Silicone-Induced Granuloma after Injection for Cosmetic Purposes: A Rare Entity of Calcitriol-Mediated Hypercalcemia

Abstract

Hypercalcemia is often a clue to the presence of unsuspected illness. We present an interesting case of an HIV-positive transgender female with a rare cause of silicone-induced granulomatous hypercalcemia. Although there have been a few case reports of silicone injections in dialysis patients causing hypercalcemia, this metabolic derangement secondary to silicone granulomas continues to be a unique entity with an unclear pathophysiology. We present a 45-year-old transgender HIV-positive female, with extensive silicone injections, who presented with symptomatic hypercalcemia. Workup for malignancy and hyperparathyroidism was negative. 1,25-Dihydroxyvitamin D level and 24-hour urine calcium level were elevated. CT scan showed extensive high-density reticulonodular densities in the buttocks and gluteal muscle fascia extending upwards to the lumbar region, along with prominent external iliac and inguinal lymph nodes. Nuclear imaging showed diffuse heterogeneity and increased uptake in the buttocks, most consistent with granuloma calcifications, and an inguinal lymph node biopsy confirmed a foreign body giant cell reaction. The patient was started on prednisone and this resulted in decrease in serum and urinary calcium levels. Physicians should have a high index of suspicion for silicone-induced hypercalcemia considering the growing prevalence of body contour enhancement with injections, implants, and fillers using this material.

Hypercalcemia associated with cosmetic injections: a systematic review

“…Biopsy of the granulomas were positive for CYP27B1 in the 3 cases that were tested (7,14,15). Gallium scanning (5,8,16,17,18) and PET/CT (6,7,15,19,20,21) revealed increased uptake/metabolic activity in 12 of the 13 cases we identified where this imaging was employed.…”

Calcitriol mediated hypercalcaemia with silicone granulomas due to cosmetic injection

“…A much less common aetiology of hypercalcaemia is from silicone injections. According to Agrawal's case report, as of 2013, there were only three prior cases of hypercalcaemia secondary to silicone injection,2 the first reported in 1964 6…”

ASIA syndrome, calcinosis cutis and chronic kidney disease following silicone injections. A case-based review

“…The association between silicone injection, granulomas and hypercalcemia has been reported since 1984 [58], and there are several reports in the literature [59][60][61][62]. As for the other granulomatous diseases, hypercalcemia is likely the consequence of a dysregulated production of 1,25-dihydroxivitamin D by activated macrophages (induced by tumor necrosis factor-a and interferon-c, and inhibited by corticosteroids) [63] and/or an increase of PTHrP levels (stimulated by TNF-a and IL-6) [64].…”