There is a certain level of confidence that comes with being a senior resident. The nurses finally trust me. My attendings allow me to manage patients with autonomy. The juniors look to me for advice. I’m learning to juggle a busy department. I still have much to learn, but most days I feel in control. Yesterday, however, was a humbling day. A young woman in respiratory distress was brought in by EMS. Within minutes, I had made the rare diagnosis, temporarily stabilized her, and arranged for to receive the confirmatory test. I was feeling like…a senior resident. Then panic set in when I realized I had no idea what was the definitive treatment for this patient. And by panic, I mean legitimate angina, and possibly spilling troponins.
This young woman in respiratory distress was hypoxic to 59% on arrival. Her boyfriend reported her symptoms started 8 hours ago, after injecting silicone into her buttocks for cosmetic purposes. On exam, she had over 20 injection marks. Hypoxia, dyspnea, and cough with this history? Easy, right? She has silicone embolism syndrome. Administer oxygen and intubate if needed, obtain a CT if stable, but then what?
Silicone embolism syndrome (SES) is a rare, but potentially fatal disease process that arises from the injection of “free” or liquid silicone, as opposed to silicone contained in a casing such as with breast implants. It can occur when patients are injected by unlicensed professionals, friends, or by themselves. There are two flavors of SES, pulmonary and neurologic. It was first described in the 1970s in transgender women who were using silicone injections as breast augmentation. Today, the two populations most likely to use silicone injections are women and transgender women. The most common injection sites include the breasts, buttocks, and face. Symptoms can arise within minutes to hours after injection. There are also case reports describing delayed presentations up to months later.
The most common symptoms in SES include hypoxia, dyspnea, fever, alveolar hemorrhage, and cough. Chest X-rays may demonstrate pulmonary edema, bilateral diffuse alveolar opacities, or consolidations. CT findings include silicone emboli, peripheral bilateral ground glass opacities, and pulmonary edema. The CT may demonstrate evidence of peripheral pulmonary emboli, pneumonitis, or ARDS. From the data available, the mortality of SES is approximately 25%, but that number approaches 100% is there are neurologic symptoms present.
There are four pathophysiologic patterns that have been observed in SES: embolic, congestive, pneumonitis, and diffuse alveolar damage. Most patients are likely to have multiple, overlapping processes occurring. Overall, the damage is believed to be due to mechanical obstructions of the capillaries and activation of the coagulation cascade. Interestingly, silicone, which was previously thought to be immunologically inert, has now been demonstrated to cause sensitivity in certain individuals after repeat exposure. Not surprisingly, most people who receive silicone injections are repeat users, putting them at significantly higher risk of complications after each use.
Multiple case reports and articles have noted the similarity in presentation and pathophysiology between SES and fat embolisms. Therefore, while little is known about the best practices for managing SES patients, it has been suggested that we treat them the same as fat emboli, including supportive care and the use of steroids. Steroids are potentially beneficial in combating the immune response to the silicone and subsequent edema, pneumonitis, and ARDS that develops. These patients need supplemental oxygen ranging from nonrebreather mask to noninvasive positive pressure ventilation to intubation. As many of these patients develops ARDS, it is wise to implement a lung protective strategy with mechanical ventilation. In severe cases, when patients are unable to be oxygenated sufficiently with mechanical ventilation, consider ECMO. These patients are often ideal candidates for ECMO because they otherwise have healthy lungs and heart, and only need to be supported until their acute lung injury resolves. However, some of these patients will go on to develop long-term lung injury depending on the severity of their disease process.
Although rare, SES is an important diagnosis to have on our radar so we can recognize it. Know who is at risk, know how it presents, and how it may look on imaging. Have a basic understanding of the pathophysiology so that you can develop a strategy for managing these patients.
Author: Nicole Munz – Chief Resident. @nmunzy
Clayton J. Silicone Embolism Syndrome. In: Learning Radiology: Recognizing the Basics. 3rd. ed. Philadelphia, PA: Saunders: 2016.
Narula T, Raza, A, et. al. Risky Aesthetics – A Case of Silicone Embolism Syndrome. Chest 2011;(140):4. doi:10.1378/chest.1119731
Schmid A, Tzur A, et. al. Silicicone Embolism Syndrome: A Case Report, Review of the Literature, and Comparison With Fat Embolism Syndrome. Chest 2005;(127):2276-2281. PMID: 15947350