SESSION TITLE: Miscellaneous Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM
INTRODUCTION: Liquid silicone is an inert material with minimal immunogenicity. It undergoes little change in physical properties secondary to environmental factors or aging, therefore is widely used for cosmetic procedures by physicians and nonmedical personnel.
CASE PRESENTATION: 24 y/o genetically male undergoing sex change to female without past medical history admitted with 2 days of dyspnea on exertion, non-productive cough and fever. Review of systems was otherwise unremarkable. Patient denied tobacco or drug use, sick contacts, recent travel or inhalational exposures. He had been getting silicone injections to the breasts and buttocks for 2 years, last one 1.5 weeks prior to presentation. On physical exam patient was hypoxic with oxygen saturation in the 70’s, at rest and with exertion, which corrected with 2 liter nasal cannula. Breath sounds were clear. Laboratory results revealed a normal white blood cell count (WBC 10.6, lymphocytes 11.9%, granulocytes 79.4%, eosinophils 1.5%,), negative respiratory viral panel, blood and sputum cultures, legionella, HIV, and other infectious workup. Negative procalcitonin and autoimmune workup. Chest imaging showed bilateral diffuse alveolar process (figures 1 and 2). Patient was started on antibiotics for community acquired pneumonia with some improvement of symptoms, but persistent hypoxia. A bronchoscopy was performed and broncho alveolar lavage (BAL) revealed frank blood consistent with diffuse alveolar hemorrhage (DAH) . During procedure patient required intubation and was transferred to the MICU. Given the diagnosis of DAH patient was started on methylprednisolone 1 gram daily. Pathology results from transbronchial biopsies revealed birefringent crystalline material predominantly in the interstitium, consistent with silicone. There was no acute inflammation, viral cytopathic change, malignancy or granulomas. Gram stain and cultures were negative. Patient was extubated 2 days later, and discharged 4 days after on prednisone 1 mg/kg with significant improvement of hypoxia and symptoms.
DISCUSSION: Liquid Silicone is frequently used for cosmetic procedures, legally and illegally. The first case of silicone pneumonitis was reported in 1975 and since then small case series have been reported. Pathophysiology is not well understood, but it is theorized that embolism can occur as a result of penetration of silicone into the venous circulation via increased perivascular tissue pressure, direct injection into the vessels or local massage after injection
CONCLUSIONS: silicone embolism can cause diffuse pneumonitis (acute or latent) and diffuse alveolar hemorrhage. There is no consensus regarding appropriate treatment, but most reports show improvement and resolution with corticosteroids. Avoidance of silicone is also part of treatment.
Reference #1: schmid A MD; silicone embolism syndrome a case report, review of the literature, and comparison with fat embolism syndrome; CHEST 2005; 127:2276-2281.
DISCLOSURE: The following authors have nothing to disclose: Maria Velez, Breion Mailloux, Adriel Malave
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