SUN-782 - The Silicone Paradox: A Case of Refractory Hypercalcemia Secondary to Foreign Body Granulomatosis in A Transgender Female with Chronic Kidney Disease

Background:
Foreign body granulomatosis is a rare cause of severe hypercalcemia, which was only documented in several case reports. Apart from a diagnostic challenge, the treatment of hypercalcemia secondary to granuloma formation is often difficult due to high prevalence of concurrent renal dysfunction, which limits treatment options.

Case presentation:
A 46-year-old transgender female with a history of chronic Hepatitis, CKD, kidney stones, was referred to the hospital after outpatient laboratory tests showed severely elevated calcium levels. She has history of mild hypercalcemia for many years presumed likely due to sarcoidosis. Of note patient had history of silicone injections in breasts, buttocks and thighs. Most recently had undergone breast implantation. On arrival complained of fatigue, nausea, mild abdominal pain. Additionally, reported pain on the area surrounding the right breast. Vital signs showed patient was afebrile, slightly tachycardic with elevated blood pressure. Physical exam notable for skin induration of the right breast and gluteal region. Laboratory examination showed Calcium levels 17.2 g/dl, albumin 4.3 g/dl, PTH intact level 5 pg/ml, creatinine 2.7 (baseline of 1.6 mg/dL) eGFR 27, 25-OH D 24.9 ng/ml. Patient was admitted at the hospital and intravenous hydration was initiated. As bisphosphonates were contraindicated given the decline of GFR. Calcitonin and short-course prednisone were started. Ultimately given one dose of Denosumab 60 mg subcutaneously during admission. Calcium levels subsequently normalized, and the patient was discharged with a close follow-up at endocrinology clinic. However, the patient missed follow up appointments and hypercalcemia remains uncontrolled on subsequent visits. Patient had previous workup in a different facility showing elevated 1,25-OH D levels of 69 (18-64 pg/ml), elevated ACE 122 (16-85 U/L), and elevated PTHrP levels 6.2 (0-2.3 pmol/L). Serum immunofixation did not show monoclonal proteins spikes. Vitamin A levels was within normal limits. A CT-guided core biopsy of the right chest was done a few months prior which showed foreign body laden macrophages. Patient was treated for severe PTH-independent hypercalcemia most likely secondary to granulomatous formation around the silicone. Diagnosis was challenging as ACE and PTHrP levels were also elevated. However elevated ACE can occur in the setting of granulomatous disease and elevated PTHrP levels can be associated to benign conditions such as chest lymphedema.

Conclusion
As the demand for cosmetic procedures continues to rise, clinicians can expect a corresponding increase in implant-related complications. This case underscores the importance of considering foreign body granulomatous disease as a potential etiology in patients presenting with unexplained or refractory hypercalcemia.

*Unless otherwise noted, all abstracts presented at ENDO must not be released to the press or the public until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.*