ASTHMA IN PATIENTS WITH SILICONE BREAST IMPLANTS.doc

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ASTHMA IN PATIENTS WITH SILICONE BREAST IMPLANTS: REPORT OF A CASE SERIES AND IDENTIFICATION OF HEXACHLOROPLATINATE CONTAMINANT AS A POSSIBLE ETIOLOGIC AGENT

R Harbut C Churchill* IJOH; 1999; 3:73-82

From: Center for Occupational and Environmental Medicine; Wayne State University, School of Medicine, Detroit, Michigan, and *Department of Internal Medicine, Providence Hospital, Southfield, MichiganAddress for correspondence: R. Harbut MD, MPH; Wayne State University School of Medicine, Detroit, Michigan, and Center for Occupational and Environmental Medicine, 22255 Greenfield; Southfield, Michigan, 48075

ABSTRACT

The following study is of 8 breast implant patients evaluated because of respiratory systems, pruritus and rhinorrhea. The presence of hexachoroplatinate in the implants was noted and support for the hypothesis that this contaminant was related to the symptoms experienced by the patients is presented. Cases of implant related asthma were defined by episodic dyspnea, cough, or breathlessness with onset or worsening after implant placement and objective evidence of reversible airways obstruction, either during the presence or after the removal of the devices. All eight patients were found to have asthma, with airway hyper-reactivity demonstrated by methacholine challenge testing performed in seven patients and by partially reversible obstruction after nebulized administration of a beta-agonist in one patient. Eight patients had urticaria and seven had rhinorrhea. Eight of eight breast implant patients evaluated had findings consistent with asthma. Hexachloroplatinate, a potent sensitizer and component of breast implants, is identified as the likely primary etiologic agent in view of findings consistent with platinosis in these patients, and the demonstration of the leaching of hexachloroplatinate from even intact silicone breast implants.INTRODUCTION

Human illness as a result of toxicity of silicone gel breast implants is an evolving and controversial area of medical investigation. The nature of any toxicity has not yet been fully characterized, but at least in part it appears to be consistent with a hypersensitivity process. The medical community is moving away from early reports of an autoimmune process, but has not yet offered a clear explanation for complaints registered by patients who have had the devices placed. There is also significant uncertainty with respect to any responsible agents of toxicity. Silicone breast implants consist of a shell encasing a gel. Both the shell and gel are formulations that include carbon and silicone and traces of many other elements. Saline implants are comprised of a saline fluid contained in a silicone shell casing. From an Occupational Medicine perspective, notable among the agents present in both gel and shell are the metals chromium, nickel, aluminum and platinum. The presence of platinum in the implants occurs as a result of its use as a catalyst in its hexasolvent form (H2PtCl6) in the production of gel and shell. (1). All three metals are known to be associated with occupational athma. Hexachloroplatinate, however, is the most potent of sensitizers reported. There is an extensive medical literature related to the occupational disease entity platinosis and airways reactivity, caused by exposure to complex platinum salts. Respiratory problems in platinum refinery workers were reported as long ago as 1911 and are extensively reviewed in the World Health Organization Monograph of the Internal Program of Chemical Safety. (2). Platinosis or platinum allergy historically refers to the triad of asthma, dermatitis and rhinitis in workers exposed to platinum. Pruritis has also been reported. Platinosis is highly prevalent in workers exposed to platinum with a cumulative prevalent rate 50% or more. The potency of platinum is such that the *TLV-TWA for platinum salts is 2 mcg/cubic meter of air. (6). As a comparison, the TLVs for two other toxic metals, lead and arsenic, are two orders of magnitude greater at 0.15 and 0.2 mg/cubic meter of air respectively. There have been case reports of platinum sensitivity from dental work and jewelry. (3, 4). Platinum asthma can be present before, after, or in the absence of positive skin prick testing. Cold air and methacholine challenge have both been shown to evoke airways hyper-responsiveness in the hexachloroplatinate-exposed lung, in the absence of existing exposure and/or laboratory or abnormal immunologic testing. (5-9).

METHODS

Eight consecutive patients referred to the clinic with breast implants and various symptoms were included, l993 with extensive histories, including a respiratory history that incorporated the questions from the Epidemiology Standardization Project (10). The patients were questioned about alternative exposure sources, such as occupational metal exposures and platinum-containing dental work. This is done to identify any sources of platinum even in the non-hexasolvent form. Patients were also asked about their surgical history, type of implant (silicone or saline), manufacturer, and whether the implants had ruptured. Symptom onset as related to implant status was also elicited. Pulmonary function testing was done in the eight patients. All had complaints of cough or breathlessness. Methacholine challenge testing was done on 7 patients with fundamentally normal pulmonary function and a beta-agonist (Albuterol) was administered by nebulizer to the patient whose pulmonary function test demonstrated airway obstruction.

CASE SUMMARIES:

CASE #1: A 31 year old, nonsmoking white female, sales account manager underwent breast augmentation surgery in 1989 using Surgitek silicone implants. There was no evidence of rupture or leakage. She had childhood pneumonia but no respiratory symptoms before implantation. Presenting complaints include exertional dyspnea with wheezing, severe pruritus several times each week, scaling and dry skin, occurring since the implant surgery. The patient had normal resting pulmonary function tests with a positive methacholine challenge test (36% decrease in FEV1).

CASE #2: A 47 year old, white female nurse, who is currently a smoker with an 8-pack-year history had breast augmentation surgery in 1970 using Dow Silastic silicone implants. The right breast implant ruptured in 1982, necessitating removal and replacement. In 1992, both implants were removed after rupture of the left implant. Spillage of silicone was confirmed operatively in both 1982 and 1992. The patient presented with complaints of loss of taste sensation, speech difficulty, muscular tics and vesiculations, memory loss, episodic confusion, intermittent rash, pruritus, chronic bronchitis and dyspnea on exertion occurring since 1970. She has coughing spells and has episodes of dyspnea on exertion on exposure to some household chemicals. Symptoms worsened after the 1982-1992 ruptures. She had a history of nonspecific allergies, bronchitis and pneumonia prior to the implants. The patient had near normal resting pulmonary function tests and a positive methacholine challenge