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Siliconoma: an unusual entity for the internist
Letter to the Editor 3. Groneberg DA, Eynott PR, Lim S, et al. Expression of respiratory mucins in fatal status asthmaticus and mild asthma. Histopathology. 2002;40:367–373. 4. Groneberg DA, Peiser C, Dinh QT, et al. Distribution of respiratory mucin proteins in human nasal mucosa. Laryngoscope. 2003;113:520 –524. 5. Groneberg DA, Eynott PR, Oates T, et al. Expression of MUC5AC and MUC5B mucins in normal and cystic fibrosis lung. Respir Med. 2002;96:81–86.
The Reply: We thank Groneburg et al for their interest in our manuscript. We agree that one of the key observations resulting from our quantification of lumenal contents in fatal asthma is the finding of, on average, a high cellular content in airway plugs in fatal asthma, although there was substantial variation in the proportion of mucus versus cells among patients and in airways of different sizes. This finding has implications for potential therapies in near-fatal attacks, as noted in the discussion in our manuscript. Furthermore, our results illustrate the need for continued research into mechanisms controlling mucus production, such as Groneburg et al are pursuing, as airway plugging is a critical part of the pathogenesis of the fatal attack in most patients, based on our study. In addition, airway plugging likely contributes to the hyperresponsiveness of airways in severe asthma (data submitted for publication). Tony R. Bai, MD Respiratory Division University of British Columbia St Paul’s Hospital Vancouver, British Columbia, Canada
SILICONOMA: AN UNUSUAL ENTITY FOR THE INTERNIST To the Editor: A healthy 62-year-old woman was referred to our department for evaluation of a right-sided facial swelling of
10 days’ duration. Before admission, she had been seen by a general practitioner and a dermatologist; had ultrasonography, which was unreliable because of subcutaneous emphysema; and had taken nonsteroidal anti-inflammatory drugs for 1 week with no benefit. Her medical history included reflux esophagitis controlled by therapy. On admission, the patient was asymptomatic, but the local clinical picture had dramatically worsened, with an evident swelling of the right cheek (4 ⫻ 2.5 cm) and the onset of a second, smaller swelling on the contralateral cheek. Small nodules appeared in the superciliary and perilabial regions. On palpation, the nodules were of increased thickness and were adherent to the cutis and underlying tissues, but no rubor or pain was present. Blood chemistry panel showed only a slight fibrinogen increase (520 mg/dL). A further ultrasonography showed several hypoechogenic spots. After retaking her history, we found that approximately 10 years before, the patient had an ambulatory aesthetic treatment with subcutaneous injections of silicone on the face in the superciliary bilateral regions. The diagnosis of siliconoma was confirmed by light microscopic study of a biopsy specimen, which showed granulomatous nodules in the dermis, with histiocytes, epithelioid histiocytes, and multinucleated giant cells surrounded by lymphocytes and containing amorphous material. The patient was then referred to plastic surgery. There are several forms of silicone in medical use: silicone oil is used as a coating for needles and syringes, silicone gel is used as an implant material (e.g., in the breast and face), and silicone elastomers are used in implanted prosthetic devices and intravenous fluid tubing. Moreover, the liquid form of silicone, or dimethicone (dimethylpolysiloxane), has been used extensively in some countries during the past 4 decades for soft-tissue augmentation. Although considered biologically inert, this maJanuary 1, 2004
terial has been reported as potentially inducing a granulomatous inflammatory response of variable severity after tissue injection. Complications of silicone injection may include chronic cellulitis, nodulation, foreign body reaction, and the movement of material to other parts of the body, sometimes many years after injection (1). Complications are not limited to the dermis or subcutis, such as at the entry points of acupuncture or venipuncture (2) or at the site of injections (3), but may include severe ocular consequences with optic nerve damage (4). Recently, new inert materials, such as polymerized silicones, have been introduced which are not likely to migrate and which usually do not produce a host-immune response. However, because reactions after cosmetic microimplants have been reported (5,6), internists should be aware that the use of biologically inert materials does not completely rule out the possibility of adverse reactions. Raffaella Salmi, MD St Anna Hospital Ferrara, Italy Benedetta Boari, MD Roberto Manfredini, MD University of Ferrara St Anna Hospital Ferrara, Italy 1. Krayenbuhl BH, Panizzon RG. Silicone granuloma. Dermatology. 2000;200:360 – 362. 2. Alani RM, Busam K. Acupuncture granulomas. J Am Acad Dermatol. 2001;45:225–226. 3. Bigata` X, Ribera M, Bielsa I, Ferra`ndiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg. 2001;27:198 –200. 4. Budde M, Cursiefen C, Holbach LM, Naumann GO. Silicone oil-associated optic nerve degeneration. Am J Ophtalmol. 2001; 131:392–394. 5. Requena C, Izquierdo MJ, Navarro M, et al. Adverse reactions to injectable aesthetic microimplants. Am J Dermatopathol. 2001;23: 197–202. 6. Hoffmann C, Schuller-Petrovic S, Soyer HP, Kerl H. Adverse reactions after cosmetic lip augmentation with permanent biologically inert implant materials. J Am Acad Dermatol. 1999;40:100 –102.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 116 67
