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. 2019 Jul 30;7:176. doi: 10.3389/fbioe.2019.00176

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Copyright © 2019 Eltit, Wang and Wang.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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Characteristic macrophage-dominated ALTR (A–C) and ALTR with lymphocyte infiltration and hypersensitivity features (D–F). Macrophage dominated lesions are associated with evidence of high wear, corrosion, and elevated Co and Cr in serum (53 and 48 μg/L, respectively, in the case shown). ALTRs with predominant lymphocyte infiltrate and hypersensitivity features usually are not associated with elevated wear or corrosion and may be present with lower Co and Cr in serum (6.2 μg/L and 1.2 μg/L in the case in D–F). Low extension of sub superficial necrosis is observed in macrophage-dominated lesion with macrophages that infiltrate the whole synovium (A), forming clusters (arrows) or epithelioid cells (arrowheads) in (B), and multiple micron/sub-micron particles (arrows) are observed in macrophages cytoplasm (C). Hypersensitivity feature ALTRs usually present with large extension of sub superficial necrosis (D), with perivascular lymphocyte infiltration that form large aggregates (over 1 mm) and may constitute tertiary lymphoid organs (arrows in D,E), with low (or none) number of particles observed in the tissues (F).