Facial fillers are common cosmetic procedures that have increased in popularity over the past few decades [1]. A large variety of facial fillers are currently available on the market each with their associated indications and longevity, including calcium hydroxylapatite, hyaluronic acid, polyalkylimide, polylactic acid, and polymethyl-methacrylate microspheres (PMMA). While most of these procedures are performed cosmetically for facial rejuvenation, other indications exist, such as post-traumatic facial disfiguration and facial lipoatrophy associated with certain HIV medications [2]. Complications for all types of facial fillers can arise a few days to weeks following the procedure (short-term), or several months to years afterward (long-term). Short-term complications include hypersensitivity reactions, infection, skin necrosis, and discoloration, while long-term complications include delayed hypersensitivity reactions, filler migration, infection, foreign-body granulomas, and scarring [3]. We report a case of an HIV-positive 63-year-old male who presented to the emergency department following a two-week history of a swollen right cheek.

Facial lipodystrophy in HIV-positive patients is a common side effect of antiviral treatments with multiple studies reporting prevalence rates between 11% and 83% [4]. Facial fillers are an accepted treatment for these side effects, and while increased infection rates among HIV-positive patients have not been reported [5], HIV-positive patients have been shown more susceptible to certain opportunistic infections [6]. While the overall rate of infections associated with facial filler procedures remains fairly low, with estimates between 0.04% and 0.2% [7], their increased use over the past few decades ensures that these radiological findings will become more common in practice.

A 63-year-old male presented to the emergency department following a two-week history of a swollen and tender right cheek. The patient had a history of diabetes, with the most recent test performed six weeks prior to the infection showing an A1C of 10.5. The patient also had a history of cirrhosis, and HIV, for which he was being treated with Cabenuva. The patient reported having multiple cosmetic procedures performed in the past, including zygomatic implants, injectable facial fillers, with his last cosmetic procedure being implant replacements following an infection of an unknown organism in 2012. Upon examination, infection was suspected, and the patient was sent for a CT scan as well as a needle aspiration of the right cheek for analysis. The CT scan indicated the presence of a peripherally enhancing organized fluid collection overlying the right zygomatic bone, surrounding the right zygomatic implant measuring about 5 × 1.3 cm axially and 2.3 cm craniocaudally (Figure 1). The fluid collection was surrounded by mild fat stranding as well as mild asymmetric thickening of the overlying skin. The CT scan also showed multiple other hypodense structures located on the left side over the left zygomatic bone (Figure 2), along the inferior margin of the left zygomatic facial implant and lateral to the left maxilla (Figure 3), all favored to represent cosmetic facial fillers. The abscess was surgically drained three days later, and the implant as well as the surrounding fillers were removed. Only the implants and fillers on the affected side were removed as the physician was concerned about the possible risk of spreading the infection. The patient was seen one week later, and no signs of any residual infection were seen, but the patient was still experiencing swelling and discomfort. At this time, the patient was informed that the results from the needle aspiration came back positive for Candida albicans, for which the patient was treated with a two-week course of fluconazole. The patient was seen again in clinic three weeks later and showed no signs of swelling or discomfort following the completion of the 2-week course of fluconazole.

We bring you a rare case of a Candida albicans-infected facial filler that resulted in a zygomatic abscess in an HIV-positive patient. Complications associated with facial fillers and implants remain rare [7] and while HIV-positive patients have been shown to be at an increased risk of surgical site infections, sepsis, and opportunistic infections [8], there is still debate as to whether patients on antiviral therapy have a higher risk of complications following cosmetic facial procedures [5],[9]. Many factors have been shown to influence the infection risk in HIV-positive patients, with CD4+ count being shown as the strongest predictor of surgical and procedural complications [10],[11]. The current research indicates that surgical complications are highest in patients with a CD4+ count of less than 200 cells/mm³, and therefore, elective procedures should be avoided in these patients [11].

With cosmetic procedures increasing significantly in the past few decades, the number of complications associated with these procedures will continue to rise proportionately. Abscesses can be difficult to differentiate from normal filler materials on CT and magnetic resonance imaging (MRI) as they can have a similar density on these modalities [3]. Familiarity with the specific imaging features of facial fillers as well as their typical anatomical locations can help make these distinctions. This case also highlights the importance of correlating clinical information with radiological findings. While rare in immunologically healthy patients, Candida albicans infections are one of the most common opportunistic infections seen in HIV-positive patients [12]. Human immunodeficiency virus-positive patients make up a significant proportion of individuals undergoing these cosmetic procedures performed. Given that these patients are more susceptible to developing opportunistic infections, special attention should be given when presented with a possible case of infected facial fillers in this patient population.

Given the increasing number of cosmetic facial procedures being performed, this case report highlights the importance for oral and maxillofacial surgeons and radiologists to be familiar with the specific imaging features and normal anatomical locations of facial fillers to avoid misinterpretations. This case report also highlights a patient population undergoing these procedures that might be more susceptible to developing infectious complications.