Severe hypercalcemia caused by repeated mineral oil injections: a case report

Abstract

Hypercalcemia is a frequent condition in clinical practice and when the most frequent causes are excluded, etiological diagnosis can be challenging. A rare cause of PTH-independent hypercalcemia is described in the present case report. A male adult with a history of androgenic-anabolic steroids abuse, and injection of mineral oil and oily veterinary compound containing vitamins A, D and E into muscles for local hypertrophy presented with hypercalcemia, nephrocalcinosis, and end-stage renal disease. On physical examination, the presence of calcified subcutaneous nodules and calcification of musculature previously infused with oily substances drew attention. Laboratory tests confirmed hypercalcemia of 12.62 mg/L, low levels of PTH (10 pg/mL), hyperphosphatemia (6.0 mg/dL), 25(OH)D of 23.3 ng/mL, and elevated 1,25(OH)2D (138 pg/mL). Imaging exams showed diffuse calcification of muscle tissue, subcutaneous tissue, and organs such as the heart, lung, and kidneys. The patient was diagnosed with PTH-independent hypercalcemia secondary to foreign body reaction in areas of oil injection. The patient underwent treatment with hydrocortisone for 10 days, single dose zoledronic acid and hemodialysis. He evolved with serum calcium levels of 10.4 mg/dL and phosphorus of 7.1 mg/dL. In addition, sertraline and quetiapine were prescribed to control body dysmorphic disorder. The medical community should become aware of new causes of hypercalcemia as secondary to oil injection since this should become increasingly frequent due to the regularity with which such procedures have been performed.

Figure 1. A and B: X-Ray imaging of frequent oil injection sites show triceps (A) and gluteus (B) calcifications (arrows). (C) Head computerized tomography imaging show: inner ear and sclera calcifications (arrow heads), meningeal dura mater calcifications (long arrow); (D) Abdominal CT showing nephrocalcinosis bilaterally, left kidney atrophy, right hydronephrosis (long arrow), and gluteus calcifications (arrow heads).

Figure 2. Whole-body 18F-FDG-PET-CT (18-fluor-deoxy-2-glucose computerized tomography) showing extensive increased metabolic activity in the glutei regions, biceps, triceps, brachii, deltoids, pectoralis major, trapezius, and latissimus dorsi, and images of diffuse calcinosis more evident in the eyeballs, meninges, heart valves, lungs, kidneys, various subcutaneous projections, and muscle planes.