When uncommon and common coalesce: adult onset Still’s disease associated with breast augmentation as part of autoimmune syndrome induced by adjuvants (ASIA)

Comprehensive Systematic Review of Breast Implant Illness: Symptoms, Management, and Long-Term Outcomes

BACKGROUND

Breast augmentation using silicone implants is common, with over 300,000 annual US surgeries. It was initially approved in 1962, there were safety concerns with the use of silicone implants, leading to a 1992-2006 FDA moratorium. Recently, Breast Implant Illness (BII) was described as a cluster of symptoms associated with silicone implants, with a lack of diagnostic criteria, which increased the likelihood of implant removal and a variety of treatment options. This comprehensive review aims to shed light on the extent, symptoms, management, and outcomes of BII.

METHODS

Multiple electronic databases were systematically searched in May 2023 for studies on Breast Implant Illness utilizing terms related to BII and its symptoms, diagnosis, and treatment. Out of 1204 studies, 20 met the inclusion criteria and were included in the systematic review. The Newcastle-Ottawa Scale for the included cohort prospective and retrospective studies, and the tool for evaluating the methodological quality of case reports and case series were utilized during quality assessment.

RESULTS

There were 20 papers on Breast Implant Illness published between 1995 and 2022, including a peak of papers published in 2020 and 2022. The majority of the studies came from the USA, with a variety of research methods, including case reports. Reports of arthralgia and fatigue were common findings. These symptoms were frequently alleviated by surgical procedures such as en bloc explantation and capsulectomy, highlighting the intricacy of the problem and the need for individualized treatment plans.

CONCLUSION

The review underscores the critical need for further research into BII, advocating for a multidisciplinary strategy that prioritizes patient safety, informed decision-making, and comprehensive care. As the medical community progresses in understanding and managing BII, emphasizing evidence-based practices and patient-provider communication will be essential in addressing this complex condition effectively.

LEVEL OF EVIDENCE III

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 .

Three Case Reports of Adult-onset Still Disease Associated with Breast Implantation

Autoimmune syndrome induced by adjuvants (ASIA) is an uncommon clinical condition reported by Shoenfeld et al. Although this syndrome is not scientifically validated, numerous reports on it have been published, and the manifestations are postulated to be diverse, including generalized symptoms such as chronic fatigue, myalgia, arthralgia, or dry mouth, induced by exogenous substances, specifically adjuvants, which can encompass vaccines, organisms, and silicone. Concurrently, adult-onset Still disease (AOSD) is also an infrequent ailment, characterized by spiking fever, arthritis, skin rash, lymphadenopathy, and serositis. Although the precise pathogenesis remains incompletely understood, some case reports suggest that ASIA may be at the root of AOSD development with the same instigator. In this context, we present three cases of patients diagnosed with AOSD, which possibly could be considered an association with ASIA, years after undergoing breast reconstruction with silicone breast implants. In one case, the patient solely received medical treatment due to her refusal to have the implant removed, resulting in multiple flares and severe complications related to glucocorticoid therapy. Conversely, in the other two cases, a combination of immunosuppressive therapy and silicone breast implant explantation led to the complete resolution of clinical symptoms. To the best of our knowledge, there are only 10 documented case reports of AOSD associated with silicone breast implants insertion. We believe this report serves as a complementary addition to prior research and offers further insights into the ongoing debate about whether explantation should be carried out early in the clinical course or not.

Breast implant illness: scientific evidence of its existence

INTRODUCTION

More than one million breast augmentation procedures using silicone breast implants (SBI) have been performed worldwide. Adverse events of SBI include local complications such as pain, swelling, redness, infections, capsular contracture, implant rupture and gel-bleed. Furthermore, patients experience systemic symptoms such as chronic fatigue, arthralgias, myalgias, pyrexia, sicca, and cognitive dysfunction. These symptoms received different names such as autoimmune/inflammatory syndrome induced by adjuvants (ASIA) due to silicone incompatibility syndrome and breast implant illness (BII). Because of chronic immune activation, BII/ASIA, allergies, autoimmune diseases, immune deficiencies and finally lymphomas may develop in SBI patients.

AREAS COVERED

Causality for SBI-related BII/ASIA is reviewed. To address the role of silicone implants in promoting causality, we utilized the Bradford-Hill criteria, with results highlighted in this article.

EXPERT OPINION

We conclude that there is a causal association between SBIs and BII/ASIA. Using data derived from patients with BII/ASIA and from other medically implanted devices, there appears to be clear pathogenic relationship between SBI and BII/ASIA. Breast implants cause characteristic systemic reactions in certain women, leading to symptoms of sufficient severity to warrant device removal. The morbidity suffered is variable. SBI removal resolves the symptoms in most women and removal is the most effective treatment.

Disease presentation and surgical treatment of patients with foreign-body granulomas and ASIA syndrome: case series

Background

The result of illicit polymer injection is chronic inflammation with foreign-body granuloma (FBG) formation. Treatment can be divided into medical and surgical. Some patients develop severe complications with need surgical treatment. This study aims to describe patients who underwent surgical removal of the FBGs and autoimmune/inflammatory syndrome induced by adjuvants (ASIA); additionally, we evaluated the quality of life after surgery.

Methods

In this retrospective single-center study, the authors examined data of patients who underwent surgical removal of FBG caused by illicit polymer injection for cosmetic purposes and confirmed ASIA from 2015 to 2020 by three different surgical approaches. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, treatment strategies, histopathology reports and quality of life.

