Titanium and Other Metal Hypersensitivity Diagnosed by MELISA® Test: Follow-Up Study
Vrbova R, Podzimek S, Himmlova L, et al. BioMed Research International 2021
This study is aimed at proving the clinical benefit of the MELISA® test in the minimization or complete elimination of health problems in patients with confirmed hypersensitivity to metals used for tissue replacements. A group of 305 patients aged 20-75 years with previously proven metal hypersensitivity (initial MELISA® test), mainly to titanium and then to another fifteen metals, was chosen from the database at the Institute of Dental Medicine. From these patients, a final group of 42 patients agreed to participate in the study, 35 of which were female and 7 were male. The patients completed a special questionnaire aimed at information regarding change of health status from their last visit and determining whether the results of the initial MELISA® test and recommendations based on it were beneficial for patients or not. They were clinically examined, and peripheral blood samples were taken to perform follow-up MELISA® tests. Questionnaire data was processed, and the follow-up MELISA® test results were compared with the results of the initial MELISA® tests. For statistical analysis, the Fisher’s exact test and paired -test were used. Thirty-two patients reported that they followed the recommendations based on the results of the initial MELISA® tests, and of these, 30 patients (94%) confirmed significant health improvement. Six patients did not follow the recommendation, and from these, only one patient reported an improvement in his health problems. By comparison of the initial and follow-up MELISA® test results, it can be stated that the hypersensitivity to the given metal decreased or disappeared after the therapeutic interventions performed based on the initial MELISA® test results. The evaluation of the data obtained from patients in this study confirmed a significant clinical benefit of MELISA® test. Full article on https://www.hindawi.com/journals/bmri/2021/5512091/
Delayed‑type hypersensitivity to metals in newly diagnosed patients with nonischemic dilated cardiomyopathy
Manousek J, et al. Cardiovascular Toxicology 2020;20:571–580.
The causes of nonischemic dilated cardiomyopathy are classified as genetic or nongenetic, but environmental factors such as metal pollutants may interact with genetic susceptibility. The presence of metal particles has been detected in the myocardium, including in those patients with dilated cardiomyopathy. It is also known that hypersensitivity reactions can induce inflammation in tissue. The present study aimed to verify if metal-induced delayed-type hypersensitivity is present in patients with nonischemic dilated cardiomyopathy. The patient group consisted of 30 patients with newly diagnosed dilated cardiomyopathy; the control group comprised 41 healthy subjects. All patients and control subjects provided blood samples for lymphocyte transformation testing (MELISA®) to assess possible hypersensitivity to seven common metals. Specific exposure to metals was based on interview data. Results showed that exposure to cadmium and lead (p=0.0002), aluminium (p=0.0006), nickel (p=0.0012), and chromium (p=0.0065) was more often reported by patients than controls. The patients also had significantly more frequent hypersensitivity reactions to mercury (26.7% vs. 7.3%, p=0.014624), nickel (40% vs. 12.2%, p=0.02341), and silver (20% vs. 4.8%, p=0.025468) than the control group. Patients with dilated cardiomyopathy had greater exposure to certain metals compared with healthy controls. Hypersensitivity to metals was more frequent in patients with dilated cardiomyopathy, suggesting a possible association that warrants further investigation.
Side effects of dental metal implants: Impact on human health (Metal as a risk factor of implantologic treatment)
Přikrylová J, Procházková J, Podzimek Š. BioMed Research International 2019(1, article no 56):1-5
Dental implants are often made of titanium alloys. Implant therapy currently promises a good long-term result without impacting health; however, its success depends on many factors. In this article, the authors focus on the most common risk factors associated with metallic surgical implants. Titanium-induced hypersensitivity can lead to symptoms of implant rejection. Corrosion and biofilm formation are additional situations in which these symptoms may occur. For medical purposes, it is important to define and discuss the characteristics of metals used in implantable devices and to ensure their biocompatibility. To avoid hypersensitivity reactions to metallic dental implants, precautionary principles for primary prevention should be established.
Interstitial lung diseases associated with metal content in silicone breast implants: a case series
Fireman E, Rosengarten D, Zelinger E, Kramer MR. Sarcoidosis Vasc Diffuse Lung Dis 2018;35:381-389
Background: Silicone gel-filled breast implants have been widely used for breast augmentation and reconstruction since the 1960’s when the FDA approved them in women over 22 years of age. Concerns have been raised about the safety of those implants, with the focus upon whether silicone leak can spread to regional lymph nodes and remote organs and possibly cause inflammatory and immune responses.
Objective: To present laboratory workup findings in 3 cases of interstitial lung diseases (ILD) linked with silicone implant leakage. Methods: ILD was diagnosed by tissue biopsy and Computerized Tomography (CT). We analyzed the metal content in both biological samples and raw material of the implants by means of scanning electron microscopy (SEM) and X-ray fluorescence (XRF). The metals lymphocyte proliferation analysis (MELISA®) was used to assess sensitization of the immune system to 19 metals.
Results: The biological samples contained metals (silicon, nickel, zinc, tungsten, iron, aluminum, and zirconium) which are also present in the silicone implant. The MELISA test showed sensitization to nickel, zinc and tin. Limitations: Some of the immunogenic metals present in the implant were under the limits of detection of SEM and XRF and the sensitivity of MELISA test is unknown.
Conclusions: The laboratory assessments of the 3 herein described women indicated that their interstitial lung disease was associated with the metal content of their silicone gel-filled breast implantations.
Metal allergy as a cause of implant failure in shoulder arthroplasty
Jia-Wei KK et al. Orthopedics. 2017 Sep 1;40(5):e844-e848.
