A case of systemic lupus erythematosus in the context of ASIA syndrome because of silicone breast implants.

Autoimmune/autoinflammatory syndrome induced by adjuvants (ASIA) includes a cluster of different immune-mediated diseases that occurs in genetically predisposed individuals because of different adjuvants like silicone breast implants (SBI). We describe the case of a 39-year-old woman presenting with a 1-year history of a 9 cm erythematous plaque on the right cheek and lesions on the upper limbs in photoexposed areas (Figure 1a,b). A skin biopsy was performed, showing a vacuolar change of the basal layer, a superficial dermal inflammation, and dermal mucin deposit. A blood test was performed without relevant findings including a negative autoimmunity test. The diagnosis of subacute cutaneous lupus erythematosus was made, and she was treated with hydroxychloroquine with a good clinical response. Two years later, the skin lesions reappeared, and she also complained of arthralgias with morning joint stiffness, asthenia, and oral aphthosis. At that time, the autoimmunity test showed ANA positive (1/80) and low levels of C3; therefore, a diagnosis of systemic lupus erythematosus was made. Treatment with oral prednisone was started for a few months, and the dose of hydroxychloroquine was increased with relatively good control. Over the next 10 years, the skin lesions on the face and forearms progressively got worse; thus, a chest x-ray was taken showing calcification of silicone breast implants (Figure 2a). At this point, she recognized that 23 years ago she had undergone SBI for breast augmentation. After these findings, ASIA syndrome was suspected so she was referred to her plastic surgeon. The SBI removed were ruptured and with capsular calcification (Figure 2b,c). Two years post removal, the patient has remained asymptomatic and without treatment. The symptoms that may be developed because of adjuvants like silicone breast implants (SBI) had received different names during the last 50 years, but it was not until 2011 when they were all assembled under a single umbrella called ASIA syndrome by Shoenfeld.1 Adjuvants are substances that enhance an antigen-driven immune response such as vaccines, some infectious agents, or silicone. To explain the pathophysiology of this syndrome, in the case of SBI, several mechanisms have been proposed, and most of them agree that SBI trigger immunological mechanisms activating TH1/17 cells that secondarily promote the production of cytokines that stimulate and maintain the immune response.2, 3 This chronic response may lead to developing ASIA syndrome in some subjects because of a favorable genetic background. Despite the initial controversy regarding its existence, recent evidence has supported this association.4, 5 The most frequent symptoms are nonspecific, such as arthralgias, myalgias, asthenia, or skin rash. In some cases, well-defined autoimmune disorders are developed such as Sjogren syndrome, scleroderma, and rheumatoid arthritis, among others. There are very few cases described in the literature of systemic lupus erythematosus as a manifestation of ASIA syndrome. Although SBI are generally safe, in some genetically predisposed subjects, they can trigger ASIA syndrome. This case aims to increase alertness between dermatologists about this syndrome, which is more known among rheumatologists or internal medicine specialists. The presence of an adjuvant substance may lead to suspicion of this syndrome in certain patients.