Is explantation of silicone breast implants useful in patients with complaints?

A population-based study of breast implant illness

Background

Despite evidence supporting the safety of breast implants, some women associate their implants with adverse health effects and have called this syndrome “breast implant illness.” We sought to characterize breast implant illness symptoms and to report how implant removal affects their symptoms.

Methods

An anonymous 20 question survey was administered to the Facebook group: “UTAH Breast Implant Illness” to characterize the symptoms these women attributed to their breast implants. Several questions allowed us to evaluate how implant removal affected women’s symptoms.

Results

Of the 182 respondents, 97% report that implants negatively affect their health and 95% identify these symptoms with breast implant illness. Ninety-six percent of respondents had implants placed for cosmetic reasons and 51% had silicone implants. The most common symptoms associated with breast implant illness are brain fog (95%), fatigue (92%), joint pain (80%), and hair loss (74%). Sixty percent of respondents learned about breast implant illness from family/friends and/or social media platforms (56%), 40% of respondents had their implants removed, and 97% report relief of their symptoms post-removal (23% complete, 74% partial). Following explantation, there was a significant improvement in all but one reported symptom. An association was found between the number of symptoms reported prior to explantation and the number of symptoms resolving following explantation.

Conclusions

Breast implant illness is a syndrome characterized by fatigue, decreased focus, hair loss, and joint pain after the placement of breast implants. Nearly all patients report improvement of symptoms after implant removal. Significant efforts should be made to better understand breast implant illness and its etiology.

Risk Factors for Explantation of Breast Implants: A Cross-Sectional Study

BACKGROUND

Explantation of breast implant surgery (EBIS) is an emerging surgical field. Precise information about patients undergoing EBIS is important for preoperative planning of breast, augmentation, complications management, and to address any medicolegal issues.

OBJECTIVES

The aim of this study was to further extend current knowledge of EBIS risk factors.

METHODS

An analytic cross-sectional study was conducted involving patients who had previously undergone cosmetic breast augmentation and were seeking EBIS.

RESULTS

The study recruited 138 patients. The average time from implant placement and decision to explantation was 59.1 months. On average, each 1-year increase in age resulted in a 4% increase in the relative risk (RR) of explantation (confidence interval (CI), 1.07-1.21). Patients who were obese or overweight present a 1.5 times higher risk of EBIS (CI 95%, 1.03-2.29). On average, this RR was 40% lower (CI 95%, 0.33-0.91) in patients who never smoked compared with those with a history of tobacco use. Women with mastalgia had a 72% higher RR for EBIS (CI 95%, 1.11-2.65). The RR of EBIS was 5.6 times higher (CI 95%, 2.42-11.47) in patients presenting major Shoenfeld's criteria for autoimmune/inflammatory syndrome induced by adjuvants (ASIA). The RR of EBIS was 4.3 times higher (CI 95%, 1.96-8.63) in patients presenting minor Shoenfeld's criteria for ASIA.

CONCLUSIONS

EBIS poses a higher risk to patients who are overweight/obese, have a history of tobacco use, suffer from mastalgia, or present Shoenfeld's criteria for ASIA. It is important to assess properly these individuals before performing implant surgery for breast augmentation.

LEVEL OF EVIDENCE: 4

Breast-related and body-related quality of life following autologous breast reconstruction is superior to implant-based breast reconstruction - A long-term follow-up study

INTRODUCTION

The better survival rates after breast cancer allow for setting of long-term goals, such as Quality of Life (QoL) and aesthetic outcomes following breast reconstruction. Studies find a higher breast-related QoL and greater satisfaction with breasts following autologous breast reconstruction (ABR) compared to implant-based breast reconstruction (IBR). However, aesthetic results from donor sites can influence body image. This concern is little addressed in the literature. Therefore, the aim of this study was to compare the long-term breast-related and body-related QoL of women who underwent ABR to women who underwent IBR.

