Abstract Introduction Silicone embolism syndrome is a rare cause of acute or subacute hypoxemic respiratory failure, most often described after illicit subcutaneous silicone injections. Chronic pulmonary silicone embolism related to ruptured breast implants is uncommon and can mimic cardiogenic pulmonary edema or diffuse alveolar damage. Case Report A 76-year-old woman with alcohol use disorder and remote silicone breast augmentation with acute hypoxemic respiratory failure following recent falls. Chest radiography revealed new bilateral opacities. Exam demonstrated altered mental status, asymmetric, firm breast implants, petechiae over the anterior chest, diffuse crackles and bilateral lower-extremity edema. N-terminal pro-B-type natriuretic peptide (NT-proBNP) was markedly elevated (6950 pg/mL) and C-reactive protein 226.6 mg/L; she was afebrile with a normal leukocyte count. Extensive infectious and autoimmune workup was negative.She initially improved on bilevel positive airway pressure and intravenous diuretics, but deteriorated several days later, requiring noninvasive ventilation. Computed tomography (CT) of the chest demonstrated rupture of the right breast implant with extravasated silicone in the chest wall (Figure 1) and diffuse bilateral ground-glass opacities with a crazy-paving pattern, most prominent in the lower lobes (Figure 2). Echocardiography revealed preserved left ventricular function, moderate right ventricular (RV) dilation with global hypokinesis and severe pulmonary hypertension with estimated pulmonary artery systolic pressure of 76 mmHg. Agitated-saline contrast study excluded intracardiac shunt. Despite broad-spectrum antibiotics, aggressive diuresis and high-dose intravenous corticosteroids, she experienced progressive RV failure and refractory hypoxemia. After electing comfort-focused care, she died shortly after withdrawal of noninvasive ventilation. Autopsy confirmed right implant rupture and bilateral yellow-tan pulmonary nodules, consistent with silicone embolic injury. Discussion This case illustrates fulminant pulmonary silicone embolism from remote cosmetic breast augmentation, presenting with chest wall petechiae, severe pulmonary hypertension and a crazy-paving pattern on CT. Diagnosis is challenging as these findings overlap with cardiogenic edema, viral pneumonitis and acute respiratory distress syndrome. Clinicians should maintain a high index of suspicion for silicone embolism in patients with unexplained hypoxemia and ruptured implants, as timely diagnosis may allow consideration of implant removal and supportive strategies to mitigate right-heart failure. This abstract is funded by: None
Gomes et al. (Fri,) studied this question.