“BLACK-MARKET” COSMETIC INJECTIONS IN A TRANSGENDER FEMALE RESULTING IN SILICONE EMBOLI SYNDROME AND INTERSTITIAL LUNG DISEASE

Abstract

SESSION TITLE: Fellows Diffuse Lung Disease SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: A thrombotic pulmonary embolism is a commonly encountered diagnosis that is often on the forefront of our minds when evaluating a patient with dyspnea. In direct contrast, nonthrombotic emboli are less frequently encountered, span a diverse set of etiologies, and involve varied pathogenesis, other than traditional mechanical obstruction as with ordinary pulmonary emboli. Septic, fat, talc, venous air, amniotic fluid, tumor, iodinated oil, mercury, hydatid, cotton, and catheter have all been described as different emboli involving the pulmonary circulation. We report a case of cosmetic injections with silicone and mineral oil in a transgender female resulting in silicone emboli syndrome and subsequent interstitial lung disease (ILD) and worsening hypoxia. CASE PRESENTATION: A 40 year old transgender female presented to our hospital with worsening dyspnea, cough, and hypoxemia over the course of a year. Her medical history was notable for multiple silicone and mineral oil cosmetic injections to her breasts, thighs, and buttocks, which the patient described as “black-market procedures.” The patient was hypoxic on presentation, requiring 3L of oxygen via nasal cannula, but otherwise was hemodynamically stable and afebrile. Her physical examination and laboratory studies were unremarkable. A chest radiograph revealed peripheral bibasilar reticular opacities. A CT chest showed diffuse reticulation, interlobular septal thickening, scattered nodules, and ground glass opacities. A bronchoscopy with bronchioalveolar lavage and transbronchial biopsies was performed. Pathology revealed spheroid silicone particles in the lung interstitium and capillaries, with histiocytic reaction and fibrosis. The diagnosis of interstitial lung disease due to silicone embolism syndrome was granted. The patient was trialed on steroids, without improvement in symptoms. She was discharged with supplemental oxygen with referral for lung transplant evaluation. DISCUSSION: Following subcutaneous injection, often from cosmetic procedures by nonmedical practitioners, liquid silicone enters the pulmonary circulation. Once in the pulmonary capillaries, interstitial inflammation, increased vascular permeability, alveolar edema and hemorrhage can ensue. Clinical features include hypoxia, dyspnea, fever, alveolar hemorrhage, and cough, with both acute and chronic presentations. CT findings of reticulonodular opacities and interlobular septal thickening are suggestive. Histopathology reveals globular deposits, alveolar inflammatory infiltrates, fibrosis, and hemorrhage. Treatment with steroids has been reported with favorable outcomes, however, severe cases can lead to ARDS and death. CONCLUSIONS: This case highlights the importance of a thorough exposure history when evaluating patients with ILD. Additionally, it is imperative to promote the awareness of this potentially lethal complication of cosmetic silicone injections. Reference #1: Zamora, A.C., Collard, H.R., Barrera, L. et al. Silicone Injection Causing Acute Pneumonitis: A Case Series. Lung 187, 241–244 (2009) Reference #2: Dawn, Samuel K. MD*; Elicker, Brett M. MD*; Leung, Jessica W. T. MD†; Reddy, Gautham P. MD, MPH*; Gotway, Michael B. MD‡ The Silicone Syndrome, Clinical Pulmonary Medicine: March 2006 - Volume 13 - Issue 2 - p 146-147. Reference #3: Sridhara S, Baksh M, Batool K, Chowdhury J, Reddy V, Norwood S, Sivaswami S. A rare case of delayed chronic pneumonitis following non-medical grade silicone injections in a transgender woman. J Unexplored Med Data 2018;3:1. DISCLOSURES: No relevant relationships by Astrid Carrion Rodriguez, source=Web Response No relevant relationships by Andrew Daya, source=Web Response No relevant relationships by Christine Girard, source=Web Response No relevant relationships by Nydia Martinez, source=Web Response No relevant relationships by Rajaganesh Rajagopalan, source=Web Response