SAT-496 Symptomatic Hypercalcemia in a Transgender Patient with Silicone-Induced Granulomas

Introduction Despite FDA-issued safety concerns, silicone injections remain legal and are practiced by unlicensed providers. Here we present a case of calcitriol-mediated hypercalcemia secondary to a granulomatous reaction induced by silicone injections. Clinical Case This is a case of a 39-year-old male to female transgender patient who presented with nonspecific symptoms that included myalgias and abdominal pain. The patient’s past medical history includes bipolar 1 disorder, well-controlled HIV, GERD, history of DVT/PE and a history of Hodgkin’s lymphoma treated with chemotherapy and autologous stem cell transplant 3 years prior to presentation. A thorough physical exam revealed infiltrative red plaques involving her buttocks and breasts at sites where, after further questioning, she reported receiving cosmetic silicone injections in Mexico as part of her gender transition 15 years ago. Laboratory evaluation revealed a serum calcium level of 13.5mg/dL (n 8.5-10.1mg/dL) and a serum creatinine level of 1.74mg/dL from a baseline creatinine of 1.1mg/dL. 1,25-dihydroxyvitamin D level was high at 92.5pg/mL (n 19.9-79.3pg/mL) while a 25-hydroxyvitamin D level was low at 16.2ng/mL (n 30-100ng/mL). PTH was undetectably low (<6.5pg/mL) and PTH-related protein level was normal at 3.4pmol/L (n<3.4pmol/L). Contrasted CT imaging of her chest, abdomen and pelvis revealed infiltrative nodular soft tissue hyperdensities throughout the breasts and buttocks likely representing a granulomatous inflammatory process. The patient was initially treated with intravenous fluids and furosemide administration. Dermatology was consulted, and biopsy of the affected plaques was performed. Patient was started on prednisone to target the exuberant 1-alpha hydroxylation thought to be occurring at the site of the granulomatous reaction. Results of the tissue biopsy revealed a foreign body giant cell reaction consistent with silicone injection. Serum calcium levels rapidly normalized after initiating steroid therapy and patient was discharged to follow-up as an outpatient where prednisone was eventually tapered off and she was started on hydroxychloroquine. Conclusion Hypercalcemia is a commonly encountered problem that is often incidentally found in patients presenting with non-specific symptoms. Clinical judgement leads us down a well-learned algorithm to attempt to diagnose the etiology. However, there is growing evidence linking silicone injections to granulomatous disease. It is therefore prudent to consider silicone granulomas as part of the differential of hypercalcemia, particularly within the transgender community. It is of vital importance to directly ask about past cosmetic injections as most patients will not readily volunteer that information.