ASIA syndrome, calcinosis cutis and chronic kidney disease following silicone injections. A case-based review

ASIA Syndrome: State-of-the-Art and Future Perspectives

The expression "Autoimmune/inflammatory syndrome induced by adjuvants (ASIA)" was coined by Shoenfeld and colleagues in 2011. It defines a group of immune-mediated disorders that arise in people, with a genetic predisposition, following exposure to adjuvant agents. This syndrome has been reported after contact with silicone implants, medications, infections, metals, vaccines, and other substances. It typically occurs in individuals with a genetic predisposition, particularly involving genes, such as HLA-DRB1 (major histocompatibility complex, class II, DR beta 1) and PTPN22 (protein tyrosine phosphatase non-receptor type 22). Some stimuli lead to an overactivation of the immune system, prompt the production of autoantibodies, and finally cause autoimmune disorders. This narrative review aims to provide an overview of the ASIA syndrome with a special focus on the role of adjuvants in different vaccines, especially after the COVID-19 pandemic, and insights into development of new treatments.

The Autoimmune/Inflammatory Syndrome Induced by Adjuvants (ASIA), Associated with Renal Compromise and Cutaneous Calcinosis: A Case Report and Literature Review

The autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was first introduced in 2011 to provide a more precise syndromic characterization of clinical manifestations observed in patients exposed to adjuvant substances such as biopolymers and silicone, among others. The clinical spectrum of this entity is variable, ranging from local involvement to potentially fatal immune-mediated systemic involvement. The interest in ASIA has grown in recent years, reinforcing diagnostic criteria and deepening the understanding of its pathophysiological behavior. This case report highlights a distinct range of clinical symptoms, such as general symptoms, advanced-stage chronic kidney disease, persistent hypercalcemia with suppressed parathyroid hormone (PTH), bilateral nephrocalcinosis, cutaneous calcinosis, and the presence of positive autoantibodies, emphasizing the significance of understanding this condition.

Autoimmune Autoinflammatory Syndrome Induced by Adjuvants (ASIA) After Injection of Foreign Materials for Cosmetic Purposes: Retrospective Analysis of 1027 Cases

BACKGROUND

The injection of illicit, non-regulated foreign materials may trigger an autoimmune autoinflammatory syndrome induced by adjuvants (ASIA).

METHODS

A retrospective review of health records was performed to identify patients' epidemiological and clinical characteristics. The issues analyzed were age and gender of cases, occupation, the person who administered the substance, anatomical site, type and volume of the injected substance, time from injection to the onset of symptoms, chief complaint, measures taken to alleviate symptoms, local complications, systemic manifestations, and imaging method to aid in diagnosis.

RESULTS

More than 70% of patients were female and dedicated to household activities; the mean age was 44 years for females and 40.7 years for males. One-quarter of patients reported some comorbidity. The most commonly reported substance was mineral oil, whereas the most frequent anatomical site was the gluteal region with volumes around one liter. Signs and symptoms occurred almost exclusively at a local level, pain (40%) and swelling (18%) being the predominant manifestations with a peak incidence after three years. Treatment was mainly medical; surgery, primarily en bloc resection, was performed in 20% of patients.

CONCLUSIONS

A myriad of substances may induce autoimmune autoinflammatory syndrome induced by adjuvants (ASIA) when injected for cosmetic purposes. Since effective treatments are scarce, public policies should be enforced to alert the community and limit the consequences of this healthcare problem.

LEVEL OF EVIDENCE V

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Cosmetic Injection of Illicit Foreign Materials: Imaging Features and Patterns of Migration in 413 Cases

BACKGROUND

The injection of illicit, nonregulated foreign materials is increasingly common and has negative consequences relative to the inflammatory process that ensues.

OBJECTIVES

The aim of this study was to identify anatomical and imaging characteristics after the cosmetic injection of illicit foreign materials.

METHODS

A retrospective review of clinical and imaging records was performed. The issues analyzed were the anatomical site, type of injected substance, imaging method for diagnosis, and patterns of migration.

RESULTS

Data on 413 patients were collected. Most patients were female, with a mean age of 44 years. The most commonly infiltrated region was the buttocks (n = 284; 53.58%) followed by the breast (n = 99; 18.67%). Magnetic resonance imaging was the most common method of diagnosis in those patients who had an imaging study (159 out of 168). The most frequent depth of foreign material detected by imaging was the muscular plane (n = 103; 61.30%). Migration was detected in 56.55% of patients who had an imaging study. Most infiltrated substances were unknown; biopolymers were the most commonly identified substances. Depending on the type of substance, migration rates varied from 13% to 29%; rate differences were not statistically significant (P = .712). Migration was more common when the depth of infiltration was in muscle (77.66%) than in subcutaneous tissue (23.4%); this difference was statistically significant (P < .0001).

