Diagnosis and management of hypercalcemia associated with silicone-induced granuloma

SUMMARY Hypercalcemia associated with silicone-induced granuloma is a rare disease. Diagnosis can be tricky as it is established after ruling out other hypercalcemia-causing entities. In addition, management is customized depending on the patient's wishes and possible solutions. We present a male bodybuilder, in his thirties, with multiple silicone injections in his upper extremities, who developed hypercalcemia and urinary symptoms. Advanced laboratory tests ruled out various causes of hypercalcemia and CT imaging revealed nephrocalcinosis. A biopsy of the upper arm showed granulomatous tissue and inflammation. The patient necessitated two sessions of dialysis and corticosteroids were given to relieve symptoms and reverse laboratory abnormalities. Silicone-induced hypercalcemia should be on high alert because of the increasing trend of body contour enhancements with injections, implants and fillers. Treatment should be optimized depending on the patient's needs and condition.

RESUMO A hipercalcemia associada ao granuloma induzido por silicone é uma doença rara. O diagnóstico pode ser complicado, pois é estabelecido depois de eliminadas outras entidades que causam hipercalcemia. Além disso, o gerenciamento é personalizado, dependendo dos desejos do paciente e das possíveis soluções. Apresentamos um fisiculturista masculino, com trinta e poucos anos, múltiplas injeções de silicone nas extremidades superiores, que desenvolveu hipercalcemia e sintomas urinários. Testes laboratoriais avançados descartaram várias causas de hipercalcemia e a imagem da TC revelou nefrocalcinoses. Uma biópsia da parte superior mostrou tecido granulomatoso e inflamação. O paciente exigiu duas sessões de diálise e foram administrados corticosteroides para aliviar os sintomas e reverter as anormalidades laboratoriais. A hipercalcemia induzida por silicone deve estar em alerta elevado devido à crescente tendência de aprimoramentos do contorno corporal com injeções, implantes e enchimentos. O tratamento deve ser otimizado de acordo com as necessidades e condições do paciente.

Pencil-core granuloma

Abstract: Pencil core granulomas are still infrequently reported in the literature. A 67-year-old woman presented with a 4mm hard blue subcutaneous nodule on the forehead. She remembered being injured with a pencil tip about 60 years before. The subcutaneous nodule was excised, which microscopically revealed a foreign body reaction with histiocytes containing fragmented coarse black particles. We diagnosed pencil-core granuloma based on the patient's history of pencil tip injury and histological examination findings.

Gestation and breastfeeding in schistosomotic mothers differently modulate the immune response of adult offspring to postnatal Schistosoma mansoni infection

Schistosoma mansoni antigens in the early life alter homologous and heterologous immunity during postnatal infections. We evaluate the immunity to parasite antigens and ovalbumin (OA) in adult mice born/suckled by schistosomotic mothers. Newborns were divided into: born (BIM), suckled (SIM) or born/suckled (BSIM) in schistosomotic mothers, and animals from noninfected mothers (control). When adults, the mice were infected and compared the hepatic granuloma size and cellularity. Some animals were OA + adjuvant immunised. We evaluated hypersensitivity reactions (HR), antibodies levels (IgG1/IgG2a) anti-soluble egg antigen and anti-soluble worm antigen preparation, and anti-OA, cytokine production, and CD4+FoxP3+T-cells by splenocytes. Compared to control group, BIM mice showed a greater quantity of granulomas and collagen deposition, whereas SIM and BSIM presented smaller granulomas. BSIM group exhibited the lowest levels of anti-parasite antibodies. For anti-OA immunity, immediate HR was suppressed in all groups, with greater intensity in SIM mice accompanied of the remarkable level of basal CD4+FoxP3+T-cells. BIM and SIM groups produced less interleukin (IL)-4 and interferon (IFN)-g. In BSIM, there was higher production of IL-10 and IFN-g, but lower levels of IL-4 and CD4+FoxP3+T-cells. Thus, pregnancy in schistosomotic mothers intensified hepatic fibrosis, whereas breastfeeding diminished granulomas in descendants. Separately, pregnancy and breastfeeding could suppress heterologous immunity; however, when combined, the responses could be partially restored in infected descendants.

Complicação tardia de preenchimento cutâneo após facelift: relato de caso / Late complication of cutaneous filling after a facelift: a case report

Os autores apresentam o caso de uma paciente submetida 7 anos após aplicação de polimetilmetacrilato (PMMA) a um facelift com implante de prótese mentoniana, o qual evoluiu com granuloma por corpo estranho em região distante da aplicação do preenchimento. Após quase um ano de tratamento, a paciente evoluiu com resolução do caso.