Metal allergy is an uncommon and poorly understood cause of failure of orthopedic implants. To the authors' knowledge, there have been no reports of the management of shoulder arthroplasty patients with metal allergy. The authors present their experience with the diagnosis and management of patients with metal allergy. Patients with metal allergy undergoing shoulder arthroplasty were identified through retrospective chart review from January 1, 2012, to January 31, 2015. Case characteristics collected included patient risk factors (age, sex, prior cutaneous reactions to metal), metal allergy factors (type of metal allergy, method of diagnosis), and surgery factors (implant type, primary/revision, type of shoulder arthroplasty). Outcomes measured included American Shoulder and Elbow Surgeons score, Penn Shoulder Score, and Single Assessment Numeric Evaluation score. Eleven patients were identified with metal allergy. Five were diagnosed prior to the index arthroplasty, and 6 were diagnosed after shoulder replacement. The diagnosis was made through skin patch testing, memory lymphocyte immunostimulation assay, or clinical history. Patients identified after implantation presented with progressive pain and stiffness, but none had cutaneous manifestations. Patients with metal allergy had better results undergoing primary shoulder arthroplasty than undergoing revision. Metal allergy is rare but may be a clinically significant cause of unsatisfactory shoulder arthroplasty. Given the superior results of primary shoulder arthroplasty compared with revision, screening for metal allergy by clinical history is recommended. Access article here: https://www.healio.com/orthopedics/journals/ortho/2017-9-40-5/%7Bf5fefba8-56fa-4741-acd1-acf5394849ce%7D/metal-allergy-as-a-cause-of-implant-failure-in-shoulder-arthroplasty#div
Delayed-type hypersensitivity to metals of environmental burden in patients with Takotsubo syndrome – Is there a clinical relevance?
Manousek J, et al. PLOS ONE | DOI:10.1371/journal.pone.0164786 November 8, 2016
Objective: Takotsubo syndrome (TS) is a heart condition characterised by a sudden transient left ventricular
dysfunction; its pathophysiology is probably associated with elevated levels of catecholamines
but the exact mechanism is not known as yet. Literature and clinical experience suggest that TS affects persons with various comorbidities. This pilot work aims to evaluate the frequency of comorbidities with potential pathological immune reactivity, and to evaluate the potential association between TS and hypersensitivity to metals assessed by LTT-MELISA®.
Methodology, Results: A total of 24 patients (23 women, 1 man) with a history of TS attack and 27 healthy controls were evaluated. Hypersensitivity was evaluated by a lymphocyte transformation test (LTT MELISA®); a questionnaire of environmental burden was used to select evaluated metals. A total of 19 patients (79%) had at least one condition that might potentially be associated with pathological immune reactivity (autoimmune thyroid disease, drug allergy, bronchial asthma, cancer, contact dermatitis, rheumatoid arthritis). Hypersensitivity to metals was identified significantly more frequently in TS patients than in healthy controls (positive reaction to at least one metal was identified in 95.8% of TS patients and in 59.3% of controls; p = 0.003); the difference was statistically significant for mercury (45.8% and 14.8%, respectively; p = 0.029).
Conclusion: Our work shows that conditions with pathological immune reactivity occur frequently in TS patients, and our data suggest a possible association between TS and hypersensitivity to metals (mercury in particular) evaluated by LTT-MELISA® . We also suggest that apart from the triggering stress factor, potential existence of other serious conditions should be considered when taking medical history of TS patients.
Identification of metal sensitization in sarcoid-like metal-exposed patients by the MELISA® lymphocyte proliferation test — a pilot study
Fireman E, et al. Journal of Occupational Medicine and Toxicology (2016) 11:18 , DOI 10.1186/s12995-016-0101-1.
Background: Pulmonary function is often affected by the inhalation of metal particles. The resulting pathology might trigger various lung diseases, e.g., parenchymal lung fibrosis and granulomatous lung disorders. We previously demonstrated that 6% of tissue-proven sarcoid patients had a positive beryllium lymphocyte proliferation test (BeLPT),thus correcting the diagnosis to chronic beryllium disease. The aim of this study was to examine if Memory Lymphocyte Immnuno Stimulation Assay (MELISA®), currently used for non-pulmonary diseases, can identify metals other than beryllium that can also trigger sensitization and induce granulomatous disease.
Methods: This pilot study included 13 sarcoid-like patients who underwent MELISA® . Eleven patients also underwent BeLPT. Biopsy samples were tested for metal content by scanning electron microscope. Eleven study patients had been exposed to metals at the workplace and 2 had silicone implants.
Results: Two patients who had undergone BeLPT were positive for beryllium. MELISA® detected 9 patients (9/13, 69 %) who were positive for at least one of the tested metals: 4 reacted positively to nickel, 4 to titanium, 2 to chromium, 2 to beryllium, 2 to silica, and one each to palladium, mercury and lead.
Conclusion: It is proposed that MELISA® can be exploited to also identify specific sensitization in individuals exposed to inhaled particles from a variety of metals.
Allergy and autoimmunity caused by metals: A unifying concept
Stejskal V, in Vaccines and Autoimmunity 2015 (eds Y. Shoenfeld, N. Agmon-Levin and L. Tomljenovic), John Wiley & Sons, Inc, Hoboken, NJ, USA. doi: 10.1002/9781118663721.ch5
Metals, such as mercury, aluminum, gold, and nickel, play a role in various allergic and autoimmune diseases. This chapter discusses the factors underlying their immunotoxic properties. Mercury (in the form of thimerosal) and aluminum are both ingredients in vaccines. They can also enter the body through dental restorative materials, cigarette smoke, and environmental pollution. These metals bind to autologous proteins and thus function as immunologocally active haptens. They also possess immunomodulating properties. Metal-specific responses are mediated by sensitized T cells and depend on the genetic makeup of the individual. This means that some individuals are resistant and others are susceptible. A better understanding of the immunopathological role of metals will contribute to improved treatment of immune-mediated diseases and hopefully to the development of safer vaccines.
Increased frequency of delayed type hypersensitivity to metals in patients with connective tissue disease
Stejskal V, Reynolds T, Bjørklund G. Journal of Trace Elements in Medicine and Biology 2015; 31:230-236
Background: Connective tissue disease (CTD) is a group of inflammatory disorders of unknown etiology. Patients with CTD often report hypersensitivity to nickel. We examined the frequency of delayed type hypersensitivity (DTH) (Type IV allergy) to metals in patients with CTD.
