A Modern and Hip Cause of Profound Hypercalcemia

Introduction: Autoimmune/Inflammatory Syndrome Induced by Adjuvants (ASIA) is triggered by adjuvants causing abnormal immune responses. Though usually linked to vaccines and medical products, its link to arthroplasty and cement leak is unexplored. We describe a hypercalcemia case due to ASIA after left hip arthroplasty. Case Description: A 69-year-old woman with chronic kidney disease had a left hip replacement complicated by dislocation. During revision, there was cement leak into her intramedullary canal. Post-operatively, she developed intermittent episodes of hypercalcemia, which progressed to hypercalcemia (14.7 mg/dL) four years later. Work-up in (see table) was suggestive of granulomatous disease. A PET scan showed intense uptake around the hip arthroplasty and iliac adenopathy, soft tissue biopsy was unrevealing. Therapy with steroids improved her condition along with Vit D 1,25 level, tapering led to return of hypercalcemia and chorioretinitis. Symptoms and response to steroids suggested ASIA with a sarcoid-like reaction. Discussion: The cement leak from arthroplasty exposes individuals to components, potentially acting as adjuvants and triggering ASIA-like symptoms. ASIA is linked to manifestations such as granulomas, hypercalcemia, uveitis, and CKD. The temporal relationship in this case between cement leak and the onset of autoimmune symptoms suggests ASIA as a potential complication of arthroplasty. More research is needed to establish diagnostic criteria and treatment for ASIA. - Test Result Test Result PTH 14 pmol/L Free light chain Normal ratio 25 Vitamin D 23 pg/mL Serum Histoplasmosis Negative 1, 25 OH Vitamin D 150 pg/mL Serum Blastomycosis Negative PTHrp 8 pmol/L Immunoglobulins Normal levels ACE 95 U/L IGRA Negative SPEP/UPEP No monoclonal disease HIV Negative