain occurred over a period of 3 weeks after application. Analysis of a biopsy specimen revealed necrotic tissue with chronically inflamed granulation tissue. The lesion persisted, and it was determined that debridement was necessary to enhance wound healing and prevent significant scar formation. The patient was reexamined 10 days and 1 month after debridement. The lesion had significantly decreased in size, and the patient reported notable reduction of pain. The final follow-up at 3 months showed a desirable result with minimal scar formation. Use of concentrated silver nitrate for cautery can result in significant damage to mucous membranes, including oral mucosa.

Safety and systemic consequences of pleurodesis with three different doses of silver nitrate in patients with malignant pleural effusion.

BACKGROUND: Silver nitrate (SN) is an alternative to talc pleurodesis in patients with malignant pleural effusion (MPE). Nevertheless, SN complications have not been thoroughly investigated so far. OBJECTIVE: To evaluate frequent adverse events (AE) of SN treatment at three different doses for pleurodesis in patients with MPE. The secondary objective was to evaluate systemic inflammation, efficacy and quality of life in these patients. METHODS: A double-blind, randomized, clinical trial was conducted in patients with recurrent MPE at a tertiary university hospital. The study patients underwent pleural catheter insertion and were randomly assigned to one of the three pleurodesis groups treated with 30 ml 0.3%, 30 ml 0.5% or 60 ml 0.3% SN. Patients were discharged 3 days after the procedure, and returned to follow-up visits on days 10 and 30. During follow-up, AE, inflammatory markers, quality of life and CT scans were systematically assessed and documented. RESULTS: Sixty patients (11 males and 49 females, median age 62.13 years) were included. Overall, 199 AE were observed, including 23 serious AE. Grade 1/2 metabolic AE, such as increases in creatinine and liver enzymes, were the most frequent. Grade 3/4 hypoxia was observed in 13 patients. Four patients died, 3 due to disease progression and in 1 patient death was possibly related to pleurodesis. C-reactive protein levels increased in a dose-dependent manner and peaked 48 h after pleurodesis. No significant difference was observed among groups regarding quality of life or clinical/radiological recurrence. CONCLUSION: Hypoxia was the most significant AE following SN pleurodesis; mild metabolic events were very common. SN instillation causes substantial dose-dependent systemic inflammatory responses.

Case Report: Beware the Silver Nitrate Stick--A Risk Factor for Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ).

Topical silver nitrate may be used in oral and maxillofacial clinical settings owing to its astringent, caustic and disinfectant properties. Uses of the toughened silver nitrate pencil stick include haemostasis at bleeding points and for the management of aphthous ulcers, hypergranulation tissue, warts and verrucas. We present an interesting case of apparent silver nitrate-induced, bisphosphonate-related osteonecrosis of the hard palate following mucosal lesion biopsy in a multiple myeloma patient receiving zoledronic acid intravenous infusions. Our review of the literature indicates that this is the first report of such a scenario. CPD/Clinical Relevance: Clinicians must consider all potential sources of chemical and mechanical trauma to the bone and overlying mucosa when managing patients at risk of developing bisphosphonate-related osteonecrosis of the jaw.

Comparing recurrence between cautery techniques in pediatric epistaxis.

OBJECTIVE: To compare the risk of recurrent epistaxis between children treated with silver nitrate (SN) in the office or electrocautery (EC) in the operating room (OR). METHODS: Patients aged 2-18 diagnosed with epistaxis (ICD R04.0) in 2018 and treated with SN or EC were retrospectively reviewed. Epistaxis laterality, history of nasal trauma, and personal or family history of a bleeding disorder were recorded. Patients with prior cautery or epistaxis secondary to a procedure were excluded. Recurrence was defined as initial encounter after cautery with documented epistaxis. Patients were followed up into 2022 to track onset of recurrence. Time to recurrence between SN and EC was compared with hazard curves with predictors for recurrence analyzed via Cox's proportional hazard regression. RESULTS: Among 291 patients cauterized for epistaxis, 62 % (n = 181) received SN compared to 38 % (n = 110) who underwent EC. There was significantly higher risk of recurrence when treated with SN compared to EC (Hazard ratio 2.45, 95 % CI: 1.57-3.82, P < 0.0001). Median time to recurrence was not statistically different between techniques (6.39 months (SN) (IQR: 2.33, 14.82) vs. 4.11 months (EC) (IQR: 1.18, 20.86), P = 0.4154). Complication rates were low for both groups (1.16 % (SN) vs. 0 % (EC), P > 0.05). CONCLUSION: Among patients with epistaxis, risk of recurrence is significantly higher in those cauterized with SN compared to EC. Time to recurrence is not significantly different between cautery techniques.

Evaluation of a silver nitrate endometrial ablation fluid delivery system as a chemical treatment for menorrhagia.

