This resulted in approximately 75lbs. Most likely the allergy to the other metals in the alloy. J. S. Gammie, M. C. Banks, C. R. Fuhrman et al., The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy, JSLS., vol. WebThe only current blood test for titanium allergy, a test called the MELISA(R) test, is available through Breakspear. ii. Clipboard, Search History, and several other advanced features are temporarily unavailable. Although contact allergic reactions to titanium have been very rarely reported, these findings support a diagnosis of titanium allergy in our patient. By IFN-gamma ELISpot, the average precursor cell frequency reactive to trivalent chromium could be defined as 26, 15, and 11 : 10(6) in volunteers with sensitization and allergy, with sensitization without allergy, and controls, respectively. I've had 2 titanium implant procedures with 2 diffenrent surgeons and both implants didn't take which caused me tremendous pain. say. I strongly recommend zircon implants. 2014;102(2):392399. WebMELISA is a blood test to aid the diagnosis of metal hypersensitivity. Furthermore, there are few op Two weeks after gallbladder surgery, a 53-year-old man experienced constant abdominal pain in addition to nausea. Do patients with implants exhibit elevated lymphocyte reactivity to metals and is this reactivity more generalized or more implant-alloy specific? However, in the lymphocyte transformation test, the patient's lymphocytes showed markedly enhanced proliferation in vitro totitanium. The behavior of Zircon facing soft tissue and bone really works, showing perfect osseointegration and unbelievable aesthetics due to white colored high tech ceramics. Mnchen, Germany. Professor Vera Stejskal is the inventor of the MELISA test. After removal of the titanium material, fracture healing was achieved and the eczema cleared. The skin patch test has not yet been developed as the valid standardized test for titanium allergy. Proper history taking, appropriate physical exams, and specific diagnostic modalities can identify rare causes of chronic abdominal pain. 2006 Dec;27 Suppl 1:31-5. I am sending you a link (copied below) to a study employing delayed hypersensitivity testing to detect metal allergy. I had bone tumor & metal rods placed in my femor a 1 yr & 6 months ago .. Nickel allergy signs and symptoms include: Rash or bumps on the skin Itching, which may be severe Redness or changes in skin color Dry patches of skin that may resemble a burn Blisters and draining fluid in severe cases When to see a doctor If you have a skin rash and don't know how you got it, talk to your doctor. WebMELISA is a scientifically proven and clinically validated blood test that detects type-IV hypersensitivity to multiple metals at the same time. 2019. Safe for patients with metal allergies Zirconia implants are a viable option for patients who have an allergy to titanium or adhere to holistic dental principles. Neuroendocrin Letters 2006;27:17-24. If LTT-MELISA testing is to be considered, test kits, locations of laboratories offering this test and other information is available at FAQs for US Customers - MELISA. I emphasize that this testing is not FDA approved. I have attached some archived Ask the Expert questions about metal allergy. In addition, I have updated it with a link to the website of the company that performs this test should you wish to investigate it further, and other abstracts dealing with this issue. Many will have seen the devastating news that singer Celine Dion has been diagnosed with Stiff Person Syndrome. Minimization of Adverse Effects Associated with Dental Alloys. 78, p. 1135, 1999. Titanium is a transition metal and thus may function as a hapten and trigger cellular hypersensitivity. MELISA is a scientifically proven and clinically validated blood test that detects type-IV hypersensitivity to multiple metals at the same time. WebMetal allergy was measured by a lymphocyte transformation test, MELISA. iii. A case by Little et al. Pigtail plastic stents are used to remove the intra-abdominal drainage during procedures such as endoscopic retrograde cholangiopancreatography (ERCP) [8]. Its possible to detect a titanium hypersensitivity ahead of time with a MELISA test. Orthopedic Analysis Contact dermatitis: A practice updateUpdate 2015. Referred to me to patch testing. The MELISA test was validated in 2003 by Valentine-Thon and Schiwara. Y. Nakashima, D. H. Sun, M. Trindade, W. Maloney, S. Goodman, and D. Schurman, Induction of macrophage C-C chemokine expression by titanium alloy and bone cement particles, Journal of Bone and Joint Surgery, vol. Titanium has also been reported as an allergen in a few studies, causing type I or type IV hypersensitivity reactions [3]. STUPID is that there is no