The development of asthma thought to result from an allergy to the titanium contained in a cardiac pacemaker, is described in a case study published in the Annals of Internal Medicine.

The patient, a 58-year-old woman who had undergone emergency pacemaker implantation surgery after losing consciousness and developing total heart block, is a nonsmoker who had experienced seasonal allergies in childhood only. The patient experienced new episodes of wheezing, chest tightness, and worsening dyspnea with minimal exertion 3 weeks after implantation of a permanent titanium-encased pacemaker.

The patient’s physical examination showed diffuse, bilateral expiratory wheezes on chest auscultation, along with an erythematous, raised, mildly pruritic, noncrusting rash that was located on the skin surrounding the pacemaker implantation site. No pulmonary abnormalities were noted on a chest X-ray or computed tomography scan. The patient’s cardiac exercise test and cardiac catheterization were both normal. Spirometry indicated considerable reductions in forced vital capacity (FVC) and forced expiratory volume in 1 second (FVC1). Following the use of a bronchodilator, a 21% increase in the patient’s FVC1 value was reported. The woman’s asthma diagnosis was based on her clinical presentation and the presence of reversible airway obstruction.

Treatment was initiated with a combination inhaler that included a long-acting β2-agonist and a corticosteroid. Since the patient’s asthma was difficult to control, she needed to be admitted to the hospital several times for exacerbations of her disease. Her asthma was classified as severe persistent. In addition, the patient had a persistent pruritic rash and mild angioedema, necessitating the addition of oral corticosteroids, a leukotriene receptor antagonist, and high-dose antihistamines to her therapeutic regimen.

When the patient’s titanium pacemaker was eventually replaced with a gold-encased pacemaker, her asthma symptoms disappeared within 24 hours. Bronchodilators, inhaled corticosteroids, and oral corticosteroids were discontinued, and the patient’s spirometry results improved.

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Although other allergies to metal have been reported in the literature among patients receiving orthopedic implants, cardiac implants, and stents, the current case appears to be the first reported case of a metal implant being linked to the development of asthma.

“We think that our patient’s asthma was caused by her allergy to the titanium in her pacemaker’s case. The evidence that supports this conclusion includes her history of allergy to costume jewelry, the documentation of her allergy to titanium during skin testing, and the timing of asthma onset and remission with insertion and removal of her titanium-encased pacemaker,” noted the case study authors.

Reference

Saha BK, Modi A, Beegle S. Asthma from allergy to titanium in a cardiac pacemaker [published online March 31, 2020]. Ann Intern Med. doi: 10.7326/L19-0647