Letter to the Editor
Systemic reaction and mediastinal involvement secondary to breast implant rupture
Reacción sistémica y afectación mediastínica secundaria a rotura de implante protésico de mama
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It is caused by a foreign body-type reaction secondary to the presence of polydimethylsiloxane polymers, which can shift as a result of a prosthetic rupture or by filtration through an undamaged capsule.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The use of silicone implants generated great controversy during the nineties for its alleged association with a higher incidence of connective tissue diseases, even banning its use for almost 14 years. Its subsequent legalization and worldwide rise have made the knowledge of possible complications very important.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 44-year-old patient with mediastinal involvement secondary to the rupture of one of her breast implants, which were implanted 8 years earlier. The patient, who had been an ex-smoker for 5 years, was admitted for a one-month history of fever, myalgias, weight loss, occasional productive cough and progressive dyspnoea. She had completed 2 antibiotic treatment regimens, with no improvement. The patient was stable from a haemodynamic perspective, with baseline peripheral oxygen saturation of 97%. Only a discrete leukocytosis with left deviation stood out in the laboratory results. Influenza A screening and sputum smear microscopy were negative, as well as the study of autoimmunity (rheumatoid factor, antinuclear and anti-DNA antibodies). The chest X-ray showed hyperlucency in the left upper lobe as the only finding; this was already present in an X-ray performed years earlier, but it was not studied. A Chest-CT angiography was requested, showing a ruptured right breast prosthesis, a 2.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>cm lymphadenopathy with a discrete density increase in the subcarinal region of the mediastinum and a large decrease in part of the left lung parenchyma, accompanied by hypovascularity (hyperlucency on X-ray), bullae and some disseminated bronchiectasis, compatible with a potential and previously unknown Swyer-James syndrome (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A linear endobronchial ultrasound (EBUS) and a transbronchial fine-needle aspiration were performed, confirming the existence of a chronic inflammatory reaction against silicone that included foreign body-type giant cells, as well as remains of said material. Plastic surgery was contacted for the urgent removal of both prostheses, after which, and having also performed broad spectrum antibiotic treatment, corticosteroid therapy and aerosolized therapy, the patient responded favourably. Based on the diagnostic criteria proposed until now, a siliconosis was considered in the context of an autoimmune/inflammatory syndrome induced by adjuvants (ASIA).</p><p id="par0020" class="elsevierStylePara elsevierViewall">According to the medical literature, the frequency of asymptomatic rupture of prosthetic implants is between 0.2–4% and increases with the time elapsed since the same were implanted.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Silicone gel filtration can be lymphatic or hematogenic, causing inflammation and the formation of silicone granulomas (siliconomas). These structures can be confused with recurrences of breast cancer that led to the implant or other types of malignant processes,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> especially lymphomas. Respiratory complications such as pneumonitis or embolisms produced by intrapulmonary migration have also been described,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> both acute and chronic, the latter being able to mimic an interstitial lung disease. Given the potential severity of these complications, the removal and replacement of implants, regardless of their integrity, is currently recommended in all cases confirmed both locally and systemically. In addition, the removal of easily accessible local lesions is recommended, not only because of the aesthetic implications or pain, but also because of the lack of knowledge about possible future filtrations.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our case, the anatomopathological result and the absence of radiological findings compatible with these entities led us to suspect an ASIA syndrome, with the patient fulfilling all the major criteria proposed by Schoenfeld in 2011 (exposure to silicone as an adjuvant, myalgia and fever, typical biopsy and improvement after external agent discontinuation).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> This entity was proposed to combine four other diseases directly associated with prolonged stimulation of the immune response by adjuvants, siliconosis among them. Respiratory symptoms, rare in these cases, were associated with the pre-existing pulmonary disease in the patient, unknown until then.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez-Rodríguez BM, Gallo-Padilla L, Romero-Ortiz AD. Reacción sistémica y afectación mediastínica secundaria a rotura de implante protésico de mama. Med Clin (Barc). 2018;151:42–43.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 912 "Ancho" => 2500 "Tamanyo" => 255430 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest CT angiography: (A) subcarinal lymphadenopathy corresponding to siliconoma; (B) right prosthetic rupture and (C) left pulmonary parenchyma showing bullae, some bronchiectasis and hypovascularity.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rupture of silicone-gel breast implants: causes, sequelae, and diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.L. 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Valdes Cuadrado" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11845-009-0369-6" "Revista" => array:6 [ "tituloSerie" => "Ir J Med Sci" "fecha" => "2010" "volumen" => "179" "paginaInicial" => "141" "paginaFinal" => "145" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19565317" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ASIA-Autoimmune/inflammatory syndrome induced by adjuvants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y. Shoenfeld" 1 => "N. Agmon-Levin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Autoimmun" "fecha" => "2011" "volumen" => "3" "paginaInicial" => "4" "paginaFinal" => "8" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015100000001/v1_201807170422/S2387020618302006/v1_201807170422/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015100000001/v1_201807170422/S2387020618302006/v1_201807170422/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618302006?idApp=UINPBA00004N" ]