sure fire way to know AHEAD of time if you will have a reaction..to me this is unacceptable..especially considering costs. The International Journal of Implant Dentistry notes that due to implants' corrosion and wear, titanium alloy particles can get deposited in the surrounding tissues. Pure Titanium is very reactive and might get binded to organic substrate which then promotes the allergic answer. However, there is no consensus for the utility of the test with critics arguing the test is overly sensitivity (5,6,7). Characterization of the Toxicological Impact of Heavy Metals on Human Health in Conjunction with Modern Analytical Methods. A decision was made to remove all the metal surgical clips laparoscopically via fluoroscopic guidance (Figure 1). Three months after surgery, in which 8 small stainless steel screws were placed in Jeske's, feet he started developing periodic episodes, where his body would go completely rigid. In addition, there is evidence in the dermatologic literature (1) indicating that lymphocyte transformation testing may be coming of age in terms of its usefulness to detect contact allergy not only to metals, but to other substances. a. viable lymphocytes are required therefore logistical issues of shipping often complicate testing; Due to ongoing chronic symptoms, CT scan incidentally revealed a portion of a lodged pigtail catheter in the cecum. Allergic responses to metals such as nickel, chromium, mercury, cobalt, and gold are widely recognized [1]. Abstract We investigated these questions by measuring lymphocyte responses to implant metals (Cr+3, Co+2, Ni+2 at 0.1 mM, and Ti+4 at 0.001 mM) in six subject groups: Group 1a = young controls, Group 1b = age matched controls, Group 2a = subjects with osteoarthritis (OA) and no history of metal sensitivity, Group 2b = OA subjects with history of metal sensitivity, Group 3a = total hip arthroplasty (THA) subjects with no to mild radiographic osteolysis, and Group 3b = THA subjects with moderate osteolysis. We wanted to highlight the remarkable case of Dana Jeske, a mechanical engineer living near Seattle, who experienced intermittent paralysis for five years, before regaining his ability to walk and move his body normally after he had all metal implants taken out of his body and teeth. Very much looking forward to the launch of the first ever podcast dedicated to the adverse effects of metals on health! since the true allergic reaction to titanium are very rare and these are different in alloys in comparison to CP titanium i strongly recommend to consult with allergist for best evaluation of patient. Among different RFB, sponges are one of the most common retained foreign bodies in the abdomen, pelvis, and retroperitoneal cavities [13]. Advances in Colloid and Interface Science. However, all the symptoms were resolved after the removal of the offending agent [57]. For statistical analysis, the Fisher's exact test and paired T-test were used. Another incredible case report of a woman with 18 surgical clips in her neck. This information is for educational purposes only. 155162, 1999. I would emphasize the lymphocyte testing is a challenge due to delivery of viable cells and lack of FDA approval and insurance coverage. The Mayo Clinic had diagnosed him with Stiff Person Syndrome. 1. The decision forward would be based upon this discussion. 1, pp. Have questions about your smile? 2022 Nov 23;10(12):716. doi: 10.3390/toxics10120716. He could breath but could not talk or actively move any muscle in his body. Our goal at OsseoNews.com is to help expand knowledge of dental implants and related dental fields by offering interactive online education and communication tools. J Biomed Mater Res 2000: 53: 480489. However, it indeed seems titanium allergy had a significant role in her abdominal discomfort owing to her positive allergy test results further proving titanium hypersensitivity in this patient. If you have any questions, call the Drug Allergy Clinic at (615) 936-2727, 8 a.m.-4:30 p.m. Monday through Thursday or 8 Combining the results of chromium chloride and potassium dichromate LTT, a positive reaction to at least one of the stimuli was highly predictive of allergy [sensitization with vs. without allergy: Odds ratio (OR)=6.4, P=0.004; sensitization with allergy vs. controls: OR=11.5, P<0.0001]. There is no need to take the MELISA test prior to surgery. Is there any validity to Lymphocyte Transformation testing (LTT) and/or Metal ION testing? The symptoms were so severe that they interfered with the mans lifestyle. 5761, 1999. It appears as if it can detect delayed hypersensitivity to metals, but its exact role, compared to patch testing for example, in detection of metal allergy has not been established to my knowledge. 