Table 17.

ASIA Syndrome: Summary

Onset	Usually 3/12 post-filler; most > 12 months
Hypersensitivity	Type lV; sometimes I/lll
Mechanisms	Heightened innate immunity, TLR binding, reinforced activity of antigen-presenting cells (APC’s), raised local reactions to antigens, and release of inflammatory cytokines
Clinical presentation	Gradual regional evolution, eventual systemic extension, or primary systemic autoimmune disease. Regional or widespread localized inflammatory reactions, with rapid progression to all previously injected areas, should raise the possibility of the ASIA syndrome
Symptoms	As in autoimmune disease Commonly include arthralgia, general weakness, myalgia, palmar-digital erythema, and arthritis. Menstrual exacerbation, sometimes severe, has been ascribed to estrogens and TNF-α, directly or through their influence on vascular endothelial growth factor (VEGF).31,96
Laboratory	Positive laboratory results include ANA (80%+), hyper γ globulinemia, raised ACE and LDH, positive anti-Ro and anti-TPO-AB.
Treatment	Challenging, generally requiring a combination of steroids and antibiotics.31 Long-term steroids, NSAIDs, Hydroxychloroquine, allopurinol, and high dose cetirizine have been utilized either alone or in combination with good results and no adverse effects.
Prognosis	In the absence of well-defined autoimmune disease, good clinical response in more than 70% after two years of chronic treatment with strong combinations of anti-inflammatory and/or immunomodulating drugs. Practically, all refractory cases are sensitive to oral tacrolimus, usually at a low dose, which inhibits interleukin-2 (IL-2) production and blocks T cell proliferation.

Note: Data from Alijotas-Reig,³¹ Clare and Rowley,⁶³ and Mackern-Oberti et al.⁹⁶