The authors present the case of a patient who underwent a facelift with a chin implant 7 years after polymethylmethacrylate (PMMA) implantation, which evolved with foreign body granuloma in a region distant from the filling application. After nearly a year of treatment, the patient evolved with resolution of the granuloma.

Suture granuloma after orchiectomy: sonography, doppler and elastography features

ABSTRACTSuture granuloma is a mass forming benign lesion that develops at the site of surgery as a foreign body reaction to non-absorbable suture material. We present a case of suture granuloma that developed at the inguinal region after orchiectomy, and define the sonography, color Doppler sonography and real-time ultrasound elastography findings in correlation with the histopathological findings.

Foreign Body Granuloma Masquerading as Bladder Tumor: A Rare Case Report.

Foreign body granuloma can occur after any surgical procedure, where non absorbable sutures have been used. It may occur due to forgotten other non-absorbable like gauze. Though foreign body granuloma has been reported involving many organs, but it is very rare to involve urinary bladder wall and to present it as urinary bladder tumor. We present such a unique case where use of Barbour thread for tubal ligation led to a large foreign body granuloma infiltrating bladder wall and presenting as bladder mass. Even contrast enhanced computed tomography showed a mass, which appeared to arise from the anterior aspect of the bladder suggestive of urachal carcinoma. Only on histopathological examination diagnosis was confirmed to be foreign body granuloma.

The Unusual Ultrasound Features of a Breast Cholesterol Granuloma Manifesting as an Intracystic Mass: Case Report and Literature Review

Cholesterol granuloma of the breast is a rare, benign disease. Here, we present the unique ultrasonographic findings of breast cholesterol granuloma manifesting as an intracystic mass. The findings of this case report may help expand existing knowledge regarding differential diagnosis of intracystic breast masses, which are found on ultrasonographic examination.

A Case of Cholesterol Granuloma in Pancreas / 대한소화기학회지

Cholesterol granuloma is a histological term used for the description of a tissue response to a foreign body such as cholesterol crystals. Cholesterol granuloma is histologically characterized as fibrous granulation tissue containing cholesterol crystals within surrounding giant cells. Cases of cholesterol granuloma of the pancreas are very rare. We report a case of a 47-year old male who had a cholesterol granuloma of the pancreas. Abdominal CT showed 24 mm-sized cyst in the pancreas and peri-pancreatic regional mass infiltrating to the stomach. PET-CT revealed increased 18F-FDG uptake at the cyst and peri-pancreatic mass. Thus, Whipple's operation was done. The disease was confirmed by surgical pathologic examination of the tissue. Pathologic examination of resected specimen showed numerous cholesterol crystals surrounded by multinucleated foreign body giant cells. We report on this case and give a brief review of the literature.

MR Spectroscopy and Perfusion MR Imaging Findings of Intracranial Foreign Body Granuloma: a Case Report

We report a case of intracranial foreign body granuloma that showed features of a high grade tumor on magnetic resonance (MR) imaging. However, the relative cerebral blood volume was not increased in the enhancing mass on perfusion MRI and the choline/creatine ratio only slightly increased on MR spectroscopy. The results suggest that the lesion is benign in nature. Perfusion MRI and MR spectroscopy may be helpful to differentiate a foreign body granuloma from a neoplastic condition.

Histological and radiographic evaluation of the muscle tissue of rats after implantation of bone morphogenic protein (rhBMP-2) in a scaffold of inorganic bone and after stimulation with low-power laser light.

Objective: The present study histologically and radiologically evaluates the muscle tissue of rats after implantation of bone morphogenic protein (rhBMP-2) in a natural inorganic bone mineral scaffold from a bull calf femur and irradiation with low-power light laser. Materials and Methods: The right and left hind limbs of 16 rats were shaved and an incision was made in the muscle on the face corresponding to the median portion of the tibia, into which rhBMP-2 in a scaffold of inorganic bone was implanted. Two groups of limbs were formed: control (G1) and laser irradiation (G2). G2 received diode laser light applied in the direction of the implant, at a dose of 8 J/cm2 for three minutes. On the 7th, 21st, 40th and 112th days after implantation, hind limbs of 4 animals were radiographed and their implants removed together with the surrounding tissue for study under the microscope. The histological results were graded as 0=absence, 1=slight presence, 2=representative and 3=very representative, with regard to the following events: formation of osteoid structure, acute inflammation, chronic inflammation, fibrin deposition, neovascularization, foreign-body granuloma and fibrosis. Results: There were no statistically significant differences in these events at each evaluation times, between the two groups (P>0.05; Mann-Whitney test). Nevertheless, it could be concluded that the natural inorganic bone matrix with rhBMP-2, from the femur of a bull calf, is a biocompatible combination. Conclusions: Under these conditions, the inductive capacity of rhBMP-2 for cell differentiation was inhibited. There was a slight acceleration in tissue healing in the group that received irradiation with low-power laser light.

