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

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.

Longitudinal changes in minerals are influenced by immunosuppressive treatment in men with granuloma disease

PURPOSE

To investigate whether granuloma formation following self-administered cosmetic oil injections affects mineral homeostasis, specifically calcium, magnesium, phosphate, iron, sodium, and potassium, and to assess the potential impact of prednisolone treatment on these mineral levels.

METHODS

In this retrospective study, we reviewed blood samples from baseline through a follow-up period of 48 months in patients referred to a tertiary center at Herlev Hospital, Denmark. Changes in serum minerals over time were assessed by a linear mixed model for repeated measures.

RESULTS

A total of 111 patients were included. Men who injected > 2,000 mL paraffin oil had higher total and ionized calcium (p = 0.029 and p < 0.001), lower PTH (p < 0.001), but also lower magnesium (p < 0.001) and higher sodium (p = 0.048) compared to those who had injected < 500 mL. Men with manifest hypercalcemia at baseline (n = 32) compared to men with normocalcemia (n = 79) experienced an increase in serum PTH and phosphate concentrations over time (p = 0.042 at 48 months), and also a transient increase in iron concentration, although this reached baseline levels again after 24 months. Prednisolone lowered calcium in hypercalcemic men but also decreased serum magnesium (p = 0.027 after 36 months), phosphate, and increased serum iron concentration.

CONCLUSION

Men who had injected large volumes of paraffin oil were more likely to have hypercalcemia, lower magnesium, and higher sodium concentrations. Minor aberration in serum minerals was more frequent in patients with more pronounced disease and this may likely be a poor prognostic sign although the mechanism behind this observation remains unclear.

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.

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.

High-dose vitamin D3 supplementation shows no beneficial effects on white blood cell counts, acute phase reactants, or frequency of respiratory infections

BACKGROUND

Vitamin D has been suggested to influence the immune system, and vitamin D metabolites and the vitamin D receptor (VDR) are generated and expressed in white blood cells (WBC). Moreover, vitamin D status has been associated with incidence and prognosis of some respiratory tract infections (RTI). Therefore, we investigated the effect of vitamin D3 supplementation on WBC, acute phase reactants (APR), and the risk of developing RTIs.

METHODS

A double-blinded, randomized, placebo-controlled clinical trial of 307 infertile men with multiple secondary immunological endpoints. The vitamin D3 group (n = 151) initially received 300,000 IU (7,500 µg) cholecalciferol once - followed by 1,400 IU (35 µg) daily for 150 days. The placebo group (n = 156) did not receive active ingredients.

RESULTS

At baseline, stratification into clinically relevant groups of vitamin D status (< 25; 25-50; 50-75; >75 nmol/L), showed an inverse association with total leucocyte concentrations (7.0 vs. 6.0 vs. 6.0 vs. 5.5 (109/L); p = 0.007), lymphocytes (2.4 vs. 2.1 vs. 2.0 vs. 2.0 (109/L); p = 0.048), CRP (2.0 vs. 1.7 vs. 1.2 vs. 1.2 (mg/L); p = 0.037), and orosomucoid (0.82 vs. 0.77 vs. 0.76 vs. 0.70 (g/L); p = 0.015). After 150 days, no differences were detected in WBC counts or APRs between the vitamin D3 and the placebo group. However, vitamin D3 treated men had a higher prevalence of self-reported RTIs compared with the placebo group (55% vs. 39%; p = 0.005).

CONCLUSIONS

High-dose vitamin D3 supplementation did not alter WBCs or APRs, but a higher prevalence of respiratory infections was observed in the vitamin D3 group. Serum 25(OH)D3 was negatively correlated with most WBCs, indicating that vitamin D status may be linked with inflammation and WBC turnover, but not an important determinant of developing RTIs.

TRIAL REGISTRATION

NCT01304927 (ClinicalTrials.gov). Registered February 20, 2011.