INTRODUCTION: Lipoid Pneumonia is an uncommon entity characterized by pulmonary accumulation of lipids from endogenous or exogenous sources. We report a case of exogenous lipoid pneumonia following illicit subcutaneous silicone injection for cosmetic purposes.
CASE PRESENTATION: A 30-year-old previously healthy female presented to our ED complaining of dyspnea for four days. Her symptoms started shortly after liquid silicon injection to her buttocks by a non-professional individual. Two days later she noticed cough with clear sputum that subsequently turned bloody. Dyspnea and hemoptysis worsened despite prescribed inhaled steroids and azithromycin at another ED. Review of systems was otherwise unremarkable. Physical exam was pertinent for an oxygen saturation of 93% on room air and bibasilar crackles. Chest radiography showed bibasilar airspace disease. Computed tomography revealed bibasilar and peripheral ground glass opacities. Bronchoscopic exam showed diffuse bright red blood in the airways. Bronchoalveolar lavage had a sanguinous appearance that cleared with subsequent aliquots of saline. Pulmonary function tests suggested a restrictive pattern with an elevated diffusing capacity. Transbronchial biopsies showed lipoid pneumonia and silicon vacuoles. Due to worsening dyspnea, hypoxemia and hemoptysis, the patient was started on high-dose methylprednisolone and she experienced a dramatic clinical improvement within 24 hours. She was discharged five days later on prednisone and without supplemental oxygen. On a 3-week follow-up visit she reported no symptoms and her pulmonary function tests showed a significant improvement. Prednisone was successfully tapered off over four weeks.
DISCUSSION: Lipoid Pneumonia (LP) is caused by accumulation of lipids in the alveoli from endogenous or exogenous sources. Endogenous LP is seen in alveolar proteinosis and hereditary errors of metabolism. Exogenous LP is typically caused by inhalation or aspiration of oils. Injectable silicon fluid is widely used in cosmetic procedures. Animal studies have shown that it can be subsequently recovered in various organs after injection.1 Illicit injections in humans are associated with adverse effects including migration to other organs, granulomatous hepatitis, and death.2 Silicone-fluid induced embolism has been implicated as a cause of acute pneumonitis with alveolar hemorrhage. The patient we present had hypoxemia, dyspnea and hemoptysis. In a series of 33 patients, 92% had hypoxemia, 88% dyspnea, 70% fever, and 64% alveolar hemorrhage.3 Symptoms started a few minutes after the injection in 72% of patients. Although our patient had hemoptysis and elevated diffusing capacity, bronchoscopy failed to demonstrate active alveolar hemorrhage. Chest radiography showed basilar infiltrates as the previously reported patients. CT showed diffuse peripheral and bibasilar ground glass opacities, characteristic features seen on previous reports of similar cases. Transbronchial biopsies revealed lipoid pneumonia and silicon vacuoles but no evidence of alveolar hemorrhage. The proposed mechanism is delivery to the lung via blood vessels and leakage into the airspaces as silicone is notorious for not staying compartmentalized. The evidence for therapy in these patients is mostly based on case reports. The patient was deteriorating rapidly until systemic steroids were started. She showed remarkable improvement in symptoms and hypoxia. She was discharged a few days later and remained symptom free after a slow taper of prednisone.
CONCLUSIONS: Silicon injection for cosmetic purposes is potentially a lethal procedure. We present the case of a woman who developed lipoid pneumonia presumably from silicon embolization that successfully recovered with systemic steroid therapy.
Reference #1 Ben-Hur N, Ballantyne DL Jr, Rees TD, Seidman I. Local and systemic effects of dimethylpolysiloxane fluid in mice. Plast Reconstr Surg 1967;39:423-6.
Reference #2 Ellenbogen R, Rubin L. Injectable fluid silicone therapy: human morbidity and mortality. JAMA. 1975;2324:308-309.
Reference #3 Smith A, Tzur A, Leshko L, Krieger BP. Silicone embolism syndrome: a case report, review of the literature, and comparison with fat embolism syndrome. Chest 2005;127:2276-81.
DISCLOSURE: The following authors have nothing to disclose: Angel Coz Yataco, Javier Diaz-Mendoza, Chad Stone
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