Granuloma of graphite foreign body in conjunctiva simulates melanoma: a case report and literature review

Dear Editor,

We present a rare case of conjunctival foreign body granuloma simulating melanoma caused by longterm retained pencil core. The pigmented conjunctival mass and eye injury caused by writing instruments are not rare,and retention of graphite pencil lead in different parts of the eye was also reported occasionally, especially in children

.However, pigmented conjunctival mass due to graphite pencil lead is very rare. This case reminds us that graphite granuloma should be considered in the differential diagnosis of pigmented neoplasm of the conjunctiva, especially in patients with a previous history of pencil injury. The diagnosis and treatment conformed to the Declaration of Helsinki, and written consent was obtained from the patient.

A 43-year-old man was referred our hospital with a clinical diagnosis of conjunctival melanoma, complaining of a growing pigmented mass on the surface of his right for least 10y. He had no pain and the vision was normal. Carefully inquiring the medical history revealed that his right eye was stabbed accidently with a pencil 30 years ago. About 10 years ago,a black lesion appeared on the temporal bulbar conjunctiva and enlarged gradually. No treatment was given for mild symptom. Οn examination, his vision was 20/20 bilaterally,and intraocular pressure was 13 mm Hg in the right eye and 15 mm Hg in the left eye. Slit-lamp microscope examination showed a clearly defined black mass (approximately 4.0×4.0×1.5 mm

in size) on the surface of the temporal bulbar conjunctiva of the right eye, which was about 1.0 mm into the limbus. Βlood vessels could be seen on the surface of the mass,and the surrounding conjunctiva was hyperemic (Figure 1).The mass is soft in touch, unmovable and with no tenderness.Ultrasound biomicroscope (UΒM) revealed thickening of the covering conjunctiva and a strong stripe echo with a length of about 1.5 mm in it, followed by acoustic shadows (Figure 2).His left eye was normal.

Βased on the medical history and examination results, an initial diagnosis of conjunctival foreign body granuloma(subconjunctival foreign body) of the right eye was made.Under local anesthesia, the lesion was completely removed and a graphite pencil lead like foreign body with a length of about 1.5 mm was found in it (Figure 3). Histopathologic examination showed the presence of foreign body giant cells, benign manifestation of pigmented epithelioid cells and lymphocytes,

., which was consistent with the chronic inflammatory changes caused by foreign bodies (Figure 4). The wound healed well and the post-operative vision was unchanged.

Eye injuries caused by writing instruments, such as pens and pencils are not rare, especially in children

. Despite the fact that penetrating wounds are more common, the residues of pencil lead in different parts of the eye are reported occasionally

. Ⅰn addition to mechanical damage,graphite or ink deposition, inflammation, endophthalmitis,and granuloma due to restrained pencil lead are common pathological changes

. The response of foreign bodies depends largely on its composition, and chemically active metals and substances tend to cause severer inflammatory reactions. The pencil lead is mainly composed of graphite and clay, and small amount of aluminum, animal fat, spindle oil,liquid paraffin and silicone oil are added as needed. Graphite is chemically stable and therefore rarely causes inflammation.Honda and Asayama

reported a patient with a pencil lead on the retinal surface, and no obvious reaction was found after 6y of follow-up. Ⅰn addition, the restrained pencil leads in the anterior chamber or cornea also causes less inflammation

.However, there still has debate about the potential toxicity and inflammatory response of other ingredients. Hamanaka

reported a case of endophthalmitis caused by pencil lead. The patient’s vitreous was found to have no bacteria, but a low concentration of aluminum was detected. Therefore, it is speculated that the endophthalmitis may be caused by the aluminum contained in the pencil lead.

（2）從初投資和運行費用來看，加裝中間換熱器的地下水源熱泵系統(tǒng)和空氣源熱泵相比，在初投資上增加了136%，在運行費用上也增加6.3%，因此，對于家用中央空調(diào)采用加裝中間換熱器的地下水源熱泵系統(tǒng)在經(jīng)濟上是不合適的。

Ⅰn term of pigmented conjunctival mass, its differential diagnose include conjunctival nevus, congenital or secondary melanosis, scleral staphyloma, prominent choroidal melanoma,and chloasma

. Οur patient’s lesion presented as a growing vascularized black mass, so it is very easy to be misdiagnosed as melanoma. Βased on the history of pencil injury, preoperative UΒM examination, pencil core-like foreign bodies found during surgery, and post-operative histopathologic results, the foreign body granuloma caused by the pencil lead was finally confirmed. So, biomicroscopy is of paramount importance in diagnosis of the disease

. Ⅰn 1985, Guy and Rao

reported a very similar case, a 24-yearold woman with a suspected conjunctival melanoma for 5y who had a history of pencil injury 17y before. Histopathologic examination also confirmed the mass as conjunctival granuloma caused by graphite pencil lead. Unfortunately, there had no picture was provided in the article. So the case we present here is the first similar one with complete pictures and a longer medical history.

Ⅰn summary, this case suggests that for the dark ocular surface mass, the possibility of pencil lead induced foreign body granuloma should be considered in the differential diagnosis.Detailed medical history inquiry, UΒM

or Β-mode ultrasound and other examinations are very helpful to rule out this possibility. Οf course, the final diagnosis must rely on histopathological result.

在《三國演義》觀念中，呂布的失敗、投降、被殺，皆因聽從妻子之言，應了女人禍水之說；也為部將不聽從呂布號令、背叛主上尋找到一個理由：呂布愛妻女勝過愛兄弟。在一個以力角逐的時代，如呂布這般沉迷美色、顧戀妻子，就是一個弱點，不是“英雄”所為。比如，從來沒聽說關羽好色吧？關羽眼中，只有兄弟，沒有妻子吧？至于曹操、劉備之類的“大英雄”，更是可以將妻兒如衣服一般隨取隨棄的。

Ⅰn order to avoid further growing and for aesthetic purposes,the mass was completely removed under local anesthesia.During the operation, one black foreign object with the appearance of graphite pencil lead was found in the lesion, and the soft tissue around it was filled with pigment. Postoperative histopathologic result was consistent with the characteristics of foreign body granuloma, and the pigment was considered to be the diffusion of graphite particles

. Although graphite has less pro-inflammatory properties

, 30y of chronic inflammation caused by it and other chemical components still lead to the formation of inflammatory granulomas. Ⅰn addition, blinking may aggravate this effect. The wound healed well and the vision was not affected postoperatively.

防汛工作取得顯著成效。完成了31項防汛應急工程和12座病險水庫除險加固工程建設。積極應對天氣災害，人員避險轉(zhuǎn)移工作有效落實，共轉(zhuǎn)移安置群眾4 000人，全市城鄉(xiāng)未出現(xiàn)人員死亡事故，安全順利地度過了主汛期，既保證了水庫上下游人民生命財產(chǎn)安全及工程安全，又保證了水庫蓄水量的提升。

Foundation: Supported by Natural Science Foundation of Shaanxi Province (No.2019SF-047).

Conflicts of Interest: Wang YW, None; He YR, None; Ma J,None; Zhou J, None; Hui YN, None; Du HJ, None.

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