7, no. The case also unfolds rare differential diagnoses to keep in mind when encountering a patient with abdominal pain and associated nonspecific symptoms. 4, pp. See this image and copyright information in PMC. Documented titanium allergy is very rare, if other metals are test positive then titanium would be an alternative; Klinik und Poliklinik fr Dermatologie und Allergologie der Ludwig-Maximilians-Universitt, The patients past surgical history includes a tonsillectomy, an appendectomy, and cholecystectomy. G. Tawil, P. Tawil, and C. Irani, Zirconium implant as an alternative to titanium implant in a case of type IV titanium allergy: case report, The International Journal of Oral & Maxillofacial Implants, vol. The most commonly used test to diagnose a metal allergy is skin patch testing. Please let me know what my possibilities are. This can take several months. This is an open access article distributed under the, Memory lymphocyte immunostimulation assay, Endoscopic retrograde cholangiopancreatography. This is why we are seeing long term immune assaults on people with titanium implants and/or replacement surgeries. Failure of the implant and delayed or poor wound or surgical site healing hav occurred; 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. A triple assay technique for the evaluation of metalinduced, delayedtype hypersensitivity responses in patients with or receiving total joint arthroplasty. Department of Technology for Health, Dermatological Clinic, IRCCS Galeazzi Hospital, University of Milan, Milan 20161, Italy. Patch testing gave no reactions to titanium nor to nickel, chromium, or cobalt. However, in chronic cases of months to years after the operation, a CT scan is usually performed to rule out malignant tumors and possible fistula formations [13]. Valentine-Thon E, Mller K, Guzzi G, Kreisel S, Ohnsorge P, Sandkamp M. Neuro Endocrinol Lett. Minor 201207, 2012. Abstract All of her symptoms were initially suspected due to the infections mentioned above, and she was placed on various antibiotic therapy regimens consisting of ciprofloxacin, amoxicillin/clavulanate potassium, and sulfamethoxazole/trimethoprim. 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. Tel: 0844 335 1070 E-mail: sales@biodent-systems.com and TBR is in France. 12, no. This is not only a simple and effective system, but also a very convenient one piece component that avoid all the abutments from regular titanium systems. Moreover, metal allergy screening should be considered for patients with past hypersensitivity reactions before any surgery. W. S. Towers and K. Kurtom, Rare systemic response to titanium spinal fusion implant: case report, Cureus, vol. Fage, Simon W., et al. Toxicology in vitro 8.5 (1994): 991-1000. The follow-up 13, no. I have summarized her observations and suggestions below. In: StatPearls [Internet]. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Have 79 year-old man with left knee replacement two years ago. In the past decade Dr Schroeder has removed over 1,000 implants in over 400 patients. Implant failed right after placement. Alas, such is not the case. Abstract It is used worldwide by healthcare professionals to help determine whether patients are hypersensitive to metals commonly used in dental restorations or medical implants. 6. She reported a complete resolution of all symptoms one-month postsurgery. MELISA is a blood test to aid the diagnosis of metal hypersensitivity. Their disadvantage is that in some individuals the HA Dr. Jacqueline A. Pongracic, FAAAAI. Usualy allergic response is seen on epidermis. Moreover, the increase in the percentage of patients who tested positive for metal sensitivity 1 year post-implantation suggests the possibility of prosthesis-induced sensitization. This patient is concurrently found to have a retained pigtail catheter in the cecum discovered incidentally through radiology. The reference to which I sent the link will give you some perspective on false-positive and false-negative tests using delayed hypersensitivity testing. Phil Lieberman, M.D. It's called Melisa. 