Methods: Thirty-eight patients; 9 with systemic lupus erythematosus (SLE), 16 with rheumatoid arthritis (RA), and 13 with Sjögren’s syndrome (SS) and a control group of 43 healthy age- and sexmatched subjects were included in the study. A detailed metal exposure history was collected by questionnaire. Metal hypersensitivity was evaluated using the optimized lymphocyte transformation test LTT-MELISA (Memory Lymphocyte Immuno Stimulation Assay).
Results: In all subjects, the main source of metal exposure was dental metal restorations. The majority of patients (87%) had a positive lymphocyte reaction to at least one metal and 63% reacted to two or more metals tested. Within the control group, 43% of healthy subjects reacted to one metal and only 18% reacted to two or more metals. The increased metal reactivity in the patient group compared with the control group was statistically significant (P < 0.0001). The most frequent allergens were nickel, mercury, gold and palladium.
Conclusions: Patients with SLE, RA and SS have an increased frequency of metal DTH. Metals such as nickel, mercury and gold are present in dental restorative materials, and many adults are therefore continually exposed to metal ions through corrosion of dental alloys. Metal-related DTH will cause inflammation. Since inflammation is a key process in CTDs, it is possible that metal-specific T cell reactivity is an etiological factor in their development. The role of metal-specific lymphocytes in autoimmunity remains an exciting challenge for future studies.
Carbon coated implants as a new solution for metal allergy in early-onset scoliosis: A case report and review of the literature
Zielinski J, Lacy TA, Phillips JH. Spine Deformity 2(1):76-80 2014
STUDY DESIGN: Retrospective case report.
OBJECTIVE: To report the first known case of immunological camouflage of a metal spinal implant with carbon coating.
SUMMARY OF BACKGROUND DATA: Metal sensitivity is common and is a consideration when choosing orthopedic implants in susceptible individuals. The sensitivity often is to nickel, cobalt, or chromium, and titanium is used as a safe alternative. However, when the allergy is also to titanium, solutions may be much more difficult. This case describes an innovative solution to a complex metal allergy that includes titanium in a child requiring spinal instrumentation for early-onset scoliosis.
METHODS: At age 6 years 7 months, the patient underwent an uncomplicated placement of bilateral posterior Vertical Expandable Prosthetic Titanium Ribs (VEPTRs; Synthes, Inc., West Chester, PA). At that time, there were no known metal allergies. At 3 weeks, the right side had become erythematous and had serosanguineous drainage. It briefly improved after each of 2 surgical debridements and a course of intravenous antibiotics, but within 6 weeks of the index procedure, the pain was still worsening. A titanium allergy was suspected and blood was sent for allergy testing. A test confirmed hypersensitivity to titanium, niobium, molybdenum, iron, and aluminum, among others. The remaining rod was removed. An in vivo trial for tolerance to high-grade stainless-steel implants was done. The implant was removed after 2 weeks because of systemic symptoms that occurred.
RESULTS:A plasma-spray, carbon-coated VEPTR rod was designed. A rod sample was inserted into the patient's forearm for trial. After 3 months, there was no appreciable reaction. Carbon-coated VEPTRs were placed without complications. The patient has undergone multiple lengthening using the carbon-coated VEPTRs. CONCLUSIONS:In the rare patient with multiple allergies, choosing orthopedic implants can be challenging. An innovative carbon coating was applied by plasma spray to the VEPTR system, with good results.
Access article here: https://www.sciencedirect.com/science/article/abs/pii/S2212134X13001317?via%3Dihub
Diagnostic use of the lymphocyte transformation test-memory lymphocyte immunostimulation assay in confirming active Lyme borreliosis in clinically and serologically ambiguous cases
Puri B, Segal D, Monro J. Int J Clin Exp Med 2014;7(12):5890-5892
Abstract: The aim of this study was to carry out an independent evaluation of the proposition that the lymphocyte transformation test-memory lymphocyte immunostimulation assay (LTT-MELISA) may be diagnostically useful in the confirmation of active Lyme borreliosis in clinically and serologically ambiguous cases. Blood samples from 54 patients consecutively presenting to a British center with clinical suspicion of Lyme borreliosis were tested for this disease by immunoglobulin M (IgM) and immunoglobulin G (IgG) Western blots and by LTT-MELISA. Forty-five of these patients had Western blot results which were negative for both IgM and IgG by the criteria of the Centers for Disease Control and Prevention (CDC); of these patients, 19 (42%) were LTT-MELISA-positive. Two of the patients who had IgM positive results by the CDC criteria were LTT-MELISA-negative. It is concluded that, for putative European-acquired Lyme borreliosis infections, it would be sensible to carry out both the LTT-MELISA and Western blot assay.
Metals as a common trigger of inflammation resulting in non-specific symptoms: diagnosis and treatment
Stejskal V. Isr Med Assoc J. 2014; 16: 753–758
The multiple symptoms of chronic fatigue syndrome (CFS) and fibromyalgia resemble those described in patients suffering from autoimmune/inflammatory syndrome induced by adjuvants (ASIA). It has been suggested that chronic metal-induced inflammation might play a role both in CFS and fibromyalgia as well as in ASIA. Three subjects with CFS and two with fibromyalgia were studied, all of whom suspected metal exposure as a trigger for their ill health. All patients except one were sensitized to metals present in their dental restorations. The remaining patient reacted to metals in his skull implant. The removal of sensitizing metals resulted in long-term health improvement. Nine healthy controls matched for gender and age showed only marginal reactivity to the metals tested.
Metal-induced inflammation triggers fibromyalgia in metal-allergic patients
Stejskal V, Öckert K, Bjørklund G. Neuroendocrinol Lett 2013; 34(6):559–565.
This article studied the frequency and clinical relevance of metal allergy in 15 fibromyalgia (FM) patients. Metal allergy was measured by a lymphocyte transformation test, MELISA®. Ten healthy age matched women were used as controls. Reduction of metal exposure in the FM patients was achieved by replacement of dental metal restorations and by the avoidance of known sources of metal exposure. Objective health assessment was performed 5 years after treatment. Subjective health assessment was established by a questionnaire, completed 2, 5 and in some cases 10 years after the start of the study. Follow-up MELISA was also performed. All FM patients tested positive to at least one of the metals tested. Objective examination 5 years later showed that half of the patients no longer fulfilled the FM diagnosis, 20% had improved and the remaining 30% still had FM. All patients reported subjective health improvement.