STUDY OBJECTIVE: To explore the safety, feasibility, and effectiveness of silver nitrate-dextran paste delivered through the cervix as a simple and inexpensive endometrial ablation therapy for menorrhagia. DESIGN: Safety, feasibility, and effectiveness trials (Canadian Task Force classification II-3). SETTING: The trials were performed at the Whittington Hospital in London. PATIENTS: Seven women were treated for menorrhagia after prehysterectomy trials on 10 patients. Studies were first performed on rats and rabbits and human uterine specimens. INTERVENTION: We dissolved 10 g 75% silver nitrate/25% potassium nitrate and 15 g dextran 70 in 10 mL distilled water and delivered this paste through the cervix with a pressure-controlled syringe under fluroscopic monitoring. We planned silver nitrate doses of 500 mg in a 50-kg woman to remain in the uterus for 8 minutes after injection and then to be neutralized with normal saline and washed out. In uterine specimens, 8-minute treatment produced local necrosis to 4 mm. LD50 (lethal dose, 50%) studies in rats and mice ranged from 1100 to 2000 mg/kg. Prehysterectomy trials on 10 patients to evaluate safety revealed no penetration into the tubes and normal complete blood count, renal, cardiac, and liver tests with plasma silver rising to 20 to 30 µmoles/L and returning to baseline after 4 weeks. Finally, 7 patients were treated and followed for 6 months. We followed blood values, complications, and degree of flow reduction. Six patients were well and discharged the same day; of those, all blood values were similar to the safety studies, 5 reported varying degrees of flow reduction, and 1 patient continued with menorrhagia. The seventh patient had passage of paste into the left fallopian tube and peritoneal cavity producing immediate pain. Laparoscopy showed several burns on the back of the uterus, sigmoid colon, and cul de sac. After neutralization with saline, she made a complete, uneventful recovery and became oligoamenorrheic. CONCLUSION: Silver nitrate could be a simple, inexpensive, safe, and potentially effective agent for endometrial ablation. However, to ensure safety, the fluid delivery system described herein must be abandoned. An alternative delivery system is needed, one which precisely controls the locus of caustic action, and further testing is required for effectiveness and safety.

The use of silver nitrate in wound management.

The use of silver nitrate for chronic wounds such as leg ulcers, as well as burns and acute wounds has already been described in literature. However there is currently conflicting evidence in the literature to support the use of silver nitrate. We present our experience on two cases with extensive co-morbidities associated, where the use of silver nitrate application reduce dramatically the size of large wounds, which eventually healed, avoiding the patients to undergone surgery. Furthermore to reduce pain and distress associated with the application we used local anaesthetic prior to applying the silver nitrate.

Rapid onset of argyria induced by a silver-containing dietary supplement.

We describe a 53-year-old man in good general health who presented with an 8-month history of progressive gray hyperpigmentation of the face. He denied using any prescription medications; however, he admitted to taking a herbal supplement. Clinically, the differential diagnosis included hemochromatosis, Wilson's disease and hyperpigmentation secondary to supplement use. Punch biopsies from the left forehead and preauricular region showed heavily sun-damaged skin with a minimal inflammatory infiltrate. Closer inspection, however, revealed minute scattered black/brown particles distributed in the basement membrane zone of eccrine and sebaceous glands. Similar particles were also present in hair follicles, blood vessels and arrector pili muscles. The particles did not stain with Gomori methenamine silver, Fontana-Masson or iron stains. Electron microscopy with energy-dispersive x-ray analysis showed numerous particles, less than 1 µm in greatest dimension, which showed peaks for silver and sulfur. This analytical result confirmed the impression of argyria. Further history revealed that the patient had indeed been taking a silver supplement for several months under the premise that it would boost his immune system. This case is unique in that the patient's hyperpigmentation developed in a short period of time as compared with other reports in the medical literature.

[Accidental silver nitrate inhalation]. / Inhalation accidentelle de nitrate d'argent.

INTRODUCTION: Silver nitrate pencil is often used to treat local granuloma caused by tracheotomy and tracheostomy cannula orifice. CASE REPORT: We report the case of a 69-year-old patient who accidentally inhaled silver nitrate lead from the tip of a pencil during treatment of local granuloma. Inhalation of this product, which is known to cause burns and a risk of perforation of the mucous membranes, could suggest locoregional complications. Clinical monitoring and radiological and endoscopic examinations were carried out. Antibiotics and corticosteroids were administered because of inflammatory lesions. After 6 months, the patient had recovered with restitutio ad integrum of anatomical structures. CONCLUSION: Silver nitrate pencil should be used with caution. Given the high risk of perforation, painstaking and repeated monitoring are necessary in case of accidental inhalation. Bronchial endoscopy is of central importance as a means of localizing the foreign substance, following which bronchial cleaning is performed, using physiological serum. Corticosteroid appears to be effective to limit the risk of inflammatory bronchial stenosis.

Silver nitrate sclerotherapy for chyluria: evaluation for the optimal instillation regime.

