Abstract
ABSTRACTSilicone/mineral oil‐induced granulomas have been described as an inflammatory granulomatous response when silicone/mineral oil is injected for cosmetic purposes. These sclerosing granulomas can lead to hypercalcemia. Here we present a 33‐year‐old man with hypercalcemia, hypophosphatemia, progressively worsening fatigue, severe proximal muscle weakness, and depression. He had an athletic build with increased muscle bulk and several areas of indurated, nontender, firm, well‐circumscribed lesions in the subcutaneous tissue of his anterior pectoralis, triceps, and biceps bilaterally because of injecting himself with silicone/mineral oil‐based product into his muscles. Sclerosing granulomas were diagnosed on the MRI. He had extremely low or undetectable serum levels of 25‐hydroxyvitamin D [25(OH)D], and persistently elevated serum levels of 1,25‐dihydroxyvitamin D [1,25(OH)2D] and calcium. He developed hypophosphatemia associated with elevated levels of fibroblast growth factor 23 (FGF‐23) and severe proximal muscle weakness. Treatment with systemic steroids, furosemide, calcitonin, ketoconazole, and denosumab resulted in a significant decrease in his serum calcium, but with minimal impact on his hypophosphatemia and fatigue.Correcting his severe vitamin D deficiency with small doses of vitamin D and raising his blood level of 25(OH)D from undetectable to 10 ng/mL without significantly affecting his serum calcium or phosphate was effective in reversing his severe proximal muscle weakness, permitting him to lift his head and to be free of his wheelchair. Although measurement of the 1,25(OH)2D level is not mandatory in all cases of hypercalcemia, it is indicated in a patient who has low serum PTH levels. Clinicians need to be aware that vitamin D deficiency can cause severe proximal muscle weakness such that the patient is unable to lift his head from his chest or ambulate. This may lead to a psychiatric disorder misdiagnosis. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
Highlights
Silicone/mineral oil injected for cosmetic purposes can stimulate an inflammatory granulomatous response
The sclerosing granulomas resulting from mineral oil or silicone injections have been associated with severe and recurrent hypercalcemia.[1,2,3] The mechanism for the silicone/mineral oil granuloma‐induced hypercalcemia has been demonstrated to be based on increased serum 1,25‐dihydroxyvitamin D [1,25(OH)2D] because of macrophage synthesis of and release of 1,25(OH)2D.(1,4) We describe a case of severe recurrent hypercalcemia and hypophosphatemia associated with extrarenal production of 1,25(OH)2D from sclerosing granulomas after injections of silicone/mineral oil for cosmetic reasons
The results of the whole‐body neuroendocrine PET/CT scan indicated there was no definite evidence of tumor‐induced osteomalacia
Summary
Silicone/mineral oil injected for cosmetic purposes can stimulate an inflammatory granulomatous response. His severe vitamin D deficiency was in part caused by a previous recommendation to eliminate all vitamin D intake because of his granulomas and hypercalcemia.his deficiency was exacerbated by the increased circulating levels of 1,25(OH)2D and FGF‐23.
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