Results

The cohort included 11 female patients with FBGs and ASIA. The most affected anatomical zones were the combination of gluteal region, thighs and legs (40%); and thighs with legs (20%). Main presentation was: skin hyperpigmentation (90.9%), skin induration (63.6%), chronic fatigue (63.6%), and ulcers (36.4%). Surgical modalities consisted of: ultrasonic-assisted liposuction in four patients (36.4%); open en bloc excision and primary closure in four patients (36.4%); and open en bloc excision and microsurgical reconstruction in three patients (27.2%). The postoperative quality of life visual analog scale score was 83.9.

Conclusions

ASIA treatment represents a challenge for the plastic surgeon. Adequate surgical treatment emphasizing, when possible, the total or near-total resection of the FBG must be performed to improve ASIA evolution.

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.

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.

[ASIA syndrome associated with breast implants: Fortuitous link or association?]

OBJECTIVE

The "Autoimmune/Autoinflammatory Syndrome Induced by Adjuvants" (ASIA syndrome) described in 2011 by Shoenfeld and Agmon-Levin is believed to be the consequence of several immunological dysfunctions triggered by exposure to an adjuvant. Controversies regarding the existence of this syndrome and its possible link to silicone breast implants (SBI) have been growing via social networks and patient groups. The objective of our review was to identify all published cases of ASIA syndromes in SBI carriers to determine the circumstances of onset, key characteristics, and possible biases.

METHOD

A literature search of the Pubmed database selecting only original articles written in English between 2011 and 2019 found 126 cases of ASIA syndromes, defined according to the criteria of Shoenfeld and Agmon-Levin, associated with SBI.

RESULTS

This syndrome was diagnosed in nearly ¾ cases in a context of prosthetic complications (rupture, effusion, peri-prosthetic shell, infection) with a median time interval of 4 years between SBI implantation and the onset of symptoms. Explantation of the SBI led to an improvement in symptoms in about half of the cases. However, animal, biological and histological studies have provided conflicting results on the links between silicone and dysimmune syndromes.

CONCLUSION

Women should be clearly, fairly and appropriately informed of our uncertainties about ASIA syndrome. Mandatory reporting of dysimmune syndromes occurring in silicone MI carriers would increase our knowledge of this still poorly understood condition, for which a genetic predisposition is being investigated.

Autoimmune syndrome induced by adjuvants after breast enhancement with polyacrylamide hydrogel: a study in Poland

Autoimmune syndrome induced by adjuvants (ASIA) is the spectrum of diseases in which the substances considered inert to the body induce autoimmune reactions and inflammation. Some of the biomaterials recently used in plastic surgery, such as silicone or polyacrylamide hydrogel (PAAG) seem to trigger clinical features of ASIA. The aim of this study was to assess the incidence of these features within a group of women after breast augmentation with PAAG. As many as 30 consecutive patients (26–59 years, mean age 39.5) referred to the Clinic of Plastic Surgery after breast enhancement with PAAG were examined. The validated criteria of ASIA syndrome were employed. Descriptive statistics were chosen based on the distribution of variables. The research was approved by the Bioethical Committee of the Centre of Postgraduate Medical Education in Warsaw, Poland. Within the studied group, 50% of patients (n = 15) fulfilled ASIA diagnostic criteria. Apart from local complications, we encountered various general symptoms, among which fever (n = 13, 43.3%), tingling and numbness of upper extremities (n = 10, 33.3%) and chronic fatigue (n = 9, 30%) were the most common. These symptoms were present on an ambulatory visit, before qualification to the operation of hydrogel removal. All patients undergoing surgical PAAG removal (n = 8) declared alleviation or complete resolution of the symptoms. Polyacrylamide hydrogel breast filling, although limiting the invasiveness of the procedure in relation to silicone breast implants, also carries the risk of developing ASIA symptoms. The removal of PAAG may bring improvement in some cases.

A Review of the Literature on the Management of Silicone Implant Incompatibility Syndrome

BACKGROUND

Silicone implant breast augmentation has been routinely performed since the 1960s. Emerging literature suggests the existence of a clinical syndrome, silicone implant incompatibility syndrome (SIIS) resulting from silicone implants. Autoimmune reactivity develops, with subsequent symptoms including myalgias, arthralgias, chronic fatigue, sleep disturbance and cognitive impairment. While the existence of a clinical entity is currently being established in the literature, there are currently no guidelines on management.

METHOD

Literature review was conducted using Medline and PubMed databases with key terms searched for, prior to hand-searching and bibliographical review until February 2019. The relevant literature was reviewed to determine whether consensus exists on the most appropriate management strategy.

RESULTS

Forty-nine articles relevant to SIIS were identified with twenty-one of these specifically outlining treatment. Of these, only five provided data on larger cohorts, three provided conclusions from literature reviews, and the remainder were small case series or isolated case reports. Improvement in symptoms was obtained by medical management of their immune response, by explantation and by simply counselling on the condition itself.

CONCLUSIONS

A new clinical condition is being described that appears to suggest a link between silicone implant use and various symptoms in a cohort of patients. The subsequent treatment of SIIS is yet to be agreed upon. Further research is required to establish guidelines for diagnosis and ensure evidence-based treatment, and that patients and clinicians have a more refined understanding of the potential risks of silicone breast implant use.

LEVEL OF EVIDENCE III

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 .