Man of Steel Syndrome: Silicone and Mineral Oil Injections With Associated Hypercalcemia, Hypophosphatemia, and Proximal Muscle Weakness

Biopolymers: Histopathologic Case Series of Patients with Permanent Synthetic Fillers Presenting Chronic Granulomatous Reaction and Hypercalcemia

Background

Biopolymers, which are diverse and permanent synthetic fillers, are nonbiocompatible allogeneic materials. Their implantation can result in clinical, radiological, and histopathological manifestations that contribute to our understanding of foreign-body-induced human adjuvant disease.

Methods

We conducted a descriptive observational case series involving 20 patients who underwent open biopolymer removal surgery in the buttocks and lumbosacral regions using the Meticulous Approach Safer and Keeper technique, followed by gluteal reconstruction with autologous tissue. Histopathological analysis was performed. This study was conducted in Bogotá, Colombia, from 2020 to 2023.

Results

Documented clinical records and histopathological analyses of the 20 patients revealed an inflammatory response that was initially considered healthy. Cytoplasmic vacuolization in reactive adipocytes was observed in all cases, meriting consideration in the differential diagnosis of liposarcoma and suggesting local aggressiveness. One patient showed a positive lymphocytic inflammatory response in the Alcian blue test. Hypercalcemia was present in 30% of the patients, elevated lactate dehydrogenase in 40%, and elevated parathyroid hormone levels in 15%.

Conclusions

Surgeons should consider measuring lactate dehydrogenase, serum calcium, and parathyroid hormone levels to assess the severity and guide clinical practice. Secondary prevention through the open surgical removal of biopolymers is recommended.

Calcinosis Universalis Secondary to Silicone Injections in a Patient With HIV and Chronic Kidney Disease: A Case Report of Silicone-Induced Hypercalcemia

Medical literature has long reported evidence of complications associated with cosmetic procedures, including silicone injections. Recent years have seen an increase in case reports involving hypercalcemia resulting from these injections. A common current hypothesis for the development of hypercalcemia associated with silicone injections is granulomatous inflammation against a foreign body.  This report aimed to describe the case of a 44-year-old African American male with human immunodeficiency virus (HIV) and chronic kidney disease (CKD) who presented to our hospital and was diagnosed with calcinosis universalis secondary to a history of silicone injections, as well as to present a literature review of silicone-induced hypercalcemia. This was a case report (n=1) from a large academic medical center for which the patient, who first presented in May 2023, had two inpatient admissions and two outpatient visits before being lost to follow-up. Relevant images, laboratory results, and treatments were included.  The patient's history was significant for HIV, hypertension, CKD, recurrent nephrolithiasis, and tobacco use disorder. Physical examination was positive for flank pain while labs were significant for Na 137 mmol/L, K 2.7 mmol/L, blood urea nitrogen (BUN) 28 mg/dL, creatinine 3.72 mg/dL, calcium 13.4 mg/dL, hemoglobin 9.3 g/dL, white blood cell count 6,700 u/L and platelet count 105,000 u/L. Renal ultrasound revealed bilateral nephrolithiasis and left-sided hydronephrosis. Computerized tomography (CT) upon admission showed hyperlucid deposits in the bilateral gluteal area. Initial management included intravenous (IV) fluids and one dose of IV pamidronate, which resulted in reduced calcium levels during the admission. Subsequent management included outpatient follow-up with endocrinology during which denosumab was prescribed. This case had similar findings to other reports in the literature detailing silicone-induced hypercalcemia, which also reported abnormal imaging or nephrolithiasis, low-normal parathyroid hormone (PTH), normal 25-hydroxyvitamin D, and elevated 1,25-dihydroxyvitamin D. Silicone injection-induced hypercalcemia should be considered as a differential diagnosis in patients presenting with otherwise unexplained elevated serum calcium and a history of past cosmetic procedures. If suspected, the use of imaging techniques (e.g. positron emission tomography (PET) scans or MRI) may help ascertain the diagnosis. Further research is needed to determine the most appropriate therapies for complex patients such as those with immunodeficiency or renal disease.

Severe hypercalcemia caused by repeated mineral oil injections: a case report

Hypercalcemia is a frequent condition in clinical practice and when the most frequent causes are excluded, etiological diagnosis can be challenging. A rare cause of PTH-independent hypercalcemia is described in the present case report. A male adult with a history of androgenic-anabolic steroids abuse, and injection of mineral oil and oily veterinary compound containing vitamins A, D and E into muscles for local hypertrophy presented with hypercalcemia, nephrocalcinosis, and end-stage renal disease. On physical examination, the presence of calcified subcutaneous nodules and calcification of musculature previously infused with oily substances drew attention. Laboratory tests confirmed hypercalcemia of 12.62 mg/L, low levels of PTH (10 pg/mL), hyperphosphatemia (6.0 mg/dL), 25(OH)D of 23.3 ng/mL, and elevated 1,25(OH)2D (138 pg/mL). Imaging exams showed diffuse calcification of muscle tissue, subcutaneous tissue, and organs such as the heart, lung, and kidneys. The patient was diagnosed with PTH-independent hypercalcemia secondary to foreign body reaction in areas of oil injection. The patient underwent treatment with hydrocortisone for 10 days, single dose zoledronic acid and hemodialysis. He evolved with serum calcium levels of 10.4 mg/dL and phosphorus of 7.1 mg/dL. In addition, sertraline and quetiapine were prescribed to control body dysmorphic disorder. The medical community should become aware of new causes of hypercalcemia as secondary to oil injection since this should become increasingly frequent due to the regularity with which such procedures have been performed.

