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A3724 - Acute Cor Pulmonale and Cardiovascular Collapse Following Illicit Cosmetic Silicone Injections
Author Block: C. Graziani1, J. Hsieh1, D. Smith1, W. Neveu1, B. Demoss1, C. Grodzin2; 1Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, United States, 2Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, United States.
Introduction: Silicone embolization syndrome (SES) is a rare clinical entity that results after silicone enters the circulation as a result of ruptured implants or illicit cosmetic injections. It classically presents with respiratory distress and hypoxemia. We describe a rare case of SES resulting in cardiovascular collapse and thromboembolic complications.
Case Description: A 44-year-old female presented to the emergency department with chest pain and dyspnea several days after receiving illicit silicone gluteal injections. She was admitted with hypertensive emergency, hypoxemia, and non-ST elevation myocardial infarction. Echocardiogram showed a moderately enlarged right ventricle (RV) with reduced systolic function. Computed tomography (CT) of the chest was significant for bilateral diffuse peripheral pulmonary opacities. She subsequently became more hypoxemic and went into pulseless electrical activity (PEA) arrest. Post arrest echocardiogram demonstrated worsening RV dilation and dysfunction with a positive bubble study. These findings were consistent with elevated right sided pressures with a right to left shunt through a patent foramen ovale (PFO). Due to hemodynamic instability, she was placed on inotropic and vasopressor support and started on high dose steroids given concern for possible SES. Over the next few days, her mental status failed to improve and brain imaging was obtained. Brain magnetic resonance imaging (MRI) revealed microinfarctions in the right occipital lobe and right post-central gyrus. The patient was eventually extubated to nasal cannula and transferred to the floor. Chest pain persisted and repeat CT imaging demonstrated a new pulmonary embolism radiographically indistinguishable from silicone versus thromboembolic etiology. Patient was started, and ultimately discharged, on anticoagulation.
Discussion: SES is a potentially lethal complication in individuals receiving silicone injections for cosmetic augmentation. Systemic complications associated with silicone injections have the highest morbidity and mortality. Direct injury, coagulation cascade activation, and blood flow stasis in the pulmonary capillary bed not only increase alveolar leak and hypoxia, but can also lead to acute cor pulmonale. In the event of a physiologic shunt (i.e. PFO), change in right sided filling pressures may be sufficient to cause right to left shunting of silicone particles to the systemic circulation, increasing risk for central embolic events. The clinical findings of SES and fat embolism syndrome are very similar, suggesting a common pathophysiology. The mainstay of treatment for both SES and fat embolism is largely supportive with oxygen and steroids. Physicians should maintain a high index of suspicion for SES in those with a history of implants or liquid silicone injections.