A 47-year-old woman who had undergone a silicone breast implant 12 years earlier complained of progressive cough and dyspnea for the past 2 years. Past history was remarkable for celiac disease and esophageal dysmotility with Raynaud phenomenon. Her serological evaluation for scleroderma was negative. PFT revealed a severe) restrictive pattern with decreased diffusion capacity. Her CT scan demonstrated diffuse interstitial and reticular ground glass changes with peripheral and basal predominance (Tables 1 and 2, Fig. 1).She was diagnosed with COP and treated with prednisone 40 mg/day with tapering down during 6 months and azathioprine as steroid sparing agent, during this time her condition deteriorated and she was listed for lung transplantation.
For all three cases we excluded tuberculosis in all three patients by performing Broncho -alveolar lavage for AF stain, TB culture and TB-PCR test.
All 3 cases were referred to our laboratory for a comprehensive study to determine a possible causative agent of the lung disease as well as a possible link between it and rupture of the silicone implants. Analysis of the biological samples was done in tissue samples in all 3 cases, as well as in the IS sample in one of them. In the latter case, the results of the SEM analysis of the silicone gel, tissue and sputum were superimposed in order to inspect any similarity of the mineral contents display among the 3 samples (Fig. 2). A wide range of metals was identified in all the samples when the analyses were performed by both SEM (which measures only selective points of the sample) and XRF (which measures the entire surface of the sample) (Table 3, Fig. 3). The analysis in the gel elastoid was performed in the 2 cases in which the implant was explanted. The results of both the SEM and XRF analysis demonstrated the presence of silicon, while XRF identified others metals (cadmium, molibden, zirconium, tungsten, aluminum, zinc, nickel, iron, and cuprum).
Since the presence of metals in the biological samples per se does not demonstrate a causative link between pulmonary disease, we performed the metal lymphocyte proliferation test (MELISA) in 2 compliant women in this series. The test was positive for nickel, zinc and tin in Case 1 and for nickel in Case 3 (Tab. 4).