Silicone Embolism Syndrome (SES): Still Out There

Abstract

INTRODUCTION: Silicone is a highly stable liquid polymer, which has been used for decades in medical and cosmetic applications. While silicone implants are approved for use in cosmetic breast augmentation, illicitly injected liquid silicone by unqualified personnel has been shown to have significant potential risk, including disfigurement and death. The subcutaneous injection of silicone can lead to migration and vascular embolization, known as the silicone embolism syndrome (SES) with severe pulmonary complications, including respiratory failure. We now report a case of repeated silicone injection leading to recurrent SES and pneumonitis. CASE PRESENTATION: A 45 year old man with a past medical history of well-controlled HIV, hypogonadism, treated pulmonary tuberculosis, and bipolar disorder presented with sudden onset shortness of breath and chest pain shortly after injecting liquid silicone into his bilateral axillae for cosmetic purposes. He noted blood in the syringe on aspiration. On presentation to the emergency room, vitals were notable for tachycardia, tachypnea and mild hypoxia that responded to supplemental oxygen. CTA chest was negative for venous thromboembolism, but did reveal new posterior and peripherally distributed ground glass opacities. The patient had a similar clinical and radiologic presentation 5 years earlier after self-injecting silicone. Bronchoscopy at that time showed no evidence of infection. The patient responded to a short course of steroids and was discharged home. DISCUSSION: We present a case of recurrent SES in a patient who self-injects silicone for cosmetic purposes. Similar to fat embolism syndrome, silicone embolism is thought to lead to induction and recruitment of local inflammatory mediators and endothelial disruption resulting in tissue inflammation, damage, and hemorrhage. Hypoxemia is the most common finding, though patients may present with variable respiratory or neurological symptoms depending on the amount and location of embolized silicone. An immune-mediated response has also been hypothesized as a mechanism of disease. In contrast, vascular obstruction is the major mediator of morbidity in venous thromboembolism. Treatment is supportive with oxygen and steroids. Injected silicone can never be removed and may be a nidus for future inflammation or infection. CONCLUSIONS: The US Food and Drug Administration prohibits the marketing of injectable liquid silicone for cosmetic purposes, though it continues to be used by medical and non-medical personnel to enhance body shape and contour. Public education that inappropriate use can cause potentially drastic complications, including death is needed.