Hypercalcemia After Cosmetic Oil Injections: Unraveling Etiology, Pathogenesis, and Severity

Value of inflammatory markers for monitoring disease severity and progression in granuloma induced by cosmetic oil injections

OBJECTIVE

Cosmetic oil injections can cause foreign body granulomas, leading to inflammation-driven extrarenal production of activated vitamin D (1,25(OH)2D3) and severe hypercalcemia. This study investigates longitudinal changes in inflammatory markers: interleukin 2 receptor (IL-2R), peptidyl dipeptidase (ACE), and ferritin in patients with oil-induced granuloma.

MATERIALS AND METHODS

109 male patients were stratified according to baseline calcium status. 28 % had hypercalcemia, and 72 % normocalcemia. Normocalcemic patients were subdivided based on serum parathyroid hormone (PTH) concentrations into suppressed (< 2.0 pmol/L, n = 30) or normal (≥ 2.0 pmol/L, n = 49) concentrations. Blood samples were collected over 48 months and longitudinal changes in inflammatory markers and calcium homeostasis were examined using Pearson correlation and mixed model analyses.

RESULTS

IL-2R, ACE, and ferritin were positively correlated with serum concentration of ionized calcium, while IL-2R was associated with serum 1,25(OH)2D3. In patients with hypercalcemia, IL-2R decreased at 6 (p = 0.041), 24 (p = 0.048), and 36 months (p = 0.035). ACE increased at 48 months (p = 0.008). In patients with normocalcemia and suppressed PTH, IL-2R increased at 24 months (p = 0.021), while serum ferritin increased in patients with normocalcemia and normal PTH at 6 (p = 0.040), 12 (p = 0.008), 24 (p = 0.028), and 48 months (p = 0.005).

CONCLUSIONS

Positive correlations were observed at baseline between ionized calcium concentrations and IL-2R, ionized calcium and ferritin, and 1,25(OH)₂D₃ and IL-2R. Hypercalcemia and suppressed PTH was associated with elevated IL-2R and ferritin concentrations at baseline. Over time, IL-2R and ferritin concentrations decreased in patients with hypercalcemia, some treated with immunomodulatory drugs. IL-2R and ferritin concentrations increased in untreated patients with normocalcemia.

Exacerbated hypercalcemia, nephrolithiasis, and renal impairment after vitamin D supplementation in granulomatous disease: a case report

BACKGROUND

The cosmetic industry is booming with unorthodox therapies aimed at improving the appearance of beauty and strength. One such therapy is self-administered, intramuscular injections of paraffin oil for the purpose of increasing presumed muscular size. Paraffin oil injections are becoming frequent among younger male individuals, who inject up to several liters in (primarily) the upper extremities. However, paraffin oil leads to the formation of granulomas, which are rich in macrophages with an upregulated extrarenal 1-hydroxylation. These macrophages will rapidly and unimpededly convert inactive vitamin D (25OHD2) to active vitamin D (1,25OH2D3), thereby causing significant hypercalcemia and derivative disease.

CASE PRESENTATION

In 2007, a Scandinavian male individual in his 20s had self-injected 1200 ml of paraffin oil into both biceps. Within 5 years, the oil had migrated and was then widely dispersed in his biceps and surrounding tissues, causing swelling and pain. By 2015, granulomas had formed at injection sites, and he was admitted to a hospital with severe hypercalcemia, which was managed with fluid therapy and slowly resolved. From 2015 to 2020, his calcium levels were intermittently elevated, and he experienced two episodes of nephrolithiasis requiring surgical intervention. In 2020, he was prescribed one dose oral vitamin D (6000 µg cholecalciferol) for suspected vitamin D deficiency based on a low serum 25OHD2. His episodic hypercalcemia increased, and he developed nephrolithiasis and exacerbated renal impairment.

CONCLUSION

Unlike most other patients with low 25(OH)D2, patients with granulomatous disease should not routinely receive vitamin D supplementation, as this may aggravate hypercalcemia and hypercalcuria, causing nephrolithiasis and renal impairment.