Pathosis associated with radiographically normal follicular tissues in third molar impactions: a clinicopathological study.

BACKGROUND: The follicular tissue around impacted third molars has a potential to develop pathosis. However, it is generally assumed that the absence of abnormal radiolucency indicates the presence of a normal follicle. AIMS: The aim of this study was to investigate abnormalities associated with radiographically normal follicular tissue of third molar impactions. MATERIALS AND METHODS: One hundred eighty-five impacted third molars from 170 patients with no signs of abnormal radiolucency (follicular space < 3 mm) were used for this study. Follicular tissues of the relevant teeth were collected. Specimens were fixed in 10% formalin and stained routinely with hematoxilin and eosin to be independently examined by two pathologists. A diagnosis was registered only when the results from both pathologists were in concordance. Clinical details for each patient were registered in WHO standard forms to undergo chi-square statistical analysis. RESULTS: Fifty-three per cent of the specimens had developed pathosis. The incidence of pathosis was higher in the age group of 20-30 years, in men compared to women and in the mandible compared to the maxilla. CONCLUSION: The findings of this study suggest that radiographic appearance may not be reliable in the diagnosis of pathosis in follicular tissue as a surprisingly high rate of pathosis was found in the absence of any radiographically detectable sign.

Rat subcutaneous tissue response to macrogranular porous anorganic bovine bone graft

The ideal bone graft must present biocompatibility, osteoconductive and osteoinductive properties, resistance and plasticity. Xenogenic grafts of bovine cancellous bone origin are particularly interesting due to their biologically designed porous structure that enhance both cellular and vascular invasion. The purpose of this study was to evaluate the tissue response induced by bovine macrogranular porous anorganic bone implanted in rat subcutaneous tissue. Forty rats were assigned to 2 groups, as follows: the control group received empty collagen capsules and the test group received subcutaneous implants of the test material. Samples were collected after 10, 20, 30 and 60 days and processed histologically. Histological analysis showed at 10 days a granulomatous inflammatory infiltrate, rich in multinucleated giant cells and free of lymphocytes or plasma cells, similarly to mineralized allograft implanted in rat subcutaneous. In later periods, there was a significant decrease in the inflammatory infiltrate and an increase in fibrosis around graft particles. In conclusion, the test material induced a foreign body-type granuloma with subsequent fibrosis around the graft particles implanted in rat subcutaneous and did not elicit any immune response, thus being considered biocompatible.

O enxerto ósseo ideal deve possuir características como biocompatibilidade, capacidade osteocondutora, osteoindutora, resistência e plasticidade. Dentre os implantes xenogênicos de origem bovina, os produzidos com o osso esponjoso revestem-se de particular interesse devido a sua arquitetura constituída de poros biologicamente desenhados que favorecem a invasão celular e vascular até o centro do defeito. O objetivo deste estudo foi avaliar a resposta tecidual ao material de osso inorgânico medular bovino macrogranular. Quarenta ratos foram divididos em 2 grupos (n=20): o grupo controle recebeu cápsulas de colágeno vazias, e o grupo experimental recebeu implante subcutâneo do material teste. As amostras foram coletadas após 10, 20, 30 e 60 dias de implantação e processadas histotecnicamente. A análise histológica mostrou aos 10 dias pós-cirúrgicos que o infiltrado inflamatório era do tipo granulomatoso rico em células gigantes multinucleadas, mas livre de linfócitos ou plasmócitos, quadro similar ao observado para aloenxertos mineralizados implantados em subcutâneo de ratos. Com o avançar do tempo experimental houve significante diminuição do infiltrado inflamatório inicial concomitantemente ao aumento no grau de fibrosamento ao redor das partículas implantadas. Concluiu-se que o material de enxerto testado em tecido conjuntivo subcutâneo de ratos induziu um granuloma tipo corpo estranho e fibrose ao redor das partículas implantadas, resposta semelhante do mesmo tecido aos aloenxertos mineralizados, e não desencadeou nenhuma resposta imune, sendo portanto biocompatível.

