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

Systemic Lupus Erythematosus (SLE) Induced by ASIA Syndrome After the Aesthetic Medicine Procedures-A Case Report

Introduction: The autoimmune/inflammatory syndrome induced by adjuvants (ASIA) is a rare condition caused by an immune response associated with over-reactivity of the immune system, triggered by adjuvants. The most common adjuvants are aluminium salts but can also be bioimplants or infectious agents. It may lead to the development of various autoimmunologic diseases. Case Report: In the following article, we present the case of a 26-year-old woman who developed SLE likely induced by ASIA syndrome after the aesthetic medicine procedures. The patient was admitted because of arthralgia and fever. She also presented with a butterfly-shaped erythema on her face and erythematous and infiltrative skin lesions on the posterior surface of the thighs and buttocks. We performed numerous diagnostic tests, including laboratory tests, immunological tests, imaging diagnostics such as chest X-ray and USG of the abdomen and joints, and the biopsy of the skin lesion on the left thigh. The results of the diagnostic process led us to diagnose SLE. The patient fulfilled the ACR/EULAR 2019 classification criteria of the SLE. Laboratory results also led to the diagnosis of autoimmune haemolytic anaemia. Due to exposure to numerous adjuvants like tattoo ink, hyaluronic acid, and piercing and the development of the delayed inflammatory reaction (DIR) to hyaluronic acid (HAF), the patient also fulfilled the criteria of ASIA. In the treatment process we applied antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), steroids, hydroxychloroquine, and cyclosporine. The treatment resulted in an improvement in the general condition, resolution of swelling and joint pain, and improvement in skin lesions. Conclusions: ASIA syndrome after bioimplantation is still underdiagnosed, probably due to ignorance or diagnostic difficulties, as symptoms are uncharacteristic and there is no immunological marker for this syndrome. In addition, as in the presented case, it can develop several years after the procedure, and it is difficult for both patient and physician to become aware of the connection. Early diagnosis requires a multidisciplinary approach and may require immunosuppressive treatment in specific cases.

Morbidity induced by the infiltration of foreign substances into the buttocks: A systematic review

The infiltration of substances into the buttocks for esthetic purposes can cause local or systemic damage. These infiltrated substances, known as adjuvants, foreign substances, and polymers, often lack sufficient and frequently controversial evidence. To identify the systemic complications associated with substances locally infiltrated in the buttocks for treatment, we conducted a systematic review following the PRISMA criteria. Of 275 publications, 29 met the eligibility criteria: 3 systematic reviews, 6 case series, and 20 case reports. The study comprises 463 cases, mainly women (87%), with an average age of 39.94 years. The average time between infiltrations was 7.65 years. Infiltrated substances included silicone, oils, methyl methacrylate, guaiacol, sodium gadolinium, collagen, paraffin, and other unknown substances. The complications fell into three categories: local, systemic with inflammatory-immune response, and renal damage due to hypercalcemia induced by the granulomatosis caused by the substance. Treatment lacked uniformity, mainly focusing on the main effect. Surgical resection of affected tissue resulted in local and systemic improvement (renal, hypercalcemia, or inflammatory-immune) for most patients. Patients who received comprehensive treatment based on inflammatory-immune control, control of renal involvement, and resection of the tissue area that contained large amounts of the infiltrated substance had a better prognosis than those with diffuse infiltration and delayed treatment.

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

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 .

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

Hyaluronic Acid Fillers and ASIA Syndrome: Case Studies

A continuous increase in the popularity of esthetic procedures with the use of substances as HA has been observed for many years, which might be contributing to an increase in the number of adverse events. The autoimmune/inflammatory syndrome induced by adjuvants (ASIA) can be provoked by hyaluronic acid (HA), which belongs to substances meeting the criteria of adjuvants. Mechanisms of the innate and acquired immune response are activated, leading to the dysregulation of T and B lymphocytes, inability to recognize one's own antigens, inflammation, damage to one's own tissues, and ultimately to autoimmunity. The objective of this article is to present a case-series study of patients who developed ASIA syndrome following HA injection after delayed inflammatory reaction (DIR) and emphasize the importance of the need for long-term monitoring after such the reaction. Lack of knowledge about ASIA can lead to delayed diagnosis and serious consequences for the patients. People with a history of immunization reactions, severe allergic reactions, individual predisposition to autoimmunity or family predisposition to autoimmunity and previous exposure to adjuvants require special attention and long-term follow-up. This applies primarily to cases of DIR after the using of bioimplants, especially with treatment resistance, as in our reported cases.

Infections in patients with adverse reactions to the use of unknown modeling substances for soft tissue enhancement in Cali, Colombia

The infiltration of foreign materials not approved for medical purposes or of modeling substances used in soft tissue to modify the anatomical appearance for aesthetic purposes represents a serious health problem. These procedures lead to the development of delayed complications, including infections. The objective of this study was to characterize infections in patients with adverse reactions to the use of modeling substances in Cali, Colombia. A cross-sectional and descriptive study was used to determine the frequency of bacterial and fungal infections associated with complications from and adverse reactions to the use of modeling substances in 113 patients. We identified microorganisms in 22 patients and a frequency of 68.1% monomicrobial infections and 31.8% polymicrobial infections. The microorganisms identified in our study included Bacillus cereus, Mycobacterium fortuitum, and Pseudomonas stutzeri, among other microorganisms. The presence of adverse effects derived from the use of illegal modeling substances has been demonstrated; among these effects, infections occur with high frequency and place the health of the patient at risk and increase problems in health care.