Mercury-induced inflammation: Yet another example of ASIA syndrome
Stejskal V. Isr Med Assoc J. 2013 Nov;15(11):714-5.
Excerpt from the Editorial: In this issue of IMAJ, the occurrence of a plethora of psychoneuro-immunological symptoms (also called ASIA or Shoenfeld syndrome) is described in three different patients. Segal and co-authors present an 85 year old woman who underwent total hip replacement and experienced side effects. Patch testing showed hypersensitivity to cobalt and chromium. The metal components were replaced with ceramics and the symptoms disappeared. The second case, reported by Pineda and team, concerns a 53 year old woman with breast implants. Since silicone was found in her lymph nodes, removal of her implants was recommended. Finally, Cruz-Dominguez et al. present the thought-provoking case of a patient exposed subcutaneously to a large amount of metallic mercury. The case illustrates that mercury might act as a potent adjuvant, inducing ASIA.
Allergological and toxicological aspects in a multiple chemical sensitivity cohort
Pigatto P, et al. Oxid Med Cell Longev. 2013;2013:356235.
Background: Multiple chemical sensitivity (MCS) is a chronic condition characterized by an exaggerated response to toxicants.We ascertained the prevalence of allergy to metals and toxicological aspects in MCS patients.
Methods: We conducted a retrospective review of medical records of 41 patients with MCS. We performed patch testing (n = 21) for dental series and did lymphocyte transformation test (n = 18) for metals. We measured mercury in samples of blood (n = 19), urine (n = 19), saliva (n = 20),and scalp hair (n = 17) to investigate the association between mercury levels and cases of MCS. Results. The prevalence of metal immune hypersensitivity in a subset of 26 patients was 92.3 percent. Elevations of mercury occurred in 81.2 percent (26 of 32). The mean (±SD) in blood concentrations of mercury was 7.6 ± 13.6 ?g/L; mean in urine was 1.9 ± 2.5 ?g/L; mean in scalp hair was 2.2 ± 2.5 ?g/g; mean in saliva was 38.1 ± 52.1 ?g/L. Subgroup analyses showed that elevation of mercury levels in biological matrices were associated with mercury amalgams in patients with MCS (22 patients), compared with controls (8 patients) (odds ratio 11 : 95 percent confidence interval 1.5 to 81.6; n = 0.023).
Conclusions: Our data show an increased prevalence of metal allergy and elevation of mercury levels in bioindicators among patients with MCS.
When patients with hypersensitivity to metals present for surgery where metallic prostheses are required, problems arise about the choice of the prosthesis. We present a case of a patient with proven metal sensitivity to cobalt, chromium, nickel and molybdenum, who required bilateral total knee replacement for osteoarthritis and was successfully managed by a titanium prosthesis. The patient’s MELISA test revealed a strongly positive allergy to nickel and chromium and weakly positive results for cobalt and molybdenum. Based on the MELISA report, the implant used in our patient was made from titanium, and a polyethylene insert was used to avoid the possible metal allergy. Our case demonstrated the need for proper investigation with tests such as MELISA and also the need for proper history in all such patients.
Read full article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081493/
Metal sensitivity in patients with orthopaedic implants: a prospective study
Frigerio, E et al. (2011). Contact Dermatitis, 64: 273–279.
A total of 100 patients referred for total hip or total knee arthroplasty were assessed for metal allergy preoperatively and then at 1 year post-implantation by means of patch tests. In a pilot study, 20 patients also underwent both patch testing and a lymphocyte transformation test (LTT-MELISA®) for the same metals. Of 31/100 patients with an apparent history of nickel sensitivity determined during preoperative assessment of subjects, 12 tested negative on both tests, and 4 with a negative history of nickel sensitivity tested positive. One year post-implantation (72 patients), 5 patients who had initially tested negative for a metal allergy became positive for at least one or more metal constituents of the prosthesis on at least one or the other test. Given the discrepancies between the information obtained while taking patient histories and test results, preoperative history-taking alone appears to be insufficient for identifying patients with metal sensitivity. Moreover, the increase in the percentage of patients who tested positive for metal sensitivity 1 year postimplantation suggests the possibility of prosthesis-induced sensitization. Therefore, objective determination of metal sensitivity at preoperative assessment should be considered in planning arthroplasty intervention, as it would help the surgeon in selecting the most appropriate prosthesis for the patient and could benefit implant performance.
The role of environmental factors in autoimmune thyroiditis.
Hybenova M, Hrda P, Procházková J, Stejskal V, Sterzl I. Neuro Endocrinol Lett. 2010;31(3):283-9.
Environmental factors can play an important role in the development of autoimmune
thyroiditis (AT) and other autoimmune diseases. This article reviews the role of heavy metals and infectious agents in AT. It has been found that patients with AT and other autoimmune diseases, such as multiple sclerosis, psoriasis, systemic lupus erythematosus and atopic eczema, show increased lymphocyte reactivity in vitro to inorganic mercury, nickel and other metals compared to healthy controls. An important source of mercury is dental amalgam. Replacement of amalgam in mercury-allergic subjects resulted in improved health in about 70% of patients.
A novel lymphocyte transformation test (LTT-MELISA) for Lyme borreliosis
Valentine-Thon E, Ilsemann K, Sandkamp M. Diagn Microbiol Infect Dis. 27;2006
In this study, we describe the development and clinical relevance of a novel LTT using a validated format (MELISA) together with well-defined recombinant Borrelia-specific antigens. From an initial screening of 244 patients with suspected Borrelia infection or disease, 4 informative recombinant antigens were selected: OspC (Borrelia afzelii), p41-1 (Borrelia garinii), p41-2 (B. afzelii), and p100 (B. afzelii). Thereafter, 30 seronegative healthy controls were tested in LTT-MELISA to determine specificity, 68 patients were tested in parallel to determine reproducibility, and 54 lymphocyte-reactive symptomatic patients were tested before and after antibiotic therapy to assess clinical relevance. Most (86.2%) of the 36.9% (90/244) LTT-MELISA positive patients were seropositive and showed symptoms of active LB. Specificity was 96.7% and reproducibility 92.6%. After therapy, most patients (90.7%) showed negative or markedly reduced lymphocyte reactivity correlating with clinical improvement. This novel LTT-MELISA assay appears to correlate with active LB and may have diagnostic relevance in confirming LB in clinically and serologically ambiguous cases.