2004 Orthopaedic Research Society. T. Okamura, M. Morimoto, D. Fukushima, and G. Yamane, A skin patch test for the diagnosis of titanium allergy, Journal of Dental Research, vol. Due to another foot problem requiring surgery, he returned to his surgeon Dr Schroeder, who noticed swelling over the areas the screws were placed and recommended removal of the screws. Antifungal activity of Ag:hydroxyapatite thin films synthesized by pulsed laser deposition on Ti and Ti modified by TiO2 nanotubes substrates. WebTitanium is a reactive metal with a including titanium may mediate metal hypersen- titanium allergy, titanium release without any native oxide film thickness of about 4 The test itself, that is, the lymphocyte transformation test, is a validated means of testing for delayed hypersensitivity, the type of hypersensitivity that results in contact dermatitis. For those affected with titanium allergy, the symptoms can be multiple and bewildering. The CT scan showing a portion of the pigtail catheter lodged within the cecum in a coronal view (a), sagittal view (b), and axial view (c). The commercially licensed, in vitro lymphocyte transformation test for detecting sensitivity to metals (LTT-MELISA) is not FDA approved and generally is not covered by insurance (1,2). The easiest and most affordable way to clinically deliver bone graft for socket preservation. 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. After your implant is placed, your oral surgeon will encourage you to rest and practice good oral hygiene to heal the area around the titanium screw. In a pilot study, 20 patients also underwent both patch testing and a lymphocyte transformation test (LTT-MELISA) for the same metals. Goolge Titanium allergy test and I'm sure you will find it. With her history of allergy to other metals in the past, a titanium allergy was suspected at this visit, and the patient promptly underwent a titanium skin patch test that turned out positive. I am skeptical that the in vitro testing would facilitate a better alloy than titanium. Traces of nickel (0.03%) may be found even in commercially pure titanium due to the production process. 2. It can feel both disappointing and overwhelming to learn that youre not taking to your new implant as well as you'd hoped. Systemic and topical steroids not helping. Oral saliva usualy "buffers" reaction. Effect of blood component coatings of enosseal implants on proliferation and synthetic activity of human osteoblasts and cytokine production of peripheral blood mononuclear cells. Correction on the last thread last word should read capsules, not injections. Patients suffering from metal hypersensitivity may have numerous local symptoms associated with an overactive immune system, such as localised pain, swelling, cutaneous allergic reactions, joint and muscle pain, implant failure, apparent recurrent infections around the operation site, and possible systemic reactions such as fibromyalgia, chronic fatigue and cognitive impairment. Patients and Methods: A total of 100 patients referred for total hip or total knee arthroplasty were assessed preoperatively and then at 1 year post-implantation by means of patch tests with the metals present in the implant alloys. WebMELISA reactivity is directly dependent on lymphocyte concentration: the higher the lymphocyte concentration per test, the stronger the reactivity. cureus.com/articles/136554-diagnosis-and-management-of-a-hypersensitivity-reaction-to-titanium-containing-surgical-clips-a-case-report See MoreSee Less, Diagnosis and Management of a Hypersensitivity Reaction to Titanium-Containing Surgical Clips: A Case Report, Two weeks after gallbladder surgery, a 53-year-old man experienced constant abdominal pain in addition to nausea. 2020;276, article 102083 doi: 10.1016/j.cis.2019.102083. Would you like email updates of new search results? Copyright 2021 Molly S. Jain et al. 62, no. The German S3 guideline on titanium hypersensitivity in implant dentistry: consensus statements and recommendations. I'm with Aaron. This makes it an adequate metal of choice for intraosseous use in medical procedures. The patient recovered well with no significant intraoperative or postoperative complications. This can be seen on the fact that bone attachment is usualy tighter and faster with pure ti-implants then in Ti-alloy-implants. Dennis K. Ledford, MD, FAAAAI The test Contact Dermatitis 2005; 53:1. I would recommend though that you take a clifford test first on Zircon Oxide due to your allergic component. Symptoms can arise as acute inflammatory response, infection, abscess, or aseptic inflammation and exudative without infection in the body cavities [13]. Metals and their alloys could lead to immediate or delayed hypersensitivity reactions. Finally, the blood test could be effectively used to diagnose type IV hypersensitivity allergic reactions, including contact dermatitis or eczema reported by few studies on titanium allergy [12]. Question posted to Ask the Expert website 4/25/2012: Moreover, titanium has been described to activate macrophages through phagocytosis to cause the release of pro- and anti-inflammatory cytokines [9]. Neuroendocrinology Letters 2003; 24(1/2):57-64, Copyright 2022 MELISA Diagnostics Limited. While nickel allergy may present as a rash or localised contact dermatitis it may also have systemic effects including chronic fatigue and muscle pain and widespread skin conditions. 3. 