Scientific Letter
Pulmonary Foreign Body Granulomatosis 11 Years After Injection of a Cosmetic Dermal Filler
Granulomatosis Pulmonar De Cuerpo Extraño 11 Años Después De La Inyección De Un Relleno Dérmico Cosmético
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(B) the skin biopsy revealed a deep and severe inflammatory process, depicting lipogranulomas with multinucleated giant cells of the foreign body type (H&E, 40× and 200×); (C) HRCT-L showing a micronodular milliary pattern of the upper lobes, ground glass areas and slight thickening of interlobular septae; (D) microphotograph of the lung biopsy showing sarcoid-like epithelioid granulomas with multinucleated giant cells of the foreign body type (H&E, 200×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary foreign body granulomatosis is a rare condition where a granulomatous inflammation reaction to foreign bodies occurs in the lungs.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> It is usually secondary to intravenous injection of pulverized pharmaceutical tablets or by nasal inhalation of drugs containing insoluble binders.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Cosmetic dermal fillers can also produce a foreign body reaction of the skin with multinucleated giant cells that can happen weeks or years after the injection of a cosmetic filler.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Its clinical incidence has been reported to range from 0.02% to 1%.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report a case of a female patient with 66 years old, ex-smoker (50 pack-years), with a history of bilateral recurrent uveitis, Parkinson's disease, depression, alcoholism and multiple plastic surgeries. She had had a cosmetic dermal filler facial injection in 1994.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Respiratory symptoms appeared after an episode of facial cellulites for which the patient was admitted to the Dermatology nursery. She presented with erythema and edema of the face, with tender areas at the inter-ciliary region and naso-genian sulc (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Biopsies of these areas were suggestive of granulomatous reaction foreign body-<span class="elsevierStyleItalic">like</span> associated with lipidic material (lipogranulomas). She was first treated with antibiotics, topical injection of 5-fluoracil and betamethasone with only partial improvement and the need for surgical debridement. Histological exam of the excised lesion showed chronic inflammatory reaction with multiple lymphocytes, epithelioid histiocytes and small rare granulomas with giant multinucleated cells, associated with round multisized vacuoles, predominantly extracellular and non-refringent (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). These changes were interpreted as foreign body granulomatous reaction to the cosmetic dermal filler injected 11 years earlier.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">She was first evaluated at the pulmonology clinic in 2005 for a 6 month history of productive cough, dyspnea, pleuritic right chest pain and weight loss of 8<span class="elsevierStyleHsp" style=""></span>kg.</p><p id="par0030" class="elsevierStylePara elsevierViewall">High resolution computerized tomography of the lungs (HRCT-L) showed mediastinal adenopathies and a micronodular milliary pattern of the upper lobes with ground glass areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) as well as interstitial fibrosis at the lower lobes. Functional respiratory assessment showed air trapping (RV 145%) and reduced DLCO (DLCO 42%, DLCO/VA 59%). Auto-immune blood tests, angiotensin conversion enzyme and HIV, HBV and HCV serologies were negative. Broncho-alveolar lavage was lymphocyte predominant (44%, CD4:CD8=14) and bacteriological, mycological and microbacteriological exams were negative. Transbronchial biopsies revealed non necrotizing granulomas with a vasculocentric distribution and with giant multinucleated cells foreign body <span class="elsevierStyleItalic">like</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The hypothesis of lung granulomatous disease secondary to the injection of a cosmetic dermal filler was admitted. The patient was started on prednisolone and azatioprin, with clinical improvement. Azatioprin was stopped in 2012 and prednisolone in 2013. The patient was not compliant to the regular follow up at the pulmonology clinic and she was later re-evaluated in 2016. DLCO had further decreased (31%) and she maintained mediastinal adenopathies, coalescent micronodules of the upper lobes, bronchiectasis and fibrosis. Prednisolone was started again (20<span class="elsevierStyleHsp" style=""></span>mg/day) and the patient was referred to the interstitial lung disease clinic. Case was discussed at the multidisciplinary meeting. The diagnosis previously considered was accepted and immunosuppression was maintained.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Cosmetic dermal fillers can be classified as resorbable fillers (such as collagen or hyaluronic acid) or permanent/nonreasorbable fillers (such as silicone).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Ideally they should be biocompatible and they should induce minimum foreign body reaction.