MATERIAL AND METHODS

A multicenter, cross-sectional survey was conducted between November and December 2020 among women who underwent postmastectomy breast reconstruction between January 2015 and December 2018. A general questionnaire, the BREAST-Q, and the BODY-Q were used to collect data. Multivariable linear regression was performed to adjust differences in Q-scores for potential confounders.

RESULTS

In total, 336 patients were included (112 IBR, 224 ABR). Autologous reconstruction resulted in significantly higher mean scores in all subdomains of the BREAST-Q. On the BODY-Q, IBR scored significantly higher on scars, while ABR scored moderately to significantly higher on all other scales. Despite a lower mean score on Hips & outer thighs in women with Lateral Thigh Perforator (LTP) flap reconstruction, no negative influence on body image was found in these women.

CONCLUSIONS

Long-term breast-related and body-related outcomes of ABR are superior to IBR. Donor site aesthetic does not adversely affect body image in women who underwent free flap breast reconstruction.

The Prevalence of Self-Reported Health Complaints and Health-Related Quality of Life in Women With Breast Implants

Background

Some of the millions of women with silicone breast implants (SBIs) report a pattern of systemic complaints, known as ASIA syndrome. However, the association between these complaints and breast implants remains uncertain.

Objectives

This study aimed to evaluate the prevalence of complaints in women with breast implants and healthy controls, and to compare their health-related quality of life.

Methods

Four groups of subjects were requested to fill in a general and a diagnostic questionnaire, and the Short Form 36. Group 1 was recruited from the Dutch foundation for breast implant illness (BII). Two groups were recruited from Dutch hospitals, where they had been augmented or reconstructed with SBIs (group 2) or saline-filled and hydrogel implants (group 3). A control group without breast implants was recruited from friends of subjects from group 2.

Results

In total, 238 women completed the questionnaires. ASIA manifestations appeared in the majority of the respondents (72.3%-98.8%), with a latency period of 0 to 35 years. Adjusted for age, smoking, and comorbidities, typical symptoms only occurred significantly more frequently in group 1. The presence of a chronic disease was an independent predictor for ASIA syndrome. The health-related quality of life was lower in women with SBIs than in women without breast implants.

Conclusions

The adjusted prevalence of BII manifestations is not significantly higher in women with SBIs than in women without implants. The findings of this study suggest that results on BII are subject to selection bias. Further studies are needed to prove an association between self-reported complaints and SBIs.

Level of Evidence: 2

Mastopexy with Autoaugmentation and Fat Transfer

Patients have been requesting implant removal in revisional breast surgery and options for breast improvement without the use of breast implants in primary breast surgery. This article focuses on perioperative decision making and surgical technique in performing a mastopexy with autoaugmentation and fat grafting. The use of a lower island of breast parenchyma relocated to the upper pole through a central pedicle in primary surgery and a superior pedicle in postexplantation cases, along with fat grafting can provide improvement in global volume or simply additional volume in areas of deficiency, such as the upper poles and medial cleavage region.

An Algorithm for the Management of Explantation Surgery

Creating pleasing breast aesthetics after an explantation can be challenging, especially when performed with a total capsulectomy. The necessity of a capsulectomy for a variety of breast issues is not completely agreed on and can increase adverse events, patient morbidity, and cost of the operation and often impairs the final aesthetic result. In this article, an algorithm for the management of explantation patients provides a framework for treatment of the capsule and the breast to optimize outcomes.

Adjunctive Procedures and Informed Consent with Breast Implant Explantation

BACKGROUND

The use of injectable or implantable materials or devices in the breast for augmentation or reconstruction has a history of innovation and controversy. Staying current in the field of breast implant management today means understanding not just the published literature but also its absence. Cutting edge breast implant treatment also means awareness of patient and media-driven interests and requests.

METHODS

Adjuvant treatments to optimize physical and psychological well-being with breast implant explantation, without replacement, will be addressed through literature review and analysis.

