Medicolegal Issues

The Fountain of Youth


 

Photo Quiz:

What is the etiology of the dermatologic and nail abnormalities in this 53‑year‑old man with cirrhosis due to chronic hepatitis B infection?

Diagnosis: Argyria

Discussion

Figure 1

Gross autopsy photos: the patient’s darkly pigmented organs are on the bottom in each image and normal specimens for comparison are on top.

Figure 2

Gross autopsy photos: the patient’s darkly pigmented organs are on the bottom in each image and normal specimens for comparison are on top.

Gross autopsy photos: the patient's darkly pigmented organs are on the bottom in each image and normal specimens for comparison are on top.

Gross autopsy photos: the patient’s darkly pigmented organs are on the bottom in each image and normal specimens for comparison are on top.

Microscopic views glomerulus demonstrating numerous darkly pigmented from silver deposition.

Microscopic views glomerulus demonstrating numerous darkly pigmented from silver deposition.

This patient had progressive liver failure and was hospitalized for possible liver transplantation. During the initial history, he disclosed that he had noticed progressive discoloration of his skin, hair, and nails for the past several months. Our clinical suspicion of argyria was confirmed when the patient’s serum silver level returned at 54 ug/ml (normal range 0.0-14 ug/ml). Serum levels of arsenic, mercury, and lead were within normal limits.

Despite treatment of encephalopathy, esophageal varices, and peritonitis, this patient’s liver disease deteriorated and he underwent orthotopic liver transplantation. Unfortunately, he died 24 days post-transplantation from progressive multi-organ failure.

At autopsy, gross silver discoloration was noted in many organs, including the bowel, bladder, pancreas, and renal papillae.

Microscopically, fine black pigments were noted in almost all basement membranes, including the skin, glomeruli (see Figure), choroid plexus, and myocardial connective tissue.

Similar fine granules were seen in the basement membranes of the patient’s native liver but not within the newly transplanted liver.

The patient admitted to drinking one pint of colloid silver almost daily for 15 years. This homeopathic remedy has been purported to cure many illnesses, including the common cold, cancer, diabetes, and HIV. Equipment and recipes are readily available on the internet, and as a “food supplement” silver remedies bypass strict regulatory controls. Colloid silver can be made easily by connecting a 9-volt battery to two silver wires placed in a tub of water. The electric reaction draws silver off the wire and into the water, producing the liquid silver elixir.

After ingestion, silver deposits permanently in the skin, producing the characteristic color changes of argyria, especially pronounced in sun-exposed areas where sunlight reduces the metal to an inert salt, analogous to processes used in photography. Although ingested silver is known to alter skin color irreversibly and deposit widely in the body, permanent extracutaneous organ damage from silver ingestion has not been firmly established. Thus, argyria remains a cosmetically altering disease and is not a contraindication to liver transplant.

Like other homeopathic remedies, colloid silver recipes may be accessed by the public directly. Despite a lack of peer-reviewed scientific evidence to support its use, public testimonials touting silver as the new panacea nonetheless will remain prevalent. Physicians must educate themselves, and inform their patients, that colloid silver is not the “fountain of youth.”

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