Debulking Surgery After Muscular Paraffin Oil Injections: Effects on Calcium Homeostasis and Patient Satisfaction

CONTEXT

Cosmetic paraffin oil injections can lead to granuloma formation, causing hypercalcemia and kidney failure.

OBJECTIVE

This study explores whether debulking surgery is an effective treatment for improving calcium homeostasis, inflammation, and clinical symptoms.

METHODS

In a retrospective study, we reviewed 33 patients undergoing debulking surgery. Changes in calcium, inflammatory markers, and renal function from baseline up to 12 months after surgery were assessed. Patients were interviewed after surgery.

RESULTS

The patients were 34.6 years of age (SD 6.9) and had 1104 grams (SD 591) of granuloma tissue removed following injection of 1329 mL (SD 803) paraffin oil 7.9 years (SD 3.2) earlier. Seventeen patients had hypercalcemia and experienced a significant decline in ionized calcium from 1.48 mmol/L (SD 0.16) at baseline to 1.33 mmol/L (SD 0.03) at 12 months (P < .002), although only 4 men (23.5%) became normocalcemic. Serum ferritin was reduced by 50% after 12 months (P = .048). Sixteen patients were normocalcemic and had no change in calcium homeostasis but experienced a 20% drop in serum ferritin levels (P = .025) after surgery. Fifteen patients completed all their planned surgeries within the study period and experienced a decline in serum ionized calcium (P = .031), ferritin (P = .011), and interleukin 2-receptor (P = .037). A survey showed that 55% of patients reported postoperative satisfaction scores of 10/10, and 59% of the patients reported reduced pain.

CONCLUSION

Surgery improved calcium homeostasis in a fraction of patients and reduced inflammation and subjective symptoms such as pain and mental well-being in a patient group left with few treatment options except high-dose prednisolone.

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.

Injection of luteinizing hormone or human chorionic gonadotropin increases calcium excretion and serum PTH in males

Animal and human studies have suggested that sex steroids have calciotropic actions, and it has been proposed that follicle-stimulating hormone (FSH) may exert direct effects on bone. Here, we demonstrate the expression of the receptor for Luteinizing hormone (LH) and human choriogonadotropin (hCG), LHCGR, in human kidney tissue, suggesting a potential influence on calcium homeostasis. To investigate the role of LHCGR agonist on calcium homeostasis in vivo, we conducted studies in male mice and human subjects. Male mice were treated with luteinizing hormone (LH), and human extrapolation was achieved by injecting 5000 IU hCG once to healthy men or men with hypergonadotropic or hypogonadotropic hypogonadism. In mice, LH treatment significantly increased urinary calcium excretion and induced a secondary increase in serum parathyroid hormone (PTH). Similarly, hCG treatment in healthy men led to a significant increase in urinary calcium excretion, serum PTH levels, and 1,25 (OH)2D3, while calcitonin, and albumin levels were reduced, possibly to avoid development of persistent hypocalcemia. Still, the rapid initial decline in ionized calcium coincided with a significant prolongation of the cardiac QTc-interval that normalized over time. The observed effects may be attributed to LH/hCG-receptor (LHCGR) activation, considering the presence of LHCGR expression in human kidney tissue, and the increase in sex steroids occurred several hours after the changes in calcium homeostasis. Our translational study shed light on the intricate relationship between gonadotropins, sex hormones and calcium, suggesting that LHCGR may be influencing calcium homeostasis directly or indirectly.

Case report: Death caused by multi-organ metastatic calcifications as a result of intramuscular injections with paraffin oil

In this forensic case report, we present autopsy findings from a young male in his thirties who had been self-injecting paraffin oil into his upper extremities 8 years prior to death. The injections induced an inflammatory response, leading to granuloma formation. This, in turn, resulted in severe hypercalcemia. The external autopsy examination revealed gross macroscopic ulcerations and enlargement of upper extremities, while calcifications of ligaments, heart, kidneys and dura mater was revealed on postmortem CT-scans. Histopathological examination showed extensive multiorgan metastatic calcifications in several tissues including the lungs, heart and kidney. Cause of death was estimated to be the extensive calcific deposits in the heart likely resulting in cardiac arrest. To our knowledge this is the first case reporting findings from an autopsy in which the cause of death was linked to cosmetic oil injections.