Diagnosis and treatment of metal-induced side-effects
Stejskal V, Hudecek R, Stejskal J, Sterzl I. Neuro Endocrinol Lett 2006; 27(Suppl 1): 7-16
Environmental factors are recognized as a cause of the increasing frequency of allergic and autoimmune diseases. In addition to external pollutants, metal ions released from dental restorations or from other body implants might trigger inflammation in susceptible subjects. In humans, genes governing metal-induced inflammation and autoimmunity are not yet known. In clinical praxis, metal-sensitive patients will present various symptoms ranging from oral mucosal changes and skin disease to excessive fatigue and autoimmune
diseases. Since genetic markers of genetic susceptibility in man are not known, one has to rely on the phenototypic markers. Such biomarkers might be certain detoxification enzymes but also the presence of metal-specific memory cells in the blood. With the increasing use of metal implants in medicine and dentistry, it is important to have a proper tool for the diagnosis of metal allergy in susceptible subjects. In addition to patch test, an in vitro blood test, an optimized commercially available lymphocyte transformation test (MELISA®) is discussed. Both tests were used for the diagnosis of metal allergy in a selected group of 15 patients who suffered from clinical metal sensitivity in addition to other health problems. The concordance of the two tests was good but MELISA® detected more metal allergies than patch test. The removal of incompatible dental material (RID) resulted in long-term health improvement in the majority of patients. We postulate that in vivo, metal ions activate T-cells, initiating systemic inflammation, which, through cytokines, affects the brain and hypothalamus-pituitary-adrenal axis. The treatment and rehabilitation of metal sensitive patients is based on a firm understanding and recognition of individual susceptibility. RID has to be done with extreme caution and according to standard working protocol. If performed properly, this treatment can result in decreased systemic inflammation and improved health in sensitized patients.
LTT-MELISA is clinically relevant for detecting and monitoring metal sensitivity
Valentine-Thon E, et al. Neuro Endocrinol Lett 2006; 27(Suppl 1): 17-24
Blood from 700 consecutive patients was tested against a total of 26 metals in the validated LTT-MELISA. For reproducibility testing, 391 single metal tests from 63 patients were performed in parallel. Finally, to assess clinical relevance, 14 patients with known metal exposure showing local (dry mouth, oral lichen planus, burning mouth Syndrome, eczema) and/or systemic (chronic infections, fatigue, autoimmune disorders, central nervous system disturbances, depression) effects were tested and their cases reported.
Hypersensitivity to titanium: Clinical and laboratory evidence
Müller K, Valentine-Thon E. Neuro Endocrinol Lett 2006; 27(Suppl 1): 31-35
OBJECTIVES: This study was carried out to investigate the potential of titanium to induce hypersensitivity in patients chronically exposed to titanium-based dental or endoprosthetic implants.
METHODS: Fifty-six patients who had developed clinical symptoms after receiving titanium-based implants were tested in the optimized lymphocyte transformation test MELISA® against 10 metals including titanium. Out of 56 patients, 54 were patch-tested with titanium as well as with other metals. The implants were removed in 54 patients (2 declined explantation), and 15 patients were retested in MELISA®.
RESULTS: Of the 56 patients tested in MELISA®, 21 (37.5%) were positive, 16 (28.6%) ambiguous, and 19 (33.9%) negative to titanium. In the latter group, 11 (57.9%) showed lymphocyte reactivity to other metals, including nickel. All 54 patch-tested patients were negative to titanium. Following removal of the implants, all 54 patients showed remarkable clinical improvement. In the 15 retested patients, this clinical improvement correlated with normalization in MELISA® reactivity.
CONCLUSION: These data clearly demonstrate that titanium can induce clinically relevant hypersensitivity in a subgroup of patients chronically exposed via dental or endoprosthetic implants.
Micro analysis of metals in dental restorations as part of a diagnostic approach in metal allergies
Muris J, Feilzer A. Neuro Endocrinol Lett 2006; 27(Suppl 1): 49-52
This paper describes a diagnostic approach from a dentist’s point of view, which enables analysis of metals in a patient’s oral cavity. If metal allergy is suspected, a micro analysis can be used to determine which metals are present in the restorations. Two patients with nickel allergy are described where removal of nickel-containing materials resulted in the marked alleviation of symptoms and improvement of health.
Removal of dental amalgam decreases anti-TPO and anti-Tg autoantibodies in patients with autoimmune thyroiditis
Sterzl I, et al. Neuro Endocrinol Lett 2006; 27(Suppl 1): 25-30
The impact of dental amalgam removal on the levels of anti- thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies was studied in patients with autoimmune thyroiditis (AT) with and without mercury allergy. Thirty-nine patients with AT were tested by MELISA for allergy to inorganic mercury. Patients were divided into two groups: Group I (n = 12) with no hypersensitivity to mercury and Group II (n = 27) with hypersensitivity to mercury. Amalgam fillings were removed from the oral cavities of 15 patients with hypersensitivity to mercury (Group IIA) and left in place in the remaining 12 patients (Group IIB). The laboratory markers of AT, anti-TPO and anti-Tg autoantibodies were determined in all groups at the beginning of the study and six months later. Compared to levels at the beginning of the study, only patients with mercury hypersensitivity who underwent amalgam replacement (Group IIA) showed a significant decrease in the levels of both anti-Tg (p=0.001) and anti-TPO (p=0.0007) autoantibodies. The levels of autoantibodies in patients with or without mercury hypersensitivity (Group I and Group IIB) who did not replace amalgam did not change.
