D3.245 - Complete Resolution of Systemic Delayed Hypersensitivity following Removal of a Titanium Fixation Screw: A Case Report

Background: Titanium is generally considered the gold standard for biocompatible implants. However, systemic hypersensitivity reactions, though rare, can lead to significant morbidity and diagnostic challenges. We report a case where systemic dermatitis and immunological abnormalities were successfully resolved following the surgical removal of a titanium fixation screw.

Case Report: A 22-year-old female underwent left ankle ligament reconstruction with titanium screw fixation on August 8, 2025. Immediate postoperative laboratory findings revealed an early rise in peripheral eosinophil counts (323/uL to 711/uL within 6 days). Two months later, she developed localized pruritus and discharge at the surgical site, which evolved into a generalized papular rash. Despite systemic steroid therapy, the symptoms persisted with relapsing eosinophilia and a peak total IgE level of 1717 IU/mL. A patch test confirmed titanium hypersensitivity.

Intervention and Results: Based on the diagnosis of titanium-induced delayed-type hypersensitivity, the patient underwent surgical removal of the titanium hardware on December 8, 2025. Following the removal, the cutaneous symptoms and systemic pruritus showed rapid and significant improvement. The peripheral eosinophil count, which was 541/uL shortly after surgery, stabilized, and the total IgE level decreased to 973 IU/mL by January 5, 2026. The patient was able to successfully discontinue all corticosteroid treatments without any recurrence of symptoms.

Conclusion: This case provides clear evidence of the causal relationship between titanium implants and systemic hypersensitivity. The dramatic clinical improvement and the successful tapering of steroids following hardware removal underscore the importance of considering metal allergy in patients with persistent postoperative dermatitis. When hypersensitivity is confirmed via patch testing and laboratory monitoring (IgE and eosinophils), surgical removal of the offending hardware remains the definitive treatment.