CONCLUSIONS

Deep infiltration is related to greater migration rates, apparently regardless of the substance injected.

LEVEL OF EVIDENCE: 3

Autoimmune/inflammatory syndrome induced by adjuvants (ASIA): past, present, and future implications

Adjuvants, as the name indicates, are adjoined material aimed to assist in functioning as when added to vaccines they are meant to boost the effect and strongly stimulate the immune system. The response of the immune system can be unpredictable, and the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was developed to address possible adverse reactions of an autoimmune and inflammatory type that may be caused by adjuvants. While ASIA, as a syndrome, was coined and defined in 2011; reports describing patients with vague and nonspecific clinical symptoms following vaccinations appeared much earlier. In other words, ASIA came to define, arrange, and unite the variety of symptoms, related to autoimmunity, caused not by the vaccine itself, rather by the adjuvant part of the vaccine such as aluminum, among others. Accordingly, the introduction of ASIA enabled better understanding, proper diagnosis, and early treatment of the disorder. Furthermore, ASIA was shown to be associated with almost all body systems and various rheumatic and autoimmune diseases such as systemic lupus erythematosus, antiphospholipid syndrome, and systemic sclerosis. In addition, the correlation between COVID-19 and ASIA was noticed during the pandemic. In this review, we summarized the reported effects of adjuvants and medical literature before and after ASIA was defined, the several ways ASIA can manifest and impact different systems of the body, and the incidences of ASIA during the COVID-19 pandemic. It is important to clarify, that vaccines are among, if not the, most effective means of fighting infectious diseases however, we believe that vaccines manufacturing is not above criticism, particularly when it comes to added substances possessing a risk of side effects.

Silicone Breast Implant Rupture From Pectoralis Muscle Contraction Causing IgA Nephropathy: A Case Report

A 34-year-old woman who was diagnosed with a left breast carcinoma underwent breast conserving surgery and axillary dissection. This was followed with adjuvant breast irradiation and endocrine therapy. She had a local recurrence in the breast 7 years later. She underwent a left nipple sparing mastectomy and submuscular implant reconstruction. The silicone implant ruptured during an episode of strong pectoralis muscle contraction, 5 years postimplantation. MRI confirmed the rupture to be intracapsular and extracapsular. She declined implant replacement. She presented with painless hematuria 2.5 years after the rupture. A renal biopsy confirmed IgA nephropathy.

A Severe Case of Siliconoma-induced Hypercalcemia due to Illicit Gluteal Silicone Injections

Siliconoma-induced hypercalcemia is a rare complication of siliconoma, occurring secondary to a foreign body granulomatous process induced by the introduction of silicone into soft tissue. This is a case report of a woman presenting with sequelae of illicit silicone injections performed in an unknown woman’s basement in Florida 20 years before presentation. A 39-year-old woman presented with a 2-month history of 20-pound weight loss, malaise, and intractable vomiting with a remote history of unregulated cosmetic injections to the bilateral gluteal and thigh regions. Her laboratory studies were consistent with severe hypercalcemia secondary to a foreign body granulomatous process. Initially, she was medically managed, with mild improvements in her symptomatic hypercalcemia and later underwent palliative debridement with siliconoma removal. Postoperatively, her course was complicated by delayed wound healing and graft failure, but the surgical defect was later closed successfully with split-thickness skin grafting after months of wound care. Although the procedure was not intended to treat her hypercalcemia, there were significant improvements in serum and ionized calcium in the months following her procedure. Severe hypercalcemia in the context of previous unregulated cosmetic injections or possible silicone implant rupture should prompt consideration of siliconoma-induced hypercalcemia as the underlying etiology. In addition to the established utility of IV fluids, bisphosphonates, and glucocorticoids, there may also be a role for surgical intervention in the management of this unique patient population’s hypercalcemia.

Migration of liquid silicone, an emerging contraindication of neuraxial anesthesia

The illegal use of liquid silicone products or biopolymers in gluteal augmentation procedures is giving rise to multiple complications, with a significant negative health impact, both in the short and long-term. The migration of polymers to the sacral and lumbar region represents a major limitation to conducting neuraxial anesthesia procedures. This silicon migration is unpredictable through the superficial tissue as is widely described in the literature. Caudal, spinal and epidural anesthesia may cross the silicone in the fascia and contaminate the neural axis with substances that are highly capable of causing inflammation, edema and tissue necrosis. In order to improve the safety of neuraxial anesthetic procedures and avoid the potential risk of dissemination and contamination of the neural axis, this complication must be ruled out, or be considered an emerging contraindication for these anesthetic procedures.