RESULTS

The body of literature demonstrates evidence of variable, and sometimes contradictory, methods to address adjunctive management of systemic concerns, the capsule, soft tissue of the native breast/chest, and treatment timing related to explantation. Few approaches are supported by very strong evidence. Many treatment methodologies are defensible. Any current attempts at optimizing management in patients undergoing explantation will be somewhat impaired by the ongoing nebulousness of related issues, such as breast implant illness. It seems clear, therefore, that plastic surgeons must fulfill their duty as caregivers to provide explantation surgery, either to attempt to improve physical health, mental well-being, or simply to respect patients' wishes. A well-informed surgeon will likely employ a variety of approaches, adapted to the unique patient presentations at hand.

CONCLUSION

It is expected that consultations, incisions, tissue rearrangements, surgical timing, and treatment indications will continue to vary as scientific investigation strives to understand and to optimize treatment of patients experiencing difficulty with breast implants.

A Case of Silicone and Sarcoid Granulomas in a Patient with "Highly Cohesive" Silicone Breast Implants: A Histopathologic and Laser Raman Microprobe Analysis

Foreign body giant cell (FBGC) reaction to silicone material in the lymph nodes of patients with silicone breast implants has been documented in the literature, with a number of case reports dating back to 1978. Many of these case reports describe histologic features of silicone lymphadenopathy in regional lymph nodes from patients with multiple sets of different types of implants, including single lumen smooth surface gel, single lumen textured surface gel, single lumen with polyethylene terephthalate patch, single lumen with polyurethane coating, and double lumen smooth surface. Only one other case report described a patient with highly-cohesive breast implants and silicone granulomas of the skin. In this article, we describe a patient with a clinical presentation of systemic sarcoidosis following highly cohesive breast implant placement. Histopathologic analysis and Confocal Laser Raman Microprobe (CLRM) examination were used to confirm the presence of silicone in the axillary lymph node and capsular tissues. This is the first report where chemical spectroscopic mapping has been used to establish and identify the coexistence of Schaumann bodies, consisting of calcium oxalate and calcium phosphate minerals, together with silicone implant material.

Autoimmune dysautonomia in women with silicone breast implants

IMPORTANCE AND OBJECTIVES

There is unmet medical need to understand the pathogenic mechanism of the panoply of clinical manifestations associated with silicone breast implants (SBIs) such as severe fatigue, widespread pain, palpitations, dry mouth and eyes, depression, hearing loss etc. We aimed to determine whether autoantibodies against the autonomic nervous system receptors can explain the enigmatic and subjective clinical manifestation reported by women with SBIs.

RESULTS

Circulating level of autoantibodies against G protein-coupled receptors (GPCRs) of the autonomic nervous system (adrenergic, muscarinic, endothelin and angiotensin receptors) have been evaluated in symptomatic women with SBIs using an ELISA method. These women with SBIs addressed our clinic due to various subjective and autonomic-related manifestations such as chronic severe fatigue, cognitive impairment, widespread pain, memory loss, sleep disorders, palpitations, depression, hearing abnormalities etc. We report for the first time, a significant reduction in the sera level of anti-β1 adrenergic receptor (p < 0.001), anti-angiotensin II type 1 receptor (p < 0.001) and anti-endothelin receptor type A (p = 0.001) autoantibodies in women with SBIs (n = 93) as compared with aged matched healthy women (n = 36). Importantly, anti-β1 adrenergic receptor autoantibody was found to significantly correlate with autonomic-related manifestations such as: sleep disorders and depression in women with SBIs.

CONCLUSIONS

Chronic immune stimulation by silicone material may lead to an autoimmune dysautonomia in a subgroup of potentially genetically susceptible women with SBIs. The appearance of autoantibodies against GPCRs of the autonomic nervous system serve as an explanation for the subjective autonomic-related manifestations reported in women with SBIs.

