ODP095 HYPERCALCEMIA FROM SILICONE BUTTOCK INJECTION INDUCED GRANULOMA.
Authors: Chin Edward , Cotter Thomas , Harned Leighton , Vemavarapu Lakshmi , Harper Rene 
Published: November 2022

Abstract
Granulomatous disease is an infrequent cause of non-PTH mediated hypercalcemia. Hypercalcemia from granulomas due to cosmetic silicone injections are not commonly recognized.
A 57 year old woman with rheumatoid arthritis was incidentally discovered to have hypercalcemia. Laboratory studies reported elevated calcium 11.0 mg/dL (RR: 8.6-10.2), suppressed PTH 12.7 pg/mL (RR: 15-65), low 25 OH - vitamin D 13ng/mL (RR 30-100), normal 1-25 dihydroxyvitamin D 78 pg/mL (RR 18-72), SPEP Kappa/Lambda Ratio 2.12 (RR 0.26-1.65), but no M spike, normal UPEP, an eleavted 24hr Urine Calcium 451.5 (RR: 100-300). PTHrp 20 pg/mL (RR: 14-27). Quantiferon test negative. ACE level 76 (RR: 9-67). X-ray of the chest showed no hilar adenopathy.
Patient had a non-FDA approved silicone buttocks injection 20 years earlier. Patient's main complaint consisted of buttocks pain and tenderness as well as discomfort upon sitting. PET/CT showed "heterogeneous density in the bilateral gluteal region from silicon implants". "The thickness of the implant is about 6 cm in the soft tissues metabolically active diffusely with a maximum SUV of 2.84. This is consistent with silicone granulomas". A biopsy showed "Clear annular histiocytic inclusions consistent with macrophage ingestion of foreign substance. Abundant surrounding inflammatory reaction with numerous multi-nucleated giant cells consistent with granulomatous response." Plastic surgery was consulted and were unable to surgically remove the silicone. Patient was offered medical treatment for hypercalcemia, but deferred due to concern for side effects.
Cosmetic enhancement is a growing industry and cosmetic fillers including silicone have been used throughout the 20th century. Previously considered inert silicon may have inflammatory reactions attributed to denatured silicon, incorrect injection and large injection volumes. Silicon induced granulomas frequency ranges from 0.01–5% and may appear 2–25 years after the injections. Histologic diagnosis is critical and is similar to those found in sarcoidosis. Treatment of silicon induced hypercalcemia is similar to treatment of other granulomatous disease utilizing glucocorticoids. Bisphosphonates are considered in cases resistant to glucocorticoid treatment. Surgical treatment is rarely considered. The patient was receiving abatacept therapy (750 mg IV monthly) for rheumatoid arthritis. Abatacept is a monocolonal antibody which binds to CD80 and CD86 on antigen presenting cells (APCs) blocking T-cell activity. Since starting Abatacept treatment the patient's hypercalcemia has improved. There are currently ongoing clinical trials of abatacept to treat sarcoidosis and granulomatosis with polyangiitis that may shed light on the efficacy of this drug to treat granulomatous disease. Due to the rise in the use of cosmetic fillers, complications are also likely to be on the rise. Soft tissue fillers injections have increased in the United States and it is likely that complications from these non-FDA approved treatments will increase. It is important that endocrinologists are familiar with the physiology and treatments.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.