Polymethylmethacrylate Contact Dermatitis after Vertebroplasty From: Ankit A. Mahadevia, BA David Weiland, MD Peter Kvamme, MD Kieran P.J. Murphy, MD Abhishek Srinivas, MD Gerald Wyse, MD Division of Interventional Neuroradiology Department of Radiology and Radiological Sciences The Johns Hopkins Medical Institutions 600 N. Wolfe Street Baltimore, MD 21287 Editor: Hypersensitivity reactions to polymethylmethacrylate (PMMA) are well documented in the literature. Reports of PMMA reaction as a consequence of vertebroplasty have identified cases in which patients and technicians presented with bronchospasm and other pulmonary symptoms (1,2). Allergic reaction secondary to PMMA skin contact was first reported in 1941 (3) and has also been documented in the literature in several applications of the compound (4–6). In this discussion, we report a case of contact dermatitis at the site of vertebroplasty. The patient is a 52-year-old female who underwent bilat- eral vertebroplasty at T12 for pain secondary to a T12 com- pression fracture. She is allergic to penicillin, sulfa drugs, and intravenous contrast media, and no intravenous con- trast was used in the procedure. The procedure was well tolerated, and the patient manifested no early complications. She reported development of a 4 inch  2 inch region of blistering at the site of PMMA injection 1 day after the procedure (Figure). The blistered area was located at and around the spine level that underwent injection and did not conform to the prepared field. The lesion was intermittently itchy with some weeping, but no purulent drainage. White blood cell count and erythrocyte sedimentation rate were within normal limits, and the patient was afebrile. A 1-week course of topical corticosteroids (hydrocortisone acetate 1.0%, generic ointment, applied twice daily) eliminated itch- ing, weeping, and dramatically reduced the size of the in- jection site lesion. In light of the pattern and location of the lesion at the injection site, skin contact with PMMA during the procedure is the most likely etiology of the patient’s symptoms. The currently accepted model of contact allergy describes a de- layed-type hypersensitivity reaction that develops in a ge- netically susceptible individual. A hapten, such as N,N- dimethylparatoluidine, conjugates with a body protein, which creates a neoantigen capable of stimulating an im- mune response. This unique antigen is processed by den- dritic cells or macrophages and presented to T cells, gener- ating a cell-mediated, inflammatory response (7). Kaplan et al (8) describe a potential protocol for detection of PMMA dermatitis susceptibility in patients undergoing knee replacement that may be applied to vertebroplasty. A detailed history is taken of any skin reaction occurring after exposure to acrylic cosmetic cement, dental implants, paints, inks, surgical tape, and additional materials known to con- tain acrylate. Patients reporting a reaction to such materials undergo standard methacrylate series patch testing preop- eratively to identify appearance of a hypersensitivity reac- tion. Topical steroids or alternative treatment methods after the procedure may be pursued depending on the nature of the reaction. We report a case of dermatitis secondary to PMMA con- tact during vertebroplasty. A detailed history followed by patch testing in susceptible individuals may help prevent uncomfortable and potentially serious reaction to acrylate cement during the procedure. References 1. Yoo KY, Jeong SW, Yoon W, Lee J. Acute respiratory distress syndrome associated with pulmonary cement embolism follow- ing percutaneous vertebroplasty with polymethylmethacrylate. Spine 2004; 29:E294 –297. 2. Kirby BS, Doyle A, Gilula LA. Acute bronchospasm due to exposure to polymethylmethacrylate vapors during percutane- ous vertebroplasty. AJR Am J Roentgenol 2003; 180:543–544. 3. Stevenson WJ. Methyl methacrylate dermatitis. Contact Point 1941; 18:171 4. Foussereau J, Cavelier C, Protois JP, Deviller J. Contact derma- titis from methyl methacrylate in an above-knee prosthesis. Con- tact Dermatitis 1989; 20:69 –70. 5. Kanerva L, Estlander T, Jolanki R. Dental nurse’s occupational allergic contact dermatitis from eugenol used as a restorative dental material with polymethylmethacrylate. Contact Dermati- tis 1998; 38:339 –340. 6. Saccabusi S, Boatto G, Asproni B, Pau A. Sensitization to methyl methacrylate in the plastic catheter of an insulin pump infusion set. Contact Dermatitis 2001; 45:47– 48. 7. Guin JD. Practical Contact Dermatitis: A Handbook for the Practitioner. New York: McGraw-Hill, 1995:631– 638. 8. Kaplan, K, Della Valle CJ, Haines K, Zuckerman JD. Preoper- ative identification of a bone– cement allergy in a patient under- going total knee arthroplasty. J Arthroplasty 2002; 17:788 –791. DOI: 10.1016/j.jvir.2007.01.026 Figure. Skin reaction 2 days after the procedure. Letters to the Editor • 585 Volume 18 Number 4