Hypercalcemia is often due to unpre-dicted illness. When hyperparathy-roidism and malignancy are ruled
out, rare causes of hypercalcemia need to be investigated. Hypercalcemia due to silicone injections has rarely been reported; however, there is concern that there will be more cases in the future as the popularity of cosmetic silicone is growing.
Case reportA 35-year-old Caucasian male bodybuilder
was referred to the clinic with left fl ank pain and dysuria. Symptoms started three months ago with recurrent attacks of left fl ank pain that is non-radiating, exacerbated by movement and associated with dysuria and intermittency. The patient’s history is positive for peptic ulcer disease, and he has had multiple injections of vitamins, testos-terone and growth hormones for increasing body mass during the past 17 years. Injec-tions were accompanied with supplements and diuretics. Ten years before presentation, the patient had a session of multiple injec-tions of silicone in the shoulder, arms and forearms, which was complicated later on and necessitated a sub-mucosal excision of a silicone mass from his right forearm. The patient had no allergies and had no family history of disease.
On inspection, the large size of the upper limbs can be noted. The physical exam-ination was positive for mild left fl ank tenderness, gynecomastia and bilateral mild testicular atrophy. The patient was admitted for a suspected urinary tract infection. His initial laboratory fi ndings showed numerous WBCs on urine analysis, creatinine of 2.3mg/dl (normal range 0.7–1.36), calcium of 13.1mg/dl (normal range 8.6–10.3), and uric acid of 13.3mg/dl (normal range 3.6–7.7). The patient was primarily diagnosed with a UTI associated with acute renal failure, hypercalcemia and hyperuricemia. Urine culture was taken, and the patient was started on antibiotics with ceftriaxone 2g by intravenous-drip daily. He was also hydrated with 1L normal saline every eight hours, and started on allopurinol 300mg orally daily.
Pan CT scan revealed bilateral nephro-calcinosis and the presence of mesenteric and retroperitoneal ganglions; no other signifi cant fi ndings were noted. Despite initial management, calcium levels in serum remained high. The patient underwent two sessions of hemodialysis to restore calcium back to normal. Further laboratory workup ruled out hyperparathyroidism, vitamin D intoxication, hyperthyroidism, malignancy, sarcoidosis and multiple myeloma (Table 1).
ABSTRACTGranulomatous hypercalcemia due to silicone injections is a rare disease with scarce literature. We present a case of a 35-year-old Caucasian male bodybuilder with multiple silicone injections in his upper extremities who developed hypercalcemia and urinary symptoms. He necessitated two sessions of dialysis. A biopsy of the upper arm showed granulomatous tissue. Corticosteroids were administered to relieve symptoms and reverse laboratory abnormalities. Silicone-induced hypercalcemia should be on high alert because of the increasing trend of body contour enhancements with injections, implants and fillers.
A biopsy from the right triceps tendon showed active granulomas with giant cells, fi brous backgrounds and histiocytes (Figure 1). Magnifi cation showed persistent silicone particles in the tissue (Figure 2). The diag-nosis of silicone-induced granulomatous hypercalcemia was made. The patient was started on oral corticosteroids, 40mg daily for three weeks, and was tapered by 5mg weekly afterwards. Calcium and creatinine levels gradually returned to normal, and symptoms resolved. A repeat blood test, one-month post treatment showed a calcium level of 9.1mg/dl.
DiscussionSilicone injections have been used
widely over the past 40 years for soft tissue enhancement. The most common of the silicone polymers, the biologically inert medical fl uid 360, has been implicated in a variety of adverse reactions, including granulomas, disfi guring nodules, and lymph-edema, with latent periods ranging from three weeks to 20 years.1
The pathogenesis of granuloma formation in similar cases is still not well established. T-cell activation triggered by infection,
Figure 1: A biopsy from the right triceps tendon showed fi brosed and sclerosed granulomas (1), active granulomas with giant cells (2) and fi brous backgrounds with histiocytes (3).
trauma, adulterants added to the silicone, or denatured host proteins has been proposed.2 Once activated, T-cells release cytokines, which promote granuloma formation. Although granulomas represent an adverse effect of silicone injections inde-pendent of the purity of silicone used, they have rarely been considered as a cause of hypercalcemia.3,4
This patient necessitated two sessions of dialysis to reverse his persistent hypercalcemia. It is vital to note that bisphosphonates need 48 hours to reach
optimal effect. Therefore, dialysis can be lifesaving.
ConclusionSilicone-induced hypercalcemia should
be on high alert because of the increasing trend of body contour enhancements with injections, implants and fi llers. Dialysis can be lifesaving in resistant cases of silicone-in-duced hypercalcemia. It is advised that silicone injections be performed by trained physicians using medical-grade silicone.
Figure 2: Magnifi cation with the polariser showed birefringent bodies corresponding to persistent silicone particles in the tissue (arrows).
Competing interests:Nil.
Author information:Majdi Hamadeh, Nephrology and Hypertension, Department of Nephrology and
Hypertension, Al-Zahraa University Hospital, Beirut, Lebanon; Jawad Fares, Medicine, Faculty of Medicine, American University of Beirut, Beirut,
Lebanon; Khalil Maatouk, Nephrology and Hypertension, Department of Nephrology and Hypertension, Al-Zahraa University Hospital, Beirut, Lebanon;
Mohamad Darwish, Nephrology and Hypertension, Department of Nephrology and Hypertension, Al-Zahraa University Hospital, Beirut, Lebanon.
Corresponding author: Jawad Fares, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
1. Bigatà X, Ribera M, Bielsa I, Ferrándiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg 2001; 27(2):198–200.
2. Desai AM, Browning J, Rosen T. Etanercept therapy for silicone gran-
uloma. Journal of drugs in dermatology. J Drugs Dermatol 2006; 5(9):894–6.
3. Agrawal N, Altiner S, Mezitis NH, Helbig S. Silicone-induced granu-loma after injection for cosmetic purposes: a rare entity of calcitriol-mediated
hypercalcemia. Case Rep Med 2013; 2013:807292.
4. Hamadeh M, Fares J. Diagnosis and Management of Hypercalcemia Associ-ated with Silicone-Induced Granuloma. Rev Assoc Med Bras (1992) 2018. In press.