Granuloma de colesterol: enfoque diagnóstico y terapéutico actual / Cholesterol granuloma: present diagnostic and therapeutic approach

El granuloma de colesterol es una patología benigna poco frecuente, esta puede presentar comportamiento bastante agresivo si no es diagnosticada y tratada a tiempo. El diagnóstico es más precoz en las lesiones intratimpánicas ya que presentan cambios precoces a la otoscopia y audiometría, por compromiso de la cadena. A diferencia de la anterior la lesión en mastoides tiende a diagnosticarse más tardíamente, con cuadros clínicos muy polimorfos y normalmente se confunden con síntomas de otras patología concominantes. Para realizar un buen diagnóstico es esencial un TC que mostrará la lesión, para poder diferenciarlo de otras patologías de oído medio se recomienda el uso de RNM ya que estas lesiones tienen características especiales a la RNM. La audiometría si bien no es útil en el diagnóstico, sirve al momento de la decisión terapéutica y al decidir el abordaje quirúrgico a utilizar. En este trabajo además se presentan 2 casos clínicos que ejemplifican lo polimorfo que pueden ser estos cuadros y diferentes evoluciones que pueden presentar

Correlaçäo anátomo-clínica: granulomatose sistêmica por talco em drogadicto HIV negativo / Systemic talc granulomatosis in a HIV-negative intravenous drug addict

É descrita a correlação anatomopatológica de um paciente usuário de drogas injetáveis com talcose sistêmica acometendo pulmões, pleuras, fígado, baço e linfonodos e que desenvolveu hipertensão arterial pulmonar e cor pulmonale. Destaca-se o fato de que apesar do uso crônico de drogas injetáveis e outros comportamentos de alto risco para infecção pelo retrovírus, o paciente era HIV negativo, não apresentava linfocitopenia, nem alterações histopatológicas compatíveis com AIDS à necropsia.

Tumor hepático por reacción a cuerpo extraño / Hepatic tumor by foreign body reaction

Entre los tumores hepáticos benignos se encuentra el granuloma hepático secundario a reacción por cuerpo extraño que puede ser provocado por agentes como el talco, almidón y materiales de sutura entre otros. Se presenta el,caso de un paciente de 34 años con antecedentes de traumatismo toracoabdominal que presenta, a los 5 años de evolución, dolor abdominal y baja de peso, evidenciándose en estudio por imágenes un tumor hepático sólido único. Se reseca quirúrgicamente, encontrándose en el examen histopatológico una lesión inflamatoria extensa con granulomas de tipo cuerpo extraño

Transmural migration of a retained surgical sponge into the intestinal lumen: an experimental study.

A retained surgical sponge in the peritoneal cavity is an occasional misadventure in modern surgery. Such a sponge can migrate into the intestinal lumen, but its mechanism is still unknown. A piece of surgical sponge, measuring 4 x 4 centrimetres, was placed at different sites of the abdominal cavity of Wistar rats. Inspite of the absence of infection, entry of the sponge into the intestinal lumen was shown microscopically in 10 out of 36 rats. Parallel statistical analysis by Cutler-Ederer estimation was found to be 0.58 of condition probability at 6 months. Transmural migration of a retained surgical sponge was not only associated with different sites placing in the abdominal cavity (P = 0.680), but also whether a seromuscular incision was made or not (P = 0.306). A hypothesis, based on a study of microscopic and macroscopic pathology, is proposed as four stages: foreign body reaction, secondary infection, mass formation and remodeling.

Petrous apex region. Surgical anatomy, lesions, and operative techniques

The author describes the anatomy of the region of the petrous apex giving emphasis to the limits of surgical resection. The cochlea, located at the apex of the angle formed by the intersection of a line along the sphenopetrosal groove and a line from the facial hiatus to the internal auditory canal, has to be protected to preserve hearing. Surgical approaches can be divided in the posterior presigmoid approach that provides exposure to the posterior petrous bone and upper two thirds of the clivus, and the anterior subtemporal approach that provides exposure to the trigeminal ganglion, petrous carotid artery, Meckel's cave, and posterior cavernous sinus. Opening of Meckel's cave provides additional space for medial and inferior resection of the petrous apex. Two illustrative cases of primary petrous apex lesions are presented to demonstrate the surgical exposure obtained with each approach

Paraffinoma of the penis

Augmentation of the body contour by localized injection of hard and soft paraffin rose to a zenith of popularity in the early 1900s, whereafter the severe destructive consequences of such injections became widely recognized. However in Korea, these injections are still performed much by nonmedical person. Paraffin or other mineral oil injection into body is no more a useful method to change body contour. We reviewed 26 cases of sclerosing lipogranuloma of penis with complications in recent 13 years after mean 18.5 months from previous injection of paraffin or vaseline. We conclude that the public should be informed of detrimental effects of paraffin injections and that the best treatment of penile paraffinoma is complete excision and appropriate penoplasty.

Aspectos radiológico e ecográfico do silicone líquido injetado nas mamas / Radiologic and echographic aspects of liquid silicone injected in the breast

É relatado um caso de paciente de 45 anos de idade com silicone líquido injetado nas mamas. Säo descritos os aspectos radiológico, ecográfico e anatomopatológico do quadro, e comentam-se as complicaçöes clínicas e dificuldades desses exames na detecçäo de lesöes malignas