Not All Breast Explants Are Equal: Contemporary Strategies in Breast Explantation Surgery

SUMMARY

Breast implant removal and replacement has been a common secondary breast procedure in the long-term maintenance of breast augmentation, but more recently growing concerns about silicone-related systemic illness, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), and changing perceptions of aesthetic beauty have seen breast implant removal without replacement become increasingly requested by patients. Explantation can be challenging, especially when performed with a total capsulectomy. Currently, there is no evidence regarding whether a partial or total capsulectomy has any effect on BIA-ALCL risk mitigation in patients that have textured implants without disease. Total capsulectomy with incomplete resection of a mass can contribute to hyperprogression of BIA-ALCL and death. There have also been cases of BIA-ALCL diagnosed years after removal of the textured device and "total capsulectomy." Therefore, the common practice of simple prophylactic capsulectomy in a textured implant to mitigate future disease has not been established and at the current time should be discouraged. In addition, aesthetic outcomes can be quite variable, and patients should have appropriate preoperative counseling regarding the indications and contraindications for explantation, associated risks, financial implications, and postoperative appearance. The authors review salient aspects related to the planning and management of breast implant removal.

Subjective Cognitive Functioning in Silicone Breast Implant Patients: A Cohort Study

Cognitive impairment is frequently reported by silicone breast implant (SBI) patients. The aim of our study is to investigate whether subjective cognitive failure indeed is more frequent in a cohort of SBI patients compared with healthy controls (HCs). Furthermore, the severity of this cognitive failure and a possible relation to other symptoms as well as the duration of SBI exposure was examined. In addition, we assessed the effect of ruptures and reinterventions on cognitive failure severity.

Methods

A cohort study was performed, including 376 women and consisting of 3 different groups of patients; 143 SBI patients (group 1), 94 age- and sex-matched HC patients (group 2), and 139 women with SBI and health issues who registered themselves at a Dutch foundation for women with illness due to SBI (group 3). All patients filled in the Cognitive Failure Questionnaire (CFQ). The American College of Rheumatology Fibromyalgia Diagnostic Criteria (2010) were used to score other symptoms.

Results

Completed CFQ data from 222 patients were available for analysis: n = 79 for group 1, n = 62 for group 2, and n = 81 for group 3. SBI patients from group 3 had a significantly higher prevalence of subjective cognitive dysfunction (CFQ score ≥ 43) compared with SBI patients from group 1 and HC (60.5% versus 13.9% and 12.9%; P = 0.000). Linear regression showed a statistically significant relation between subjective cognitive functioning scores and other symptoms (P = 0.000). Implant duration as well as rupture rate and reinterventions were not found to significantly influence CFQ scores.

Conclusion

An increased risk of cognitive failure in consecutive SBI patients when compared with HCs could not be found.

Association of Silicone Breast Implants, Breast Cancer and Anti-RNA Polymerase III Autoantibodies in Systemic Sclerosis: Case-Based Review

Some case reports and small case series of patients with silicone breast implant (SBI) have reported the development of systemic sclerosis (SSc) many years later, despite conflicting evidence of this association in the literature. Recently, patients with SSc and anti-RNA polymerase III antibodies positivity have been associated with previous silicone implants and/or breast cancer, showing clinical features that differ from the classic SSc, such as rapid and diffuse cutaneous involvement and scleroderma renal crisis (SRC). The specific autoimmune reaction is not yet fully understood, although knowledge in this regard is increasing. We describe a case that can support these previous observations, strengthening this association which must be taken into account. Clinicians should be aware of this new clinical entity, given the widespread use of silicone implants.

Classical Examples of the Concept of the ASIA Syndrome

Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was first introduced in 2011 by Shoenfeld et al. and encompasses a cluster of related immune mediated diseases, which develop among genetically prone individuals as a result of adjuvant agent exposure. Since the recognition of ASIA syndrome, more than 4400 documented cases have been reported so far, illustrated by heterogeneous clinical manifestations and severity. In this review, five enigmatic conditions, including sarcoidosis, Sjögren's syndrome, undifferentiated connective tissue disease, silicone implant incompatibility syndrome (SIIS), and immune-related adverse events (irAEs), are defined as classical examples of ASIA. Certainly, these disorders have been described after an adjuvant stimulus (silicone implantation, drugs, infections, metals, vaccines, etc.) among genetically predisposed individuals (mainly the HLA-DRB1 and PTPN22 gene), which induce an hyperstimulation of the immune system resulting in the production of autoantibodies, eventually leading to the development of autoimmune diseases. Circulating autonomic autoantibodies in the sera of patients with silicone breast implants, as well as anatomopathological aspects of small fiber neuropathy in their skin biopsies have been recently described. To our knowledge, these novel insights serve as a common explanation to the non-specific clinical manifestations reported in patients with ASIA, leading to the redefinition of the ASIA syndrome diagnostic criteria.