Sensitization to inorganic mercury could be a risk factor for infertility
Podzimek S, et al. Neuroendocrinology Letters, 2005:26(4);277-282
Heavy metals can negatively influence the reproduction due to the fact that they are able to impair the immune reactions including autoantibody production in susceptible individuals used by altered pathologic immune reaction. The diagnosis of metal allergy was performed by the lymphocyte proliferation method modified for metals. In supernatants of tissue cultures of lymphocytes without the antigen stimulation and after stimulation with mercury chloride, the in vitro production of gamma interferon and antisperm antibodies was studied by ELISA.
More than 50% of patients were reacting to mercury, iron, aluminium and silver as mean by lymphocyte reactivity. When compared the lymphocyte reaction in patients with and without mercury allergy we found that the lymphocytes of patients with mercury intolerance produced less gamma interferon and more antisperm antibodies in supernatants after mercury stimulation of their lymphocytes.In patients with metal intolerance diagnosed by the MELISA test the release of metal ions from dental materials can be one of the stimulating factors which may adversely affect fertility.
Metal-specific lymphocyte reactivity is down-regulated after dental metal replacement.
Yaqob A, et al. Neuro Endocrinol Lett. 2006 Feb-Apr;27(1-2):189-97.
This study was done to evaluate the results and clinical relevance of an optimized lymphocyte proliferation test, MELISA, for metal-induced inflammation in patients with CFS-like symptoms. The treatment of patients consisted of the replacement of incompatible dental materials (RID) together with supportive anti-oxidant therapy. 513 patients were tested by MELISA at the beginning of the study. Out of this group, 248 patients were available for follow-up MELISA after RID. Replacement of incompatible dental materials resulted in down-regulation of metal-induced lymphocyte sensitivity in vitro, as well as in the improvement of health status of majority of patients with unspecific CFS-like symptoms.
The beneficial effect of amalgam replacement on health in patients with autoimmunity
Prochazkova J, et al. Neuroendocrinology Letters 2004;25(3):211-218
This study examines the health impact of amalgam replacement in mercury-allergic patients with autoimmunity. The suitability of MELISA for the selection of susceptible patients and monitoring of sensitization was also examined. Amalgam fillings, which were the single restorative material in the patients’ teeth, were replaced with composites and ceramic materials. Follow-up health status and lymphocyte reactivity were assessed and evaluated half a year or later following amalgam removal.
MELISA indicated that in vitro reactivity after the replacement of dental amalgam decreased significantly to inorganic mercury, silver, organic mercury and lead. Out of 35 patients, 71% showed improvement of health. The remaining patients exhibited either unchanged health or worsening of symptoms. The highest rate of improvement was observed in patients with multiple sclerosis, the lowest rate was noted in patients with eczema.
Valentine-Thon E, Schiwara HW, Neuroendocrinology Letters 2003; 24(1/2):57-64
OBJECTIVE: This study was carried out to evaluate the reproducibility, sensitivity, specificity, and reliability of the MELISA® Test for detecting metal sensitivity in patients with clinical symptoms of a type IV hypersensitivity to metal.
DESIGN: Blood from 250 patients was tested in MELISA® against up to 20 different metals in 2 to 3 concentrations. The frequency and distribution of metal reactivities, the sensitivity and specificity of nickel reactivity in patients with and without confirmed or suspected sensitivity to nickel, and the roles of lymphocyte concentration and concentration of inorganic mercury were analyzed. In addition, for reproducibility testing, 196 metal tests were performed in duplicate, and intra- and interassay variations of MELISA® results were examined in patients patch-test positive for the relevant metal.
RESULTS: Among the 250 patients, reactivity to 0, 1, 2, 3, 4, or ≥ 5 metals was 26%, 36%, 15%, 12%, 6%, and 5%, respectively. Reactivity was most frequent to nickel (73%), followed by titanium (42%), cadmium (18%) gold (17%), palladium (13%), lead (11%), beryllium (9%), inorganic mercury (8%), tin (8%), and phenylmercury (6%). All patients (n=15) with confirmed or suspected nickel allergy were positive in MELISA®, while patients with no suspicion of nickel allergy were either negative (n=6) or very low positive (n=4) in MELISA® . MELISA® reactivity is directly dependent on lymphocyte concentration: the higher the lymphocyte concentration per test, the stronger the reactivity. Concentrations of inorganic mercury > 0.5 μg/ml cause non antigen-specifi c (mitogenic) reactions in a majority of patients. The reproducibility rate was 94% using a cut-off of Stimulation Index ≥ 3 or 99% using a cut-off of ≥ 5. While the absolute intra- and interassay Stimulation Index values may vary, the qualitative results are highly reproducible.
CONCLUSION: The MELISA® Test is reproducible, sensitive, specific, and reliable for detecting metal sensitivity in metal-sensitive patients.
Removal of dental amalgam and other metal alloys supported by antioxidant therapy alleviates symptoms and improves quality of life in patients with amalgam-associated ill health.
Lindh U, et al. Neuro Endocrinol Lett. 2002;23(5-6):459-82.
The purpose of this study was to evaluate treatment of patients suffering from chronic ill health with a multitude of symptoms associated with metal exposure from dental amalgam and other metal alloys.Treatment of the patients by removal of offending dental metals and concomitant antioxidant therapy was implemented according to the Uppsala model based on a close co-operation between physicians and dentists. More than 70% of the responders, remaining after exclusion of those who had not begun or completed removal, reported substantial recovery and increased quality of life. Comparison with similar studies showed accordance of the main results. Plasma concentrations of mercury before and after treatment supported the metal exposure to be causative for the ill health.
Nickel allergy is found in a majority of women with chronic fatigue syndrome and muscle pain – and may be triggered by cigarette smoke and dietary nickel intake
Regland B, et al. Journal of Chronic Fatigue Syndrome, Vol. 8(1) 2001
Two hundred and four women with chronic fatigue and muscle pain, with no signs of autoimmune disorder, received immune stimulation injections with a Staphylococcus vaccine at monthly intervals over 6 months. Good response was defined as a decrease by at least 50% of the total score on an observer’s rating scale. Nickel allergy was evaluated as probable if the patient had a positive history of skin hypersensitivity from cutaneous exposure to metal objects. The patient’s smoking habits were recorded. Fifty-two percent of the patients had a positive history of nickel contact dermatitis. There were significantly more good responders among the non-allergic non-smokers (39%) than among the allergic smokers (6%). We also present case reports on nickel-allergic patients who apparently improved after cessation of cigarette smoking and reducing their dietary nickel intake. Our observations indicate that exposure to nickel, by dietary intake or inhalation of cigarette smoke, may trigger systemic nickel allergy and contribute to syndromes of chronic fatigue and muscle pain.
