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Winthrop-University Hospital Mineola, NY 11501
A 20-year-old transsexual man presented to our institution with a 3-day history of progressive exertional dyspnea, intermittent fever, and a cough productive of a small amount of blood. A week earlier, the patient underwent bilateral, anterior subcutaneous silicone injections into the chest to simulate breast tissue. This procedure was performed under nonsterile conditions by a nonphysician friend. The patient reported multiple risk factors for HIV and admitted to other prior nonsterile surgical procedures. The patient denied using illicit drugs, including cocaine. At physical examination, the patient was febrile to 101.4°F (38.6°C), tachycardic with a pulse of 107, and mildly tachypneic with a rate of 18 breaths per minute. There were decreased breath sounds at the lung bases; no erythema or obvious chest wall abscess was present. The patient was hypoxemic on room air, with a PO2 level of 77 mm Hg. Admission chest radiography showed symmetric air-space disease at both lung bases. The patient became more dyspneic and hypoxemic over the next 48 hr, and chest radiographs showed development of diffuse air-space disease. The creatinine level remained normal, and no evidence of vasculitis was found on laboratory workup. Broad-spectrum IV antibiotics were begun, including coverage for possible Pneumocystis carinii pneumonia. Unenhanced CT of the chest showed diffuse peripheral and bilateral air-space disease, as well as heterogeneous relatively high-attenuation areas representing the freely injected silicone in the subcutaneous tissues (Fig. 1A, 1B, 1C). The pulmonary findings were interpreted as a direct lung injury response to the silicone; this pattern was consistent with either bronchiolitis obliterans organizing pneumonia or a secondary eosinophilic pneumonia [1], although no eosinophilia was found in the blood or sputum. The patient refused other invasive tests including bronchoscopy and open lung biopsy. Therefore, empiric IV steroids were started for presumed acute lung injury. Serologic and culture data revealed no evidence of HIV, P. carinii, or Mycobacterium tuberculosis. Over the next week, the patient improved, with complete resolution of dyspnea and hemoptysis and corresponding resolution of the chest radiographic findings. The patient was discharged 12 days after admission.
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Polydimethylsiloxane fluid, also known as injectable silicone, is sometimes used for cosmetic enhancements. Unfortunately, its use is not without occasional severe adverse effects, including death [2]. In one such patient, a 40-year-old woman who died within 1 day after injection of a large amount of silicone into the breasts, significant concentrations of silicone were found at autopsy in the lungs, kidneys, liver, brain, and serum [2]. Other reported complications include granulomatous hepatitis [2]. Acute silicone pneumonitis presents with fever and acute lung injury and can evolve to respiratory distress syndrome. A latent pneumonitis may also occur, typically characterized by local inflammation at the sites of prior silicone injection and mild lung injury [3, 4]. Finally, direct trauma to the areas of prior silicone injection may also trigger acute lung injury [3].
Chest radiographic findings of acute silicone pneumonitis include bilateral interstitial disease or findings consistent with acute respiratory distress syndrome [3, 4]. To our knowledge, the CT findings in this disorder have not been previously reported. CT reveals the pulmonary abnormalities and the extent of silicone that has been injected into the subcutaneous tissues. The previous literature has termed this disorder as a generic "pneumonitis." Although the striking peripheral distribution of air-space disease in our patient would be consistent with either bronchiolitis obliterans organizing pneumonia or secondary eosinophilic pneumonia, a specific diagnosis was not possible because of the absence of pathologic proof; however, both disorders are steroid responsive [1].
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  G. E. Gurvits Silicone Pneumonitis after a Cosmetic Augmentation Procedure N. Engl. J. Med., January 12, 2006; 354(2): 211 - 212. [Full Text] [PDF]
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