ASIA syndrome symptoms induced by gluteal biopolymer injections: Case-series and narrative review

Background

The number of plastic surgery procedures have been rising in the last few years. The morbi-mortality due to illegal use of biopolymers is a public health problem. One of the clinical consequences, foreign body modelling reaction, may be a precursor of ASIA (Autoimmune/Inflammatory disease induced by adjuvants) syndrome.The objective of this article is to present a case-series study of patients who developed ASIA syndrome following gluteal injection with biopolymers and emphasize the importance of toxic exposure in triggering autoimmune responses. A surgical technique used on some of the patients in the study is described.

Methods

A group of thirteen patients, diagnosed with foreign body modelling reaction, who developed ASIA syndrome confirmed by approved criteria was followed between May 2016 and May 2018. The "Butterfly Wings Technique," a new surgical procedure for patients who have medium to severe compromise, was used on five of them.A narrative literature review was done to look for subjects with ASIA syndrome and gluteal biopolymer infiltration.

Results

All the patients in the present case-series with foreign body modelling reaction developed ASIA syndrome. Some of them had a background of familial autoimmunity. Five of the patients were surgically treated and saw a clinical improvement after the extraction of the biopolymer with the proposed technique.The narrative literature review identified 7 articles related to the disease through the database search.

Conclusions

We suggest that foreign body modelling reaction should be considered a precursor to ASIA syndrome. New research projects will be needed in the future to evaluate the factors that determine when ASIA syndrome is triggered in a patient with this reaction.

SILICONE GRANULOMATOUS INFLAMMATION RESULTING IN HYPERCALCEMIA: A REVIEW OF THE LITERATURE

Objective

Silicone usage for cosmetic enhancement is common, although it is not approved by the U.S. Food and Drug Administration. Granulomatous inflammation leading to hypercalcemia is a rare complication. We present a case of non-parathyroid hormone (PTH), calcitriol-mediated hypercalcemia in a woman with a history of cosmetic injections.

Methods

Case report and review of the literature.

Results

A 48-year-old female with metabolic syndrome was evaluated for severe hypercalcemia (calcium >15 mg/dL). Laboratory tests revealed low-normal PTH, normal 25-hydroxyvitamin D, elevated 1,25-dihydroxyvitamin D, and hypercalciuria. Imaging studies, including a computed tomography (CT) scan of the lungs, was nonrevealing. Positron emission tomography/CT showed symmetric hypermetabolic subcutaneous stranding of bilateral gluteus and proximal thighs. She admitted to silicone injections in the buttocks 10 years prior. Her examination was unremarkable except for an intermittent pruritic rash over the right thigh. Labs revealed total serum calcium 11.3 mg/dL, PTH 18 pg/mL, 24-hour urinary calcium 509 mg, and PTH-related peptide 18 pg/mL. Serum and urine electrophoresis were normal, 25-hydroxyvitamin D was 47 pg/mL, and 1,25-dihydroxyvitamin D was 121 pg/mL. Angiotensin-converting enzyme level was 80 U/mL. A diagnosis of granulomatous inflammation resulting in calcitriol-mediated, PTH-independent hypercalcemia was entertained.

Conclusion

Silicone-induced hypercalcemia should be thought of in those with prior cosmetic injections. Tissue biopsy confirms the diagnosis, which is often delayed. We reviewed 19 cases with silicone usage and variable levels of hypercalcemia. Renal injury was common. One death was reported. Glucocorticoids, calcium restriction, and hydration have been used to treat calcitriol-mediated hypercalcemia but are not curative. Ketoconazole and bisphosphonates have been used with variable success. Surgical excision tends to be ineffective due to silicone migration. The treatment of this disorder is difficult and often ineffective.

The ASIA syndrome: basic concepts

The autoimmune/inflammatory syndrome induced by adjuvants (ASIA), also known as Shoenfeld's syndrome, encompasses several autoimmune conditions/phenomena that are induced following the exposure to substances with adjuvant activity. The disease spectrum is heterogeneous in respect to clinical presentation as well as severity of the clinical manifestations. Adjuvants are included in vaccination formulations for their immunogenic properties. Despite being generally well tolerated, safe and effective, some genetically predisposed individuals can develop generalized non-specific constitutional symptoms, autoantibody production, new onset, or worsening of disease presentation. In this review, we focus on the current knowledge presented in the literature on ASIA syndrome, increasing physician awareness about the basic concepts of ASIA syndrome and highlight the devastating amount of data accumulated in the last few years concerning the relationship between various adjuvants and autoimmunity.