Stejskal J, Stejskal V. Neuroendocrinology Letters 1999; 20:351-364
Current available literature indicates a risk for metal-induced autoimmunity in man. Metal pathology may be due to toxic or allergic mechanisms where both may play a role. The main factors decisive for disease induced by metals are exposure and genetics which determine the individual detoxifying capacity and sensitivity to metals. This paper reviews the possible mechanisms which may play a role in metal-induced autoimmunity with the emphasis on multiple sclerosis (MS), rheumatoid arthritis (RA) and amyotrophic lateral sclerosis (ALS). We also discuss the role of inflammation-induced changes in the hypothalamus-pituitary-adrenal axis as a possible explanation of fatigue, depression and other psychosomatic symptoms observed in these diseases. The increased knowledge about individual sensitivity based on genotype and phenotype variability together with the use of biomarkers for the diagnosis of this individual susceptibility seems to be the key in elucidation of the operating mechanisms. Since metal-induced sensitization may be induced by chronic low-dose exposure, the conventional toxicological approach comparing concentrations of metals in brain autopsies, organ biopsies and
body fluids in patients and controls may not provide answers regarding the metal-pathology connection. To address this issue, longitudinal studies of metal-sensitive patients are preferable to the traditional case-control
Mercury and nickel allergy: risk factors in fatigue and in autoimmunity
Sterzl I, et al. Neuroendocrinology Letters 1999; 20:221-228
This study further explores the link between hypersensitivity to dental metals with chronic fatigue syndrome (CFS). It looks at 22 patients with autoimmune thyroiditis, 28 fatigued patients free from endocrinopathy and 22 fatigued professionals with no evidence of autoimmunity. All had their dental amalgams replaced with non-metallic materials. After six months, many patients reported disappearance of many symptoms previously encountered. Their MELISA response also fell considerably. We suggest that hypersensitivity to metal affects the hypothalamic-pituitary-adrenal axis (HPA axis) and indirectly triggers psychosomatic symptoms characterising CFS, fibromyalgia and other diseases of unknown etiology.
Metal-specific lymphocytes: biomarkers of sensitivity in man
Stejskal V, et al. Neuroendocrinology Letters 1999; 20:289-298
Many patients attribute their health problems to amalgam and other dental metals. In genetically susceptible indviduals, mercury and gold may function as haptens and elicit allergic and autoimmune reactions. The frequency of metal-induced lymphocyte responses was examined in 3,162 patients in three European laboratories using MELISA®, an optimized lymphocyte proliferation test. The patients suffered from local and systemic symptoms attributed to dental restorations. The effect of dental metal removal was studied in 111 patients with metal hypersensitivity and symptoms resembling Chronic Fatigue Syndrome (CFS). After consultation with a dentist the patients decided to replace their metal restorations with non-metallic materials. The changes in health and in vitro lymphocyte reactivity were studied by inquiries and follow-up MELISA®. Lymphocyte reactivity was also analyzed in 116 healthy subjects with no complaints of metal allergy. A signifi cant number of patients had metalspecific lymphocytes in the blood. Nickel was the most common sensitizer, followed by inorganic mercury, gold, phenylmercury, cadmium and palladium. As compared to lymphocyte responses in healthy subjects, the CFS group had significantly increased responses to several metals, especially to inorganic mercury, phenylmercury and gold. Following dental metal removal, 83 patients (76%) reported long-term health improvement. Twenty-four patients (22%) reported unchanged health and two (2%) reported worsening of symptoms. Following dental metal replacement, the lymphocyte reactivity to metals decreased as well. We propose that an inflammatory process induced by metals may modulate
the hypothalamic-pituitary-adrenal axis (HPA axis) and trigger multiple non-specific symptoms characterizing CFS and other chronic conditions like myalgic encephalitis (ME) and multiple chemical sensitivity (MCS).
Human hapten-specific lymphocytes: Biomarkers of allergy in man
Stejskal V, Drug Information Journal, Vol. 31, pp. 1379-1382, 1997
Environmental pollutants and other chemicals may have increasing impact on the immune systems of human beings. Disregulation of the immune system by chemicals may be one of the reasons why the frequency of allergies and autoimmune diseases increases. Human hapten-specific memory lymphocytes can be detected in the blood from patients with drug-induced immunologic side-effects but not in similarly exposed healthy individuals. The immune reactivity of human lymphocytes in vitro to white coloring agent – titanium dioxide (TiO2), and to the mercurial conservatives thimerosal and phenyl mercury – has been studied. It was found that out of 650 patients tested, 3% reacted to titanium dioxide. The percentages for phenyl mercury and thimerosal were 14% and 7%, respectively. Human memory cells can be used as markers of susceptibility in future choices of appropriate additives in pharmaceutic products.
Immunological and brain MRI changes in patients with suspected metal intoxication
Tibbling L, et al. International Journal of occupational Medicine and toxicology, Vol 4, No. 2, 1995
Thirty-four patients with central nervous system and and systemic symptoms were examined with magnetic resonance imaging (MRI) of the brain and with MELISA. Lymphocyte phenotype was analyzed with flow cytometry in 22 of the patients. 120 age-matched patients server as controls for the MRI study, 77 healthy subjects with dental amalgam filling served as controls for the MELISA test and for lymphocyte phenotype determination. Pathological MRI findings were present in 81% of the patients, most of them with degeneration in the basal ganglia. Lymphocyte phenotype determination was pathological in 58%. 60% of patients showed increased lymphocyte proliferation to mercury. The authors conclude that immunological mechanisms may play an important role in the development in brain lesions in amalgam intoxicated patients.
