An unexpected cause of severe and refractory PTH-independent hypercalcemia: case report and literature review

Abstract

SUMMARYHypercalcemia is a common condition in the internal medicine practice. Sometimes its cause is not readily apparent, so extensive investigation is appropriate. Here we report an unexpected cause for hypercalcemia in an elderly woman. The case of an 82-years old woman with PTH-independent hypercalcemia, lymphocytosis, normal serum 1,25 (OH)vitamin D levels, and low serum PTHrp levels, is described. Medical history and complementary investigation were unremarkable, except for increased metabolic activity in the glutei regions, as measured by whole body 18F-FDG PET-CT. Reviewing her medical history, her sister recalled that she had been submitted to intramuscular methylmethacrylate injections, for cosmetic purposes, five years before presentation, which was confirmed by muscle biopsy. Low calcium intake, parenteral bisphosphonates, calcitonin, and glucocorticoids were used to control serum calcium levels. Methylmethacrylate injections, used cosmetically, are a new cause for hypercalcemia, even after many years. Hypercalcemia was probably due to calcitriol overproduction in foreign body granulomas. Persistent reactive lymphocytosis could be a clue for this inflammatory cause of hypercalcemia. Arch Endocrinol Metab. 2015;59(3):277-80

Hypercalcemia-induced acute kidney injury in a Caucasian female due to radiographically silent systemic sarcoidosis

“…Foreign body reactions in sites other than the lungs have also produced granulomatous immune reactions in past. In one reported case, methylcrylate injections in the muscles produced refractory hypercalcemia with parathyroid suppression and granuloma formation similar to what we describe [14]. Moreover, anti-tumor necrosis factors can lead to secondary sarcoidosis.…”

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.…”

Non-parathyroid hypercalcemia associated with paraffin oil injection in 12 younger male bodybuilders: a case series

“…Plasma interleukin-2 receptor and peptidyl-di-peptidase are often measured to diagnose sarcoidosis (2). In recent years, a few case reports have been published on non-parathyroid hypercalcemia attributable to use of various body fillers for cosmetic purposes, including subcutaneous injections with silicone and ruptures of silicone implants, as well as injection of methylmethacrylate and mineral/organic oil (3,4,5,6,7). In three case reports, non-parathyroid hypercalcemia have been reported in bodybuilders who have used intramuscular injections of paraffin oil to augment muscle size (8,9,10).…”