Breast Prosthesis Syndrome: Pathophysiology and Management Algorithm

The cosmetic use of devices like prostheses to increase breast volume is nothing new. It is calculated that millions of people have been exposed to silicone in several ways, including breast implants, and since 1964 there has been uncertainty regarding their safety. We did not find in the literature any studies that reported the appearance of a specific immunological disease in patients with silicone breast implants. Furthermore, there are also neither case-control studies nor reports of patients proving that symptoms of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) occurred after the placement of silicone implants nor that the patients had pre-existing symptoms. Several studies link silicone to allergic reactions and the development of systemic autoimmune diseases; however, other studies deny this association. There are currently several theories about the effect of silicone on the body. One theory with greater acceptance proposes an adjuvant effect of silicone on the development of autoimmune diseases in genetically predisposed patients. However, the variety of symptoms occurring in patients who develop these pathologies leads to doubts about the relationship between the adjuvant effects of a silicone prosthesis may have with a specific autoimmune disease or a mix of these diseases. The lack of consensus on this topic obliges a full review of what has already been reported in the literature to integrate the knowledge and propose a focus for new research on this matter. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast Implant Illness: A Biofilm Hypothesis

Background

"Breast implant illness" (BII) is a poorly defined cluster of nonspecific symptoms, attributed by patients as being caused by their breast implants. These symptoms can include joint pain, skin and hair changes, concentration, and fatigue. Many patients complaining of BII symptoms are dismissed as psychosomatic. There are currently over 10,000 peer-reviewed articles on breast implants, but at the time of commencing this study, only 2 articles discussed this entity. At the same time, mainstream media and social media are exploding with nonscientific discussion about BII.

Methods

We have prospectively followed 50 consecutive patients, self-referring for explantation due to BII. We analyzed their preoperative symptoms and followed up each patient with a Patient-Reported Outcome Questionnaire. All implants and capsules were, if possible, removed en bloc. Explanted implants were photographed. Implant shell and capsule sent for histology and microbiological culture.

Results

BII symptoms were not shown to correlate with any particular implant type, surface, or fill. There was no significant finding as to duration of implant or location of original surgery. Chronic infection was found in 36% of cases with Propionibacterium acnes the most common finding. Histologically, synoviocyte metaplasia was found in a significantly greater incidence than a matched cohort that had no BII symptoms (P = 0.0164). Eighty-four percent of patients reported partial or complete resolution of BII symptoms on Patient-Reported Outcome Questionnaire. None of the 50 patients would consider having breast implants again.

Conclusion

The authors believe BII to be a genuine entity worthy of further study. We have identified microbiological and histological abnormalities in a significant number of patients identifying as having BII. A large proportion of these patients have reported resolution or improvement of their symptoms in patient-reported outcomes. Improved microbiology culture techniques may identify a larger proportion of chronic infection, and further investigation of immune phenotypes and toxicology may also be warranted in this group.

Inflammatory State After Intrathoracic Breast Implant Placement for Postpneumonectomy Syndrome

We describe a case of a 16-year-old patient who underwent right pneumonectomy for pulmonary vein atresia and developed postpneumonectomy syndrome. She had an 800-cm³ saline-filled silicone tissue expander placed in the right hemithorax with resolution of her postpneumonectomy syndrome. However, 2 years later, she developed fevers, night sweats, and arthralgias. Her medical workup was negative for vasculitis, inflammatory bowel disease, and infectious etiologies. She underwent tissue expander removal, resulting in resolution of her symptoms. This report describes a case of an inflammatory state created by a tissue expander placed for postpneumonectomy syndrome.