Mercury-specific lymphocytes: An indication of mercury allergy in man
Stejskal V, Forsbeck M et al, Journal of Clinical Immunology, Vol. 16, No 1, 1996
In this study, 18 patients with oral lichen planus (OLP), adjacent to amalgam fillings, were tested in vitro with MELISA and with patch test. Some of the patients also suffered from systemic symptoms such as arthralgia, myalgia, eczema, diabetes and chronic malaise. Twenty healthy subjects with amalgam fillings and twelve healthy amalgam-free subjects served as controls. The results show that the patient group had significantly higher reactivity to inorganic mercury, a corrosion product of amalgam, compared to the control group. Removal of amalgam fillings resulted in the disappearance of oral mucosal changes, thus indicating a causal relationship.
MELISA – an in vitro tool for the study of metal allergy
Stejskal V, Cederbrant K, Lindvall A, Forsbeck M. Toxicology In Vitro, 1994, vol 8, p. 991-1000
This article describes how to diagnose allergy to various mercury compounds such as thimerosal, phenyl mercury and inorganic mercury. Since these mercurials are immunologically non-cross reacting, it is possible by MELISA® not only to determine the existence of mercury allergy but also the source of sensitization. Thimerosal, a component of vaccines, eye drops and nose drops, is ethyl mercury salt of thiosalicylic acid. Strong allergenic properties of thimerosal have been known for years, as reflected by the presence of thimerosal as a standard component of patch-tests.
Immunologic basis for adverse reactions to radiographic contrast media
Stejskal V, Nilsson R, Grepe A. Acta Radiologica 31(6):605-12:1990
The lymphocyte transformation test (LTT) was used to elucidate whether certain side effects induced by radiographic contrast media have an immunologic etiology. Groups studied were: 8 patients who had previously experienced adverse reactions in association with urography, 6 patients who underwent urography without notable side reactions, 17 occupationally exposed nurses, and 9 unexposed controls. The lymphocytes from 2 hypersensitive patients and from 11 nurses exhibited a positive proliferative response to amidotrizoate. Five nurses who had shown a positive response, had a previous history of hypersensitivity reactions when handling contrast media, whereas the remaining 6 were free of symptoms. Amidotrizoate-specific memory cells were absent in patients who underwent urography without signs of hypersensitivity and in 7/9 of unexposed control subjects. Lymphocytes from patients sensitive to amidotrizoate cross-reacted to structurally related ionic contrast media while non-ionic contrast agents did not induce proliferation of the lymphocytes. Thus, ionic radiographic contrast agents have antigenic properties in man. Irradiated mixtures of radiographic contrast media and serum proteins were, in general, not effective in inducing an LTT response.
Lymphocyte transformation test for diagnosis of isothiazolinone allergy in man
Stejskal V, Forsbeck M, Nilsson R. J Invest Dermatol 94:789-802, 1990
The lymphocyte transformation test (LTT) has been used for evaluation of in vitro lymphocyte responses in 18 patients with dermatitis and positive patch tests to 200 ppm of a combination of 5-chloro-2-methylisothiazolinone and 28methylisothiazolinone (MCI) in nine patients with dermatitis unrelated to MCI and in seven subjects without skin diseases. Lymphocytes from nine patch-test-positive patients proliferated vigorously to MCI in vitro. Lymphocytes from the remaining nine patients were not stimulated. The lymphocyte proliferation to isothiazolinones indicates the presence of memory cells in the patients’ blood and confirms immunologic reaction to the inducing agent. To establish clinical relevance of LTT results, 12 MCI patch-test-positive patients underwent “use test” with lotion containing 15 ppm MCI. Four of five LTT-positive patients were use-test-positive, whereas seven of seven LTT-negative patients were use-test-negative, despite of positivity in patch test. LTT-positive and lotion-positive patients responded to 100 ppm or lower concentrations of MCI on patch testing, whereas seven of eight LTT-negative and lotion-negative patients responded to 200 ppm only. Finally, MCI-specific lymphocyte proliferation was observed only in patients with MCI-positive skin test, but not in nine patients with dermatitis induced by other agents, or in seven subjects without skin diseases. Thus, the lymphocyte transformation test is able to distinguish between irritant and allergic skin responses. It may also be valuable in establishing the clinically relevant patch-test concentration of allergens with irritative properties.
The lymphocyte transformation test for diagnosis of drug-induced occupational allergy
Stejskal V, Olin R, Forsbeck M. Journal of Allergy and Clinical Immunology March 1986:411-426
Twenty-five workers with clinically diagnosed or suspected occupational hypersensitivity caused by contact with bacampicillin, alprenolol, and/or quinidine were studied by the lymphocyte transformation test and by skin tests. Ten healthy exposed workers, 16 job applicants, and seven healthy nonexposed laboratory workers served as control subjects. Lymphocytes from workers with contact eczema or with eczema in combination with conjunctivitis and rhinitis responded to offending drugs in vitro as demonstrated by an increased 3H-thymidine incorporation and by the presence of lymphoblasts in the cultures. In vitro proliferative responses were reproduced during a 4-year period. Drug-specific allergy was confirmed by positive patch test in most workers with eczema. In addition, bacampicillin-specific lymphocyte proliferation was also observed in workers with suspected bacampicillin hypersensitivity but with negative skin tests. They suffered mostly from eczema in combination with conjunctivitis and rhinitis or from conjunctivitis/rhinitis only. Lymphocytes from most control subjects did not respond in vitro to bacampicillin, alprenolol, or quinidine. Weak proliferative responses to bacampicillin were observed in two of the 16 job applicants. The exquisite specificity of drug-induced lymphocyte responses is demonstrated. Thus, lymphocytes from a quinidine-sensitive worker did not respond in vitro to the quinidine stereoisomer, quinine. Furthermore, lymphocytes from a bacampicillin-sensitive worker responded to some penicillins, such as pivampicillin and ampicillin, but not to others, such as benzylpenicillin or pivmecillinam. These data suggest the role of N-acylamido side chain in the sensitization of lymphocytes from this particular donor.