Alveolar hemorrhage after parenteral injection of industrial silicone

A previously healthy 24-year-old male-to-female transsexual presented with a 48-h history of dyspnea, fever, and signs of severe hypoxemia (SpO 2 , 72%). The patient reported having undergone an illegal procedure 10 days prior, when industrial liquid silicone had been injected into her buttocks for cosmetic purposes. The patient had previously received silicone breast implants. After admission, the patient rapidly evolved to severe respiratory failure and required mechanical ventilation. During intubation and throughout the period on mechanical ventilation, pulmonary bleeding was observed. Her hemoglobin level was 6 g/dL (hematocrit, 18%), and she was given a blood transfusion. Her platelet count, partial thromboplastin time, and prothrombin time were all normal. Chest CT scans showed patchy, bilateral ground-glass opacities, suggestive of alveolar hemorrhage, and bibasilar consolidations (Figure 1). Mild bilateral pleural effusion was also observed. Ultrasound examination of the site of the injection showed no abnormal liquid collection that would require drainage or any other type of surgical intervention. Because of the severe hypoxemia, bronchoscopy and BAL were not performed. Blood cultures were negative throughout the treatment period. The patient was given a diagnosis of silicone pulmonary embolism with alveolar hemorrhage, which was initially treated with mechanical ventilation, accompanied by methylprednisolone pulse therapy, together with a 14-day course of empirical antimicrobial therapy (with oxacillin and ceftriaxone). The evolution was favorable, her hemoglobin level gradually returning to a value that was within the normal range (11.4 g/dL). On post-admission day 14, she was extubated and her SpO 2 was 91%. On post-admission day 21, her overall health status was good and she was discharged. Silicone is the chemical and commercial name for polydimethylsiloxane (dimethicone), an organic compound comprising a chain of alternating silicon and oxygen atoms bonded to other organic groups. The chemical state of the polymer—gel (elastomer), liquid, or solid—is determined by the number of cross-links in the molecule. It has been long considered an inert compound with good thermal stability, favoring its use in medicine in various implantable devices. In its pure form, silicone has been used in cosmetic and esthetic procedures for the last five decades, and it is known to produce minimal tissue reactions and no significant immune response, although, in many countries, it is approved only for use in breast augmentation devices and is prohibited as an injectable liquid. However, the widespread underground practice of industrial liquid silicone injection within the transsexual community worldwide has produced various cases …