Complex syndromes of chronic pain, fatigue and cognitive impairment linked to autoimmune dysautonomia and small fiber neuropathy

Chronic fatigue syndrome, postural orthostatic tachycardia syndrome, complex regional pain syndrome and silicone implant incompatibility syndrome are a subject of debate among clinicians and researchers. Both the pathogenesis and treatment of these disorders require further study. In this paper we summarize the evidence regarding the role of autoimmunity in these four syndromes with respect to immunogenetics, autoimmune co-morbidities, alteration in immune cell subsets, production of autoantibodies and presentation in animal models. These syndromes could be incorporated in a new concept of autoimmune neurosensory dysautonomia with the common denominators of autoantibodies against G-protein coupled receptors and small fiber neuropathy. Sjogren's syndrome, which is a classical autoimmune disease, could serve as a disease model, illustrating the concept. Development of this concept aims to identify an apparently autoimmune subgroup of the disputable disorders, addressed in the review, which may most benefit from the immunotherapy.

21-year-old silicone breast implants causing recurrent pneumonia, chest pain and coughing

A 50-year-old former smoker presented with recurrent pneumonia, fever and atypical chest pain on and off for a year and was treated with antibiotics several times. Meanwhile, her lung function deteriorated with an obstructive pattern and therefore she was treated with inhalation medication without effect. Tests of the heart, bronchoscopy, gastroscopy and a CT-scan of the lungs did not reveal the cause. Finally, an FDG-PET scan showed inflammation of the tissue on the backside of a 21-year-old silicone chest implant, which was intact but encapsulated. The chest implants were removed after which the patient has remained free of infections. However, the lung function impairment did not improve, and a new HRCT-scan demonstrated widespread emphysema.

Scleroderma-like syndrome in a woman with silicone breast implants - case report and critical review of the literature

Various silicon compounds have been reported to stimulate autoimmune reactions in the human body. Based on case reports, a possible causal association between silicone breast implants and systemic sclerosis has been suggested since the end of the 1970s. Although the relationship between systemic sclerosis and silicone breast implants has been intensely investigated, no clear evidence of such an association has ever been found in epidemiological studies. Instead, it is now proposed that silicone breast implants can induce nonspecific symptoms of inflammatory diseases, despite not fulfilling the diagnostic criteria for a specific autoimmune disease. This phenomenon was named autoimmune syndrome induced by adjuvants (ASIA syndrome). ASIA syndrome is worth considering in the differential diagnosis in rheumatology patients. In this paper, we present a case of the scleroderma-like syndrome in a 48-year-old woman with a broken silicone breast implant and a review the current literature on this issue.

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Sonographic Confirmation of Intracapsular and Extracapsular Breast Implant Rupture

Breast implant ruptures are a recognized complication associated with both cosmetic augmentation and breast reconstruction. After a breast implant has been placed, a fibrous capsule forms around the shell of the implant. If the shell of the implant ruptures but the fibrous capsule remains intact, the rupture is known as intracapsular. If both the implant shell and fibrous capsule have ruptured, the implant content is freely extravasated into surrounding tissue, and the rupture is defined as extracapsular. This case study reviews a silicone implant rupture. Following an initial routine mammogram, bilateral extracapsular rupture was suspected and subsequently confirmed sonographically. Sonography was able to target focal areas of extracapsular silicone implant rupture as well as intracapsular rupture. The use of both diagnostic imaging modalities allowed for a quick, accurate diagnosis, and helped to establish the next step in appropriate treatment for the patient.

Autoinflammatory/autoimmunity syndrome induced by adjuvants (ASIA; Shoenfeld's syndrome): A new flame

In the present review, recent findings regarding autoimmune/inflammatory syndrome by adjuvants (ASIA) are described. Patients with ASIA present with complaints such as fatigue, cognitive impairment, arthralgias, myalgias, pyrexia, dry eyes and dry mouth. During the last few years, it has been postulated that these symptoms in patients with foreign body implants are due to a chronic inflammatory process and an adjuvant effect of the implanted biomaterial. Ultimately, these inflammatory reactions result in (an increase of) allergies, autoimmune diseases, immune deficiency and/or lymphomas. Pre-existent allergic disease has been found to be an important risk factor for the development of ASIA after foreign body implantation. Explantation of the foreign body results in the majority of patients in an amelioration of the symptoms. There is an urgent need to start adequately adjusted epidemiological studies to obtain better evidence which percentage of patients does develop symptoms and/or diseases such as ASIA, immune deficiency, and/or autoimmune diseases after implant surgery.

