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

Abstract

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.