The Reply: We thank Groneburg et al for their interest in our manuscript. We agree that one of the key observations resulting from our quantification of lumenal contents in fatal asthma is the finding of, on average, a high cellular content in airway plugs in fatal asthma, although there was substantial variation in the proportion of mucus versus cells among patients and in airways of different sizes. This finding has implications for potential therapies in near-fatal attacks, as noted in the discussion in our manuscript. Furthermore, our results illustrate the need for continued research into mechanisms controlling mucus production, such as Groneburg et al are pursuing, as airway plugging is a critical part of the pathogenesis of the fatal attack in most patients, based on our study. In addition, airway plugging likely contributes to the hyperresponsiveness of airways in severe asthma (data submitted for publication). Tony R. Bai, MD Respiratory Division University of British Columbia St Paul’s Hospital Vancouver, British Columbia, Canada
SILICONOMA: AN UNUSUAL ENTITY FOR THE INTERNIST To the Editor: A healthy 62-year-old woman was referred to our department for evaluation of a right-sided facial swelling of
10 days’ duration. Before admission, she had been seen by a general practitioner and a dermatologist; had ultrasonography, which was unreliable because of subcutaneous emphysema; and had taken nonsteroidal anti-inflammatory drugs for 1 week with no benefit. Her medical history included reflux esophagitis controlled by therapy. On admission, the patient was asymptomatic, but the local clinical picture had dramatically worsened, with an evident swelling of the right cheek (4 ⫻ 2.5 cm) and the onset of a second, smaller swelling on the contralateral cheek. Small nodules appeared in the superciliary and perilabial regions. On palpation, the nodules were of increased thickness and were adherent to the cutis and underlying tissues, but no rubor or pain was present. Blood chemistry panel showed only a slight fibrinogen increase (520 mg/dL). A further ultrasonography showed several hypoechogenic spots. After retaking her history, we found that approximately 10 years before, the patient had an ambulatory aesthetic treatment with subcutaneous injections of silicone on the face in the superciliary bilateral regions. The diagnosis of siliconoma was confirmed by light microscopic study of a biopsy specimen, which showed granulomatous nodules in the dermis, with histiocytes, epithelioid histiocytes, and multinucleated giant cells surrounded by lymphocytes and containing amorphous material. The patient was then referred to plastic surgery. There are several forms of silicone in medical use: silicone oil is used as a coating for needles and syringes, silicone gel is used as an implant material (e.g., in the breast and face), and silicone elastomers are used in implanted prosthetic devices and intravenous fluid tubing. Moreover, the liquid form of silicone, or dimethicone (dimethylpolysiloxane), has been used extensively in some countries during the past 4 decades for soft-tissue augmentation. Although considered biologically inert, this maJanuary 1, 2004
terial has been reported as potentially inducing a granulomatous inflammatory response of variable severity after tissue injection. Complications of silicone injection may include chronic cellulitis, nodulation, foreign body reaction, and the movement of material to other parts of the body, sometimes many years after injection (1). Complications are not limited to the dermis or subcutis, such as at the entry points of acupuncture or venipuncture (2) or at the site of injections (3), but may include severe ocular consequences with optic nerve damage (4). Recently, new inert materials, such as polymerized silicones, have been introduced which are not likely to migrate and which usually do not produce a host-immune response. However, because reactions after cosmetic microimplants have been reported (5,6), internists should be aware that the use of biologically inert materials does not completely rule out the possibility of adverse reactions. Raffaella Salmi, MD St Anna Hospital Ferrara, Italy Benedetta Boari, MD Roberto Manfredini, MD University of Ferrara St Anna Hospital Ferrara, Italy 1. Krayenbuhl BH, Panizzon RG. Silicone granuloma. Dermatology. 2000;200:360 – 362. 2. Alani RM, Busam K. Acupuncture granulomas. J Am Acad Dermatol. 2001;45:225–226. 3. Bigata` X, Ribera M, Bielsa I, Ferra`ndiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg. 2001;27:198 –200. 4. Budde M, Cursiefen C, Holbach LM, Naumann GO. Silicone oil-associated optic nerve degeneration. Am J Ophtalmol. 2001; 131:392–394. 5. Requena C, Izquierdo MJ, Navarro M, et al. Adverse reactions to injectable aesthetic microimplants. Am J Dermatopathol. 2001;23: 197–202. 6. Hoffmann C, Schuller-Petrovic S, Soyer HP, Kerl H. Adverse reactions after cosmetic lip augmentation with permanent biologically inert implant materials. J Am Acad Dermatol. 1999;40:100 –102.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 116 67