Simultaneous HIFEM and Synchronized RF Procedure Can Be Effectively Used for Increasing Muscle Mass and Decreasing Fat in the Upper Arm

Objective

Several studies on the simultaneous use of high-intensity focused electromagnetic field (HIFEM) and radiofrequency (RF) have shown safety and effectiveness of fat reduction and muscle mass increases in other parts of the body. This study investigated HIFEM+RF procedure effect on muscle mass and adipose tissue in the upper arms.

Methods

Thirty-four subjects enrolled in this multicentric study underwent four, 30-minute bilateral procedures over the upper arms spaced one week apart, with the device simultaneously emitting HIFEM and RF energies. Fat and m. triceps muscle tissue change was measured via magnetic resonance imaging at baseline, 1-month, and 3-month follow-up visits. Additionally, digital photographs, patient comfort, and satisfaction questionnaires were obtained. The trial is registered on ClinicalTrials.gov under NCT04596241.

Results

MRI images analysis showed significant improvement at both follow-up visits. At 1-month follow-up (n=28) patients showed 22.3 percent (-4.0±1.2 mm) decrease of average fat tissue, and 21.5 percent (+8.2±2.3 mm) muscle mass increase. Twenty-five patients completed the 3-month follow-up visit, with average decrease in fat tissue by 25.5 percent (-4.9±1.5 mm) and average increase in muscle mass by 23.9 percent (+8.9±2.01 mm). Analysis of questionnaires revealed high satisfaction with the results (84.64%), high comfort during the treatment (91.18%), and low VAS score (1.58±2.0), indicating painless procedure.

Conclusion

Presented results demonstrate the safety and effectiveness of the HIFEM+RF procedure for muscle mass increase and fat reduction in the upper arm area. These findings correspond with the outcomes seen in other body parts.

Treatment options for hypercalcemia after cosmetic oil injections: Lessons from human tissue cultures and a pilot intervention study

OBJECTIVE

Granuloma formation following self-administered cosmetic oil injections can lead to severe hypercalcemia and renal calcifications due to extra-renal vitamin D activation. This translational study aims to identify Prednisolone sparing therapeutics for hypercalcemia after development of granulomatous disease secondary to paraffin oil injections.

MATERIALS AND METHODS

Granuloma tissue isolated from five men were cultured ex vivo and treated with selected drugs to block generation of activated vitamin D (1,25(OH)₂D₃). In a retrospective study, we included data before and during different treatments of 21 men with paraffin oil induced granulomatous hypercalcemia (46 treatment courses) where serum calcium, parathyroid hormone, vitamin D metabolites, creatinine and inflammatory markers were measured.

RESULTS

Addition of Ketoconazole or Ciclosporin to granuloma tissue ex vivo culture, significantly suppressed production of 1,25(OH)₂D₃ after 48 h (both p < 0.05). Prednisolone was the first treatment option in most men and lowered serum levels of ionized calcium after 1, 2, 3 and 6 months compared with baseline (p < 0.05). Ketoconazole or Hydroxychloroquine had no significant effect on serum calcium levels and were unable to reduce the concomitant daily Prednisolone doses (p > 0.05). Azathioprine did not reduce calcium levels. However, addition of Tacrolimus to Prednisolone treatment enabled a reduction in Prednisolone dose after 3 months (p = 0.014), but with no additional effect on calcium homeostasis.

CONCLUSION

This study verifies that Prednisolone is an effective treatment and suggests that calcineurin inhibitors may be used as Prednisolone sparing treatment for paraffin oil-induced granulomatous hypercalcemia. Randomized clinical trials are needed to determine clinical efficacy.

Symptomatic Cervical Tumoral Calcinosis due to Cosmetic Body Contouring Mineral Oil Injections

Tumoral calcinosis (TC) is an uncommon disease that has been linked to familial genetic mutations but can often be due to secondary causes such as chronic renal failure and hyperparathyroidism. There are rare instances of tumoral calcinosis induced by foreign body injections, often for cosmetic purposes. Here we describe operative management of spinal cord compression due to mineral oil injection induced tumoral calcinosis. A 54-year-old transgender female presented with signs of myelopathy so severe that she had become wheelchair bound. Labs demonstrated hypercalcemia and imaging of the neuroaxis revealed significant calcification resulting in cervicothoracic and lumbar central canal stenosis. Given symptomatic cervical spinal cord compression, she was taken to the OR for urgent laminectomy and decompression. Postoperatively, she recovered well and was ambulating independently by postoperative day (POD) 9. This is the first reported case of localized mineral oil injections causing distant calcification with subsequent symptomatic cord compression requiring operative intervention.