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Foreign body reaction occurs when large foreign bodies cannot be phagocytosed by macrophages triggering aggregation of macrophages into multinucleated giant cells and formation of granulomas. There are different types of foreign body granulomas with different clinical and histologic features (cystic granulomas, lipogranulomas and sclerosing granulomas) depending on the type of filler used. However mixed type granulomas can also occur. Cystic granulomas are composed of giant cells and macrophages and usually occur with the injection of hyaluronic acid or collagen. Lipogranulomas occur mainly with the injection of silicone, paraffin or polyacrylamide gels and they have variously sized vacuoles, macrophages, and giant cells. Finally sclerosing granulomas (appearing usually with the injection of polymethylmethacrylate microspheres or polylactic acid microspheres) are made of empty vacuoles with even sizes and shapes, and the spaces between the vacuoles are filled with multinucleated giant cells, macrophages, fibroblasts, and collagen fibers produced by fibroblasts.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">One of the most probable causes for non-infectious granulomatous lung disease, sarcoidosis, remains without a known cause. It is thought that sarcoidosis occurs when a patient with genetic susceptibility to the disease is exposed to a specific environmental antigen. According to Marcoval et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> the immune system's capacity of sarcoidosis patients to handle foreign matter is compromised and the presence of foreign bodies in the skin might provide the stimulus necessary to granuloma formation. However it is still uncertain if the presence of polarizable foreign material within sarcoidal granulomas is compatible with the diagnosis of sarcoidosis.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The injection of a cosmetic dermal filler normally induces a weak granulomatous reaction which can be exacerbated by interferon and other immunostimulatory medications triggering systemic sarcoidosis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> Our patient, however, was not exposed to any of those medications.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion pulmonary involvement following skin granulomatous reaction to foreign bodies is not frequent<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> and pathophysiology is not totally understood. In our patient a larger lung biopsy could have confirmed the presence of lipogranulomas or foreign body material and strengthened the diagnosis. However the case was discussed in our interstitial lung disease multidisciplinary meeting and that was the accepted diagnosis. To our knowledge, this is the first case of granulomatous lung disease manifesting after cutaneous granulomatous reaction secondary to the injection of a cosmetic dermal filler.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 907 "Ancho" => 1200 "Tamanyo" => 243911 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Patient with erythema and edema at the inter-ciliary region and naso-genian sulc; (B) the skin biopsy revealed a deep and severe inflammatory process, depicting lipogranulomas with multinucleated giant cells of the foreign body type (H&E, 40× and 200×); (C) HRCT-L showing a micronodular milliary pattern of the upper lobes, ground glass areas and slight thickening of interlobular septae; (D) microphotograph of the lung biopsy showing sarcoid-like epithelioid granulomas with multinucleated giant cells of the foreign body type (H&E, 200×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of pulmonary foreign body granulomatosis secondary to intravenous injection of acetaminophen/oxycodone" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 3 | 7 |
| 2024 October | 65 | 19 | 84 |
| 2024 September | 85 | 14 | 99 |
| 2024 August | 76 | 39 | 115 |
| 2024 July | 45 | 19 | 64 |
| 2024 June | 55 | 20 | 75 |
| 2024 May | 60 | 22 | 82 |
| 2024 April | 35 | 26 | 61 |
| 2024 March | 27 | 17 | 44 |
| 2024 February | 17 | 17 | 34 |
| 2023 March | 18 | 6 | 24 |
| 2023 February | 61 | 14 | 75 |
| 2023 January | 49 | 23 | 72 |
| 2022 December | 62 | 22 | 84 |
| 2022 November | 82 | 16 | 98 |
| 2022 October | 58 | 60 | 118 |
| 2022 September | 44 | 25 | 69 |
| 2022 August | 38 | 36 | 74 |
| 2022 July | 43 | 46 | 89 |
| 2022 June | 42 | 44 | 86 |
| 2022 May | 55 | 23 | 78 |
| 2022 April | 50 | 34 | 84 |
| 2022 March | 46 | 38 | 84 |
| 2022 February | 66 | 32 | 98 |
| 2022 January | 45 | 29 | 74 |
| 2021 December | 40 | 41 | 81 |
| 2021 November | 52 | 48 | 100 |
| 2021 October | 50 | 41 | 91 |
| 2021 September | 44 | 48 | 92 |
| 2021 August | 62 | 34 | 96 |
| 2021 July | 43 | 29 | 72 |
| 2021 June | 45 | 37 | 82 |
| 2021 May | 50 | 40 | 90 |
| 2021 April | 88 | 77 | 165 |
| 2021 March | 51 | 27 | 78 |
| 2021 February | 32 | 27 | 59 |
| 2021 January | 20 | 16 | 36 |
| 2020 December | 28 | 25 | 53 |
| 2020 March | 24 | 8 | 32 |
| 2020 February | 24 | 11 | 35 |
| 2020 January | 26 | 13 | 39 |
| 2019 December | 64 | 18 | 82 |
| 2019 November | 21 | 34 | 55 |
| 2019 October | 41 | 9 | 50 |
| 2019 September | 28 | 18 | 46 |
| 2019 August | 19 | 14 | 33 |
| 2019 July | 21 | 18 | 39 |
| 2019 June | 18 | 6 | 24 |
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