Hypercalcemia is often due to unpredicted illness. When hyperparathyroidism 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 report

A 35-year-old Caucasian male bodybuilder was referred to the clinic with left flank pain and dysuria. Symptoms started three months ago with recurrent attacks of left flank 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, testosterone and growth hormones for increasing body mass during the past 17 years. Injections were accompanied with supplements and diuretics. Ten years before presentation, the patient had a session of multiple injections 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 examination was positive for mild left flank tenderness, gynecomastia and bilateral mild testicular atrophy. The patient was admitted for a suspected urinary tract infection. His initial laboratory findings 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 nephrocalcinosis and the presence of mesenteric and retroperitoneal ganglions; no other significant findings 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).

Table 1:Important lab findings.

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A biopsy from the right triceps tendon showed active granulomas with giant cells, fibrous backgrounds and histiocytes (Figure 1). Magnification showed persistent silicone particles in the tissue (Figure 2). The diagnosis 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.

Figure 1: A biopsy from the right triceps tendon showed fibrosed and sclerosed granulomas (1), active granulomas with giant cells (2) and fibrous backgrounds with histiocytes (3).  

Figure 2: Magnification with the polariser showed birefringent bodies corresponding to persistent silicone particles in the tissue (arrows).

Discussion

Silicone 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 fluid 360, has been implicated in a variety of adverse reactions, including granulomas, disfiguring nodules, and lymphedema, 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, 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 independent 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.

Conclusion

Silicone-induced hypercalcemia should be on high alert because of the increasing trend of body contour enhancements with injections, implants and fillers. Dialysis can be lifesaving in resistant cases of silicone-induced hypercalcemia. It is advised that silicone injections be performed by trained physicians using medical-grade silicone.

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