**43. Hyaluronic acid embolism**

Hyaluronic acid (HA) is an approved dermal filler used for correction of facial wrinkles and folds (H. J. Park et al., 2010). All other uses are considered off label and illegal. HA associated pulmonary emboli (HAAPE) have been described in few case reports (Famularo et al., 2001; H.J. Park et al., 2010). Typical presentation of HAAPE is acute respiratory failure within hours after the HA injection in the anterior wall of the vagina, G-Spot amplification or for lip amplification by an unlicensed medical practitioner. Due to the extensive venous plexus, procedures involving injections in and around the injection site can cause NTPE. Although HA is thought to be non-immunogenic, it can cause localized granulomatous foreign body reactions with multinucleated giant cells around amorphous basophilic materials in the pulmonary vessels and lung parenchyma, as seen on video-assisted lung biopsy (Fernandez-Acenero et al., 2003; Honig et al., 2003; Raulin et al., 2000). Treatment is mainly supportive.

#### **44. Others**

Any material that is injected intravenously can potentially enter the pulmonary circulation leading to pulmonary embolism. Foreign materials such as talc, starch, cotton, and cellulose

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used as insoluble binding agents in oral tablets, are first pulverized, then dissolved in water and injected by intravenous drug users, and may be carried by the bloodstream until they lodge in the pulmonary capillary bed to cause NTPE (Farber et al., 1989; Ferrer et al., 2002; Low & Nicol, 2006; Pare et al., 1989).

The advent of modern percutaneous interventional procedures has led to a rise in catheter or fragment related pulmonary embolism. Catheter embolism usually takes place when the catheter is withdrawn from the introducing needle causing the distal portion of the catheter be sheared off (Propp et al., 1988). Spontaneous catheter breakage accounts for 25% of the catheter emboli. Retained catheter fragments have high rate of complications such as arrhythmias, perforations and thrombus formation (Fisher & Ferreyro, 1978; Richardson et al., 1974).

Prostate brachytherapy can also lead to embolization of radioactive seeds. On imaging the radioactive seeds appear as small (Iodine-125 measures 4.8 mm in length and 0.8 mm in diameter) metallic densities, usually detected incidentally. Clinical implications of these embolized radioactive seed implants remain unclear. Patients with arteriovenous malformations undergo therapeutic cerebral embolization with different materials such as cyano-acrylate agents, polyvinyl alcohol foam particles, micro-coils, silk or dacron thread and balloons. Cyano-acrylate has been reported to cause symptomatic pulmonary embolism (Kjellin et al., 2000; Pelz et al., 1995). Intravenous injection of elemental mercury is rare and has typically been reported in relation to psychiatric or suicidal incidents (Givica-Perez et al., 2001). Systemic embolization of mercury has been reported as well (Shareeff et al., 2000; Vas et al., 1980). On imaging, multiple metallic densities are seen. Mercury may remain in the body for a long time and metallic densities may remain visible for years after the injection (Ambre et al., 1977).
