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A6605 - Alveolar Hemorrhage in Acute Pneumonitis After Gluteus Adjuvant Injection
Author Block: S. Rodriguez-Llamazares1, E. F. Castro-Arellano1, C. Castillo-Villlatoro2, L. J. Arroyo-Hernandez1, H. Rodríguez Bautista1, T. Aguirre Pérez2, R. Del Razo-Rodríguez2; 1Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico, 2Bronchoscopy, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico.
BACKGROUND: Cosmetic silicone injection prevalence has tripled in the last 20 years. Currently, many non-FDA approved products are applied through illicit marketing. These unregulated products can produce systemic afflictions including infection and necrosis. Liquid silicone (poly-dimethylsiloxanes) injections have been reported to cause lung disease such as acute pneumonitis, pulmonary embolism and bronchiolitis obliterans; all of which may have deadly consequences if left untreated. CASE REPORT: A previously healthy 26 year old female hair stylist arrived to the emergency department with a two day mMRC4 dyspnea and chest pain which started four hours after injection of 60ml of biopolymer in each gluteus. She had a history of breast implant surgery 7 years before arrival and a 3 cigarettes per day active smoking. With 84% oximetry upon arrival that improved to normality with 3Lt/min supplemental oxygen, she denied cough or hemoptysis.DIAGNOSTIC APPROACH: Initial blood gas analysis showed hypoxemia without hypercapnia with a alveolar arterial gradient of 15.6. Chest X ray revealed bilateral diffuse glass ground opacities. High resolution CT scan uncovered areas of high attenuation with diffuse subpleural consolidation along with peripheral ground glass opacities in both hemithorax without apico-basal gradient. Videobronchoscopy showed a red stained bronchoalveolar lavage (BAL) that did not clear during the procedure, suggesting alveolar hemorrhage. Cytomorphological analysis displayed a lymphocytic (21%) and neutrophilic (13%) predominance that included hemosiderin filled macrophages. Pulmonary embolism was discarded by a normal D-Dimer. Al microbiological tests including those excluding fungi and tuberculosis infection were negative. HIV testing proved negative as well. A full panel of autoantibodies proved negative.TREATMENT: After a 6 day treatment fo oral prednisone 50mg per day, supplemental oxygen requirements decreased until a 90% oximetry was achieved and the patient was discharged. She was advised about the risks of a polymer re-injection.CONCLUSION: Acute pneumonitis due to liquid biopolymer injection is a serious complication that requires early diagnosis and treatment as it can develop into Acute Respiratory Distress Syndrome. Of all the different case reports and case series currently published, only two reports describe the existence of alveolar hemorrhage: one being only a microscopic finding through Perls staining and the other found as a rare macroscopic hemoptysis that did clear out during BAL procedure. Although pathophysiology of this disease is yet unknown, the fact that steroid regimens have been useful suggest that there is an immune-mediated mechanism that explains inflammation and, in this case, endothelial destruction.