Critical Care: Student/Resident Case Report Poster - Critical Care I |

Successful Use of Extracorporeal Membrane Oxygenation for Silicone Embolism Syndrome and Pulmonary Hemorrhage FREE TO VIEW

Snehitha Vijaykumar, MD; David Baran, MD; Adaeze Nwosu-Iheme, MD; Harish Seethamraju, MD; Dustin Suanino, MD; Sowmini Medavaram, MD; Nancy Holder, MD; Thiri Anandarangam, MD
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Newark Beth Israel Medical Center, Newark, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):369A. doi:10.1016/j.chest.2016.08.382
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Non-professional injection of silicone for breast augmentation or any cosmetic procedures is a growing problem in the USA giving rise to multiple complications, particularly in the lungs.

CASE PRESENTATION: 17 y/o male-to-female transgender patient presented with progressive dyspnea, non-productive cough and pleuritic chest pain 2 days after injecting silicone for breast augmentation. On admission, the patient was tachycardic, tachypneic and required supplemental oxygen. She was noted to have decreased breath sounds, bilateral breast tenderness and ecchymotic lesions in the upper quadrant of left breast. Lab results revealed leukocytosis of 21,000 cells/µL & D-dimer of 1.29 µg/L. Initial CXR showed diffuse bilateral hazy airspace opacities with interstitial thickening. CT chest angiography was negative for acute emboli but showed patchy ground-glass opacities throughout both lungs. On the night of admission, the patient had several coughing paroxysms with oxygen saturation(O2sat) of 85-87% & multiple episodes of hemoptysis. 48 hours later, respiratory status worsened, initially requiring high flow oxygen, then BiPAP and ultimately 125mg IV methylprednisolone. Patient minimally improved & was emergently intubated. Post-intubation the O2sat remained at 80% on FiO2 of 100% and PEEP of 16cmH2O. Nitric oxide(NO) at 20ppm was added, but O2sat was still <90%. Repeat CXR showed worsening bilateral infiltrates. 5 hours post-intubation and NO administraton, hypoxemia and acidosis worsened. Subsequently, the patient was placed on VenoVenous(V-V) ECMO support & continued with pressure-controlled ventilation. Bronchoscopy post-ECMO showed fresh blood in both bronchi with hemorrhagic fluid return & cytology revealed rare clusters of reactive bronchial epithelial cells and alveolar macrophages. Patient was kept on IV steroids while unfractionated heparin was given for V-V ECMO. The patient's overall clinical status progressively improved & was successfully weaned off ECMO on day 5 and extubated on day 6.

DISCUSSION: Silicone embolism syndrome (SES) is a life threatening complication which involves formation of multiple silicone fluid pulmonary emboli. Uptake of silicone by alveolar macrophages results in modulation of pulmonary immunoregulatory mechanisms that ultimately promote an exaggerated inflammatory response, leading to ARDS or pneumonitis. Treatment is largely supportive with high dose steroids and supplemental oxygen. Unfortunately, some patients develop refractory respiratory failure from massive pulmonary hemorrhage which requires mechanical ventilation and/or ECMO. V-V ECMO was used in this patient as rescue therapy for bridge to recovery, reducing barotrauma and allowing pulmonary rest.

CONCLUSIONS: Evidence of successful ECMO use in refractory respiratory failure with pulmonary bleeding is growing and encouraging.

Reference #1: Y-M Chen, C-C Lu, R-P Perng “Silicone Fluid-induced Pulmonary Embolism”, Am Rev of Resp Dz, Vol. 147, No. 5 (1993), pp. 1299-1302

DISCLOSURE: The following authors have nothing to disclose: Snehitha Vijaykumar, David Baran, Adaeze Nwosu-Iheme, Harish Seethamraju, Dustin Suanino, Sowmini Medavaram, Nancy Holder, Thiri Anandarangam

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