2/20/2020: Metal patch test positive with rash and knee replacement A 72- and 96-hour reading is provided. In cases of documented delayed type metal hypersensitivity or when an individual has a strong belief related to this possibility, legal concerns may outweigh medical concerns; This is a blood in vitro test used for the diagnosis of delayed hypersensitivity to metals. A quote from Fishers textbook on contact dermatitis is the following: if metal salts were tested close to each other a strong positive to nickel would be accompanied by false positive patch test reactions to adjacent metal salts, particularly cobalt and copper (2). There are zyrconia implants like White Sky, that are monoblock type implants, and that are a real option for you.Also Rocksolid from straumann is a combination that may also help you Conclusions: In contrast to the patch test, the LTT appears to be a method that is predictive of chromium allergy. Results: Only 72 of 100 patients were patch tested both before and after surgery, and 12 of 20 also underwent LTT-MELISA before and after surgery. In the following years, the patient went through an ERCP procedure multiple times due to her sphincter of Oddi dysfunction followed by laparoscopic rectopexy for a rectal prolapse. Regardless of all these factors, surgeons and clinicians must have a high clinical suspicion of RFB and appropriate diagnostic imaging for diagnosis and removal of the RFB. Materials (Basel). Thus interpreting these tests is much like interpreting the immediate hypersensitivity skin tests and tests for serum-specific IgE. 97100, 2017. Even low grade allergies are causing significant symptoms. Very much looking forward to the launch of the first ever podcast dedicated to the adverse effects of metals on health! Journal of Biomedical Materials Research PART A. These HA-implants heel quite well and also fast. It also sheds light on retained foreign bodies as a possible cause of abdominal pain in patients who have gone through various surgical procedures in the past. There is only one test that can be used to establish titanium allergy, called the MELISA test . So how can I recognize if I have a dental implant allergy? Transpiration sweat is very aggressive and can induce allergic response to materials we never had problem with. e.g. A test was developed in Europe to detect and measure Titanium allergies. This study determined the relev Clinics providing access to MELISA testing. Disclaimer. Therfore a immediate or a delayed immediate response can be excluded. The patient had delayed hypersensitivity reaction to nickel in the past with erythematous rash formation and severe itching. I hope Sarah was able to discern what she needs to do for her particular situation. 35, no. The MELISA test may be used in two ways for orthopaedic patients. WebMELISA is a simple blood test which can separate those individuals which may suffer side-effects from metal exposure and those that will not. Contact Dermatitis 74.6 (2016): 323-345. She had to be hospitalized with strict isolation to wait for her medication regimen to work along with the infusion of IV fluids. After the diagnosis of RFB, the preferred approach is to remove the RFB laparoscopically [13]. The bio compatibility of this implant is really impressive. The patient started having another episode of intermittent right lower quadrant (RLQ) pain starting in January 2020. Ask The Expert Archive Main Page If LTT-MELISA testing is to be considered, test kits, locations of laboratories offering this test and other information is available at FAQs for US Customers - MELISA. viii. The Editor-in-Chief of this journal has a copy of the written consent available for review. THA subjects with moderate vs mild osteolysis (Group 3b vs 3a) were more reactive to Co (43% vs 0% incidence). -, Catauro M., Bollino F., Papale F. Preparation, characterization, and biological properties of organic-inorganic nanocomposite coatings on titanium substrates prepared by sol-gel. Treasure Island (FL): StatPearls Publishing; 2022 Jan. The patient initially had intermittent RLQ abdominal pain accompanied by nonspecific symptoms. Pernicious anemia (B 12 def) sneaks up on people very slowly. She reported extensive health issues such as skin rash, hair loss, memory loss, difficulty concentrating, severe shortness of breath, hot and cold flashes, metallic taste in the mouth, abdominal bloating, joint and body aches, muscle pain and tightness, insomnia and more. Stainless steel: chromium, manganese, molybdenum, nickel, tungsten Wood MW, Warshaw EM. The one we elected is from a German/Swiss based company called Z-Systems. The criteria for postimplant metal hypersensitivity are: Have you seen an allergist to confirm you are allergic? Dental implant surgery is performed in stages, requiring adequate healing time after each one. With a vit B 12 deficiency, you need to eat beef liver or receive the B 12 injections. The Mayo Clinic had diagnosed him with Stiff Person Syndrome. Did you have any skin reaction on one of those products containig Titaniumoxides ? The results were correlated with clinical and anamnestic data. 