OBJECTIVE: To compare the efficacy of the 3-instillation regime with the 9-instillation regime of 1% silver nitrate solution for renal pelvic instillation sclerotherapy in patients with chyluria. PATIENTS AND METHODS: 59 Patients with chyluria were prospectively evaluated and randomized into two groups. The study group received 3 instillations (n = 29) while the control group received 9 instillations (n = 30). 1% silver nitrate was used. RESULTS: In the study group of the 29 patients given sclerotherapy, 28 (96.5%) had complete symptomatic relief while symptoms persisted in 1 (3.44%). None of the patients had hematuria or any other severe complication. In the control group of the 30 patients given sclerotherapy, 29 (96.66%) had complete symptomatic relief while chyluria persisted in 1 (3.33%), 5 patients developed hematuria (16.66%) and 1 patient developed fever with UTI (3.33%). The results of the 3-instillation regime match the results of the more commonly used 9-instillation regime. With this shorter regime, the hospital stay, morbidity and overall complication rate is less and it is more cost effective. CONCLUSION: We recommend the 3-instillation regimen in patients with chyluria refractory to conservative treatment.

Advances of native and non-native Antarctic species to in vitro conservation: improvement of disinfection protocols.

Plants that inhabit Antarctica have raised scientific interest due to their resilience to climate change, abiotic tolerance mechanisms and potential biological applications. In vitro propagation is useful for conservation, genetic material availability of these species and avoiding mass collection in their habitat. In vitro culture protocols for the native plants Colobanthus quitensis and Deschampsia antarctica and the non-native Juncus bufonius have been affected by endophytic microorganisms that proliferate when introduced to tissue cultures. This study evaluated the microbicidal and phytotoxic effect of calcium hypochlorite (Ca(ClO)2), silver nitrate (AgNO3) and silver nanoparticles (AgNPs), and their use at different concentrations for different time periods. The Ca(ClO)2 at 100 mg mL-1 showed the best microbial contamination control in D. antarctica (applied for 20 min) and for the three C. quitensis populations (applied for 15 min). In J. bufonius, AgNO3 at 10 mg mL-1 for 10 min reduced the microbial growth, but oxidative damage was generated. AgNPs did not prevent contamination or have adverse effects on tissues. Survival plantlets from each treatment, population or species were effectively introduced to the tissue culture and their propagation was successful. These results constitute a fundamental advance for the introduction, propagation and conservation of Antarctic species and their use in scientific research.

The addition of silver nitrate cautery to antiseptic nasal cream for patients with epistaxis: A systematic review and meta-analysis.

OBJECTIVE: To compare the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis. METHODS: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic information was conducted to identify all Randomised Controlled Trials (RCTs) and non-randomised studies comparing the outcomes of the addition of silver nitrate cautery versus antiseptic cream alone in paediatric patients with recurrent epistaxis. Treatment success and persistence of bleeding were primary outcome measures. Secondary outcome measures included treatment side effects. Fixed effects modelling was used for the analysis. RESULTS: Four studies enrolling 240 patients were identified. There was no significant difference between silver nitrate cautery group and antiseptic cream alone group in terms of complete resolution (Odds Ratio [OR] = 1.07, P = 0.81), the partial resolution (OR = 1.02, P = 0.96) and persistence of bleeding (OR = 0.91, P = 0.71). For secondary outcomes, antiseptic nasal cream was associated with few side effects such as rash in one case and several complaints of bad smell or taste. CONCLUSIONS: The addition of silver nitrate cautery is not superior to the use of antiseptic cream alone in paediatric patients with recurrent epistaxis as it does not improve treatment success or persistence of bleeding.

Monoclonal anti-vascular endothelial growth factor antibody reduces fluid volume in an experimental model of inflammatory pleural effusion.

BACKGROUND AND OBJECTIVE: Vascular endothelial growth factor (VEGF) is known to increase vascular permeability and promote angiogenesis. It is expressed in most types of pleural effusions. However, the exact role of VEGF in the development of pleural effusions has yet to be determined. The anti-VEGF mAb, bevacizumab, has been used in the treatment of cancer to reduce local angiogenesis and tumour progression. This study describes the acute effects of VEGF blockade on the expression of inflammatory cytokines and pleural fluid accumulation. METHODS: One hundred and twelve New Zealand rabbits received intrapleural injections of either talc or silver nitrate. In each group, half the animals received an intravenous injection of bevacizumab, 30 min before the intrapleural agent was administered. Five animals from each subgroup were sacrificed 1, 2, 3, 4 or 7 days after the procedure. Twelve rabbits were used to evaluate vascular permeability using Evans's blue dye. Pleural fluid volume and cytokines were quantified. RESULTS: Animals pretreated with anti-VEGF antibody showed significant reductions in pleural fluid volumes after talc or silver nitrate injection. IL-8 levels, vascular permeability and macroscopic pleural adhesion scores were also reduced in the groups that received bevacizumab. CONCLUSIONS: This study showed that bevacizumab interferes in the acute phase of pleural inflammation induced by silver nitrate or talc, reinforcing the role of VEGF as a key mediator in the production of pleural effusions. The results also suggest that bevacizumab should probably be avoided in patients requiring pleurodesis.