Delayed oleoma formation with injection of oil-suspended testosterone: A case report and review of pathogenesis

This is the case report of a 51-year-old man who was seen in consult with plastic surgery presenting with painful, disfiguring, submuscular nodules in the bilateral deltoids and right gluteal regions. Pre-operative investigations confirmed the presence of multiple heterogeneous, complex non-vascular fluid collections in the subcutaneous and intramuscular layers. The origin of these lesions was unknown until the post-operative follow-up appointment where the patient revealed that he had injected those areas with testosterone suspended in oil 9 years prior. Later, pathology reports confirmed the presence of numerous granulomas containing yellow viscous fluid and focal areas of calcification consistent with the diagnosis of oleomas. This case presents an important differential in the diagnosis of subcutaneous nodules and a review of pathophysiology of granuloma formation, and highlights some of the complications of oil injection use by bodybuilders.

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.

Possible Relevance of Soluble Luteinizing Hormone Receptor during Development and Adulthood in Boys and Men

Simple Summary

The reproductive hormones luteinizing hormone (LH) and human chorionic gonadotropin (hCG) are both agonists for the luteinizing hormone receptor (LHCGR) and essential for male reproduction during development and adulthood. LHCGR is expressed and stimulates testosterone production from the testicular Leydig cells. In this study, we demonstrate the presence of soluble LHCGR in blood, urine, and seminal fluid in both healthy boys and men, and patients with aberrations in sex-chromosomes. We show how circulating levels of sLHCGR are associated with pubertal development, testicular function, and semen quality and demonstrate that LHCGR is released from fetal human non-gonadal tissue. sLHCGR is released into serum by testis and other organs, which suggests possible extra-gonadal effects of LH or hCG in boys and men.

Abstract

Luteinizing hormone (LH) and human chorionic gonadotropin (hCG) are agonists for the luteinizing hormone receptor (LHCGR) which regulates male reproductive function. LHCGR may be released into body fluids. We wish to determine whether soluble LHCGR is a marker for gonadal function. Cross-sectional, longitudinal, and intervention studies on 195 healthy boys and men and 396 men with infertility, anorchia, or Klinefelter Syndrome (KS) were used to correlate LHCGR measured in serum, seminal fluid, urine, and hepatic/renal artery and vein with gonadal function. LHCGR was determined in fluids from in vitro and in vivo models of human testicular tissue and cell lines, xenograft mouse models, and human fetal kidney and adrenal glands. Western blot showed LHCGR fragments in serum and gonadal tissue of similar size using three different antibodies. The LHCGR-ELISA had no species cross-reactivity or unspecific reaction in mouse serum even after human xenografting. Instead, sLHCGR was released into the media after the culture of a human fetal kidney and adrenal glands. Serum sLHCGR decreased markedly during puberty in healthy boys (p = 0.0001). In healthy men, serum sLHCGR was inversely associated with the Inhibin B/FSH ratio (β −0.004, p = 0.027). In infertile men, seminal fluid sLHCGR was inversely associated with serum FSH (β 0.006, p = 0.009), sperm concentration (β −3.5, p = 0.003) and total sperm count (β −3.2, p = 0.007). The injection of hCG lowered sLHCGR in serum and urine of healthy men (p < 0.01). In conclusion, sLHCGR is released into body-fluids and linked with pubertal development and gonadal function. Circulating sLHCGR in anorchid men suggests that sLHCGR in serum may originate from and possibly exert actions in non-gonadal tissues. (ClinicalTrials: NTC01411527, NCT01304927, NCT03418896).