P50 Gossypiboma causing SLE and dermatomyositis overlap

Abstract

Abstract Background Gossypiboma is a term referring to tumours arising from a retained, non-absorbable cotton matrix left behind during surgery. Serious implications for patients include infections, migration of the retained particles into a systemic circulation, local obstructions, as well as autoimmune reactions. To our knowledge, we describe the first case of SLE-dermatomyositis overlap associated with the gossypiboma. Methods A 44 year old lady, who is originally from Poland, presented with a few months history of oral ulcers, photosensitive rash over her chest and neck, myalgia, heliotrope rash and subcutaneous calcified nodules. Her ANA screen was positive 1:100 homogenous pattern, ENA, DsDNA negative, normal complements, CK up to 1636 u/L, nailfold capillaries demonstrated dilated capillaries and capillary dropouts. She was initially managed by a hydroxychloroquine and methotrexate combination for a presumed lupus and dermatomyositis overlap, followed by rituximab for recurrent lupus flare ups. The left knee MRI revealed a well-defined lesion medial to the tibia measuring 4.5 x 2.8 x 2.2 cm. It was heterogenous and contained calcium depositions. The initial diagnosis was in favour of peripheral nerve sheath tumour (schwannoma). However, surgical resection and histological analysis revealed foreign body sponge like material consistent with a retained surgical sponge. On revisiting the past medical history, the patient recalled some form of an operation on her left knee, evidenced by a small scar over posterior aspect of the knee, around twenty-five years ago. A subsequent operation was undertaken to remove the gossypiboma. After this, the patient’s symptoms had gradually improved and ANA screen came back as negative, and she was able to cease steroid therapy. Results Immune type of reactions secondary to adjuvants (silicone, pristane, aluminium, vaccines, etc) have been described by Israeli immunologist Shoenfeld and named ASIA syndrome (Autoimmune Syndrome Induced by Adjuvants) in 2011. He described late-onset (sometimes after many years) systemic symptoms associated with the immune reaction following silicone breast implantation. As per his theory, adjuvants influence both adaptive and innate arm of the immune system via different mechanisms, especially in genetically predisposed individuals. The great variety of manifestations have been described, among which Sjögren’s and lupus-like syndromes. We believe that our patient developed autoimmune disease secondary to constant antigenic stimulation caused by a retained cotton wool in the knee. The fact that the symptoms have improved after the removal of the foreign body combined with the negative ANA test is the evidence of the above-mentioned causality. Conclusion In summary, we believe that the presence of the foreign body in our patient’s knee has propagated the foreign body reactions and lead to an autoimmune disease. Disclosures L. Borukhson None. C. Wing None. R.J. Stratton None.