A 22-year-old transsexual man who was HIV-positive (CD4 count, 325 cells/μL), presented with cough, progressive severe dyspnea, chest tightness, and fever. The symptoms began 4 days prior to hospitalization, which was 1 day after the illegal subcutaneous injection of liquid silicone for bilateral breast augmentation. He had received smaller injections during the past 4 years without complications. The volume injected was approximately 700 mL, whereas previous infiltrations were < 100 mL. The physical examination findings were notable for tachycardia, tachypnea, a temperature of 99.7°F, and somnolence. Arterial blood gas measurements performed while the patient was breathing room air were as follows: pH, 7.40; Paco2, 38 mm Hg; Pao2, 67 mm Hg; and arterial oxygen saturation, 92%. Bilateral, patchy, predominantly peripheral densities were seen on the chest radiograph (Fig 1
). A CT scan of the chest demonstrated extensive peripheral airspace consolidations in both lungs (Fig 2
). Fiberoptic bronchoscopy showed fresh blood in both major bronchi. During BAL of the left upper lobe with 100 mL of normal saline solution, the fluid return became progressively more hemorrhagic, indicating alveolar hemorrhage. Cytology showed 50% polymorphonuclear leukocytes, 44% macrophages, 4% lymphocytes, and 2% eosinophils. Silver staining of the BAL fluid had negative results as did stains and cultures for Mycobacterium, fungi, and bacteria. The transbronchial biopsy specimens from the left upper and left lower lobes showed foci of intra-alveolar hemorrhage with fibrin, focal thickening of alveolar walls due to inflammatory infiltrates, and prominent type II pneumocytes. In the interstitial capillaries, vacuolated globular deposits of silicone were found (Fig 3
). Tests for other etiologies of alveolar hemorrhages, including antiglomerular basement membrane antibody (Ab), antinuclear Ab, antinuclear cytoplasmic Ab, and cryoglobulins, and drug screening for cocaine all had negative results. A pulmonary function test on hospital day 6 showed restrictive changes (total lung capacity, 4.4 L [52% predicted]) with increased diffusion capacity (184% predicted). IV methylprednisolone (initial dose, 120 mg/d; tapered to zero during the hospitalization) was administered, and the patient had a rapid clinical and radiographic improvement. He was discharged home without the need for further treatment on the sixth hospital day.