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 Titanium alloy (TiAl6V4): titanium, vanadium, aluminium, traces of nickel. They were clinically examined, and peripheral blood samples were taken to perform follow-up MELISA tests. The patients social history is insignificant, with no smoking or alcohol consumption. Very small amounts of various Ask The Expert Archive Main Page If one of your teeth is damaged, youre probably excited to learn that you can replace it with a dental implant. 3, pp. PMC Neuro Endocrinol Lett. (SOURCE Lymphocyte responses in patients with total hip arthroplasty, JOURNAL of ORTHOPEDIC RESEARCH 23(2), 384-391, 2005). Immediately after removal of his last palladium containing white gold crown all of his paralysis resolved.At the November 2019 meeting of the FDA's Committee Investigating Metals Used in Medical Devices, Dr. Schroeder presented Jeske's case and the cases of some of his other patients. All the best! LTT is another more sensitive test than the skin-patch test; however, there are reports of some false-positive results [3]. Accessibility Lisa Eads. Hallab N J, Mikecz K, Jacobs J J. V. A. Zejnullahu, B. X. Bicaj, V. A. Zejnullahu, and A. R. Hamza, Retained surgical foreign bodies after surgery, Open Access Maced J Med Sci., vol. A. Serati, B. Sharif-Kashani, Z. H. Ahmadi et al., Removing an entrapped pigtail catheter by re-enforcing a traditional method, Tanaffos., vol. She was diagnosed with pneumonia twice followed by two sinusitis episodes from January 2020 to March 2020. 15, 2019. doi: 10.1016/j.apsusc.2013.12.029. The authors declare that they have no competing interests. This might be therefore be a solution for about 10 years oral function. A LTT metal allergy test showed a mild reactivity to nickel and titanium. sharing sensitive information, make sure youre on a federal Metal hypersensitivity and Yoshihisa, Yoko, and Tadamichi Shimizu. Medical content developed and reviewed by the leading experts in allergy, asthma and immunology. We present a case of a 28-year-old female with a chronic history of intermittent abdominal pain aggravated due to titanium allergy and retained foreign surgical body. Dear Richard Hughes, DDS,FAAID, FAAIP.DABOI Titanium is another type of metal that is utilized extensively in cardiac pacemakers, dental procedures, arthroplasty, body piercing, and spectacle frames [2]. This elevated incidence and averaged level of lymphocyte reactivity supports a metal-specific adaptive immune response and suggests involvement in the pathogenesis of poor implant performance, e.g. The evaluation of the data obtained from patients in this study confirmed a significant clinical benefit of MELISA test. M. Little, P. C. Munipalle, and O. Nugud, A rare late complication of laparoscopic cholecystectomy, Case Reports, vol. i. Why don't I believe them ??? 2011 May;64(5):273-9. doi: 10.1111/j.1600-0536.2011.01886.x. In the study, 35 patients with failed orthopedic implants and 15 patients scheduled for orthopedic implant surgery were tested for metal hypersensitivity using the MELISA test. 2022 Jul 11;8(1):29. doi: 10.1186/s40729-022-00428-0. WebMELISA test for the minimization or complete elimination of health problems in patients with conrmed hypersensitiv-ity to metals. The ideal barrier membrane for most applications. MELISA is the only test that has been scientifically proven to detect titanium allergy and determine its severity. Enfermedades de Inmunodeficiencia Primaria, AAAAI Diversity Equity and Inclusion Statement, Titanium allergy and lymphocyte transformation test. The most likely adverse effect of an allergy to an orthopedic implant is dermatitis, often at the site of the implant but can become generalized and affect the hands; Mediators of Inflammation. iv. I am severely allergic to many metals..confirmed nickel was "off the charts"..worst case they'd ever seen which I'd know obviously for my entire life. Making this recommendation on a test that is not generally accepted is difficult, but you may wish to document a shared decision making discussion regarding this controversy. 5, no. 3, no. CT scan was promptly ordered to rule out the severe complication of toxic megacolon as a result of C. difficile infection. Second, post-surgery, MELISA can be used to identify if metal hypersensitivity is responsible for any of the symptoms that have developed. -, Erakovi S., Jankovi A., Ristoscu C., et al.