Autoinflammatory/autoimmunity syndrome induced by adjuvants (Shoenfeld's syndrome) in patients after a polypropylene mesh implantation

In both hernia repair and pelvic organ prolapse surgery, polypropylene (PP) meshes are increasingly used. Although these technologies offer tremendous clinical benefits, the efficacy of these implants can be hindered by the body's immunologic reaction to the implanted material. Undesirable local effects such as chronic pain have been extensively described. Systemic effects, however, are not yet reported. Because systemic effects after implantation of other biomaterials have been described, we evaluated patients with implanted PP meshes for signs and symptoms of biomaterial-related systemic illnesses. Patients referred to an Autoimmunity Clinic between January 2014 and December 2017 were analyzed. In 40 patients, mesh implants were present. These patients were evaluated for the development of a systemic illness. Thirty-two consecutive women and eight men were included in the current study. Median age at the time of operation was 49.5 years (range, 28-75 years). Eighteen patients had a hernia repair and 22 patients had a vaginal mesh implant. Thirty-nine of 40 patients presented with chronic fatigue, and 38 of 40 patients had myalgia or muscle weakness. In most patients, these symptoms started shortly after the operation. All patients fulfilled the diagnostic criteria for autoinflammatory/autoimmunity syndrome induced by adjuvants (ASIA). In addition, most patients reported localized pain and (often-invalidating) irritable bowel syndrome. One quarter of the patients had an immunodeficiency, whereas a diagnosis of well-established systemic and/or localized autoimmune diseases was made in 45% of patients. Importantly, 75% of patients had a pre-existing allergic disease. In 6 patients, the hernia mesh could be completely removed, thereby resulting in (partial) recovery of the systemic disease. In conclusion, 40 patients developed symptoms of a systemic illness after a mesh operation. All patients fulfilled the diagnostic criteria for ASIA. One quarter of the patients had an immunodeficiency, whereas in approximately half of the patients, an autoimmune disease developed. We postulate that PP mesh implants may increase the risk of developing (auto)immune diseases by acting as an adjuvant.

Vitamin D deficiency as a risk factor for the development of autoantibodies in patients with ASIA and silicone breast implants: a cohort study and review of the literature

The development of autoimmunity and/or autoimmune diseases is multifactorial. Vitamin D is one of the factors that might play a role. We postulated that both the presence of adjuvants and insufficient levels of vitamin D may result in the development of autoimmunity in patients with autoimmune/inflammatory syndrome induced by adjuvants (ASIA) in relation to silicone implant incompatibility. We measured vitamin D levels in 135 patients with ASIA in relation to silicone implant incompatibility and related findings to the presence of autoantibodies that are commonly used to diagnose systemic autoimmune diseases. Furthermore, we systematically reviewed the literature regarding vitamin D deficiency as a risk factor for the development of autoantibodies. Vitamin D measurements were available for analysis in 131 of 135 patients with ASIA in relation to SIIS. Twenty-three patients (18%) tested positive for autoantibodies, from which 18 patients (78%) had either a vitamin D deficiency or insufficiency (median vitamin D level 60.5 mmol/L), whereas five patients (22%) had sufficient vitamin D levels. The risk to develop autoantibodies was significantly increased in vitamin D deficient and/or insufficient patients [RR 3.14; 95% CI, 1.24–7.95; p = 0.009]. Reviewed literature suggested an association between vitamin D levels and the presence and/or titer levels of autoantibodies in different autoimmune diseases. From our current study and from our review of the literature, we conclude that vitamin D deficiency is related to the presence of autoantibodies. Whether vitamin D supplementation results in a decrease of autoimmunity needs to be studied prospectively.