Beauty is Kidney-Deep: Renal and Systemic Particle Embolization from Gluteal Implants

Introduction: There is limited literature on migration of foreign particles from cosmetic implants to different organs and systems; mostly to the capsule formed around the implant, local lymph nodes, lungs and liver. There are few reported cases of biopsy-proven migration of silicone or other particles to the kidney. Case Description: A 49-year-old woman with pulmonary hypertension (PH) identified in the last seven months, hypercalcemia with recurrent renal calculi, CKD G3 and presumed sarcoidosis presented with worsening dyspnea. She had undergone gluteal and breast implants 16 and 9 years before respectively and gluteal injections with an unknown substance. Exam was remarkable for 94% O2 saturation on 5 L by nasal cannula and bluish discoloration of the buttocks. BMP revealed creatinine at baseline 1.3 mg/dL and calcium 10.5 mg/dL. UA had microscopic hematuria and pyuria. Other analyses included PTH 22 pg/mL, PTHrP 1.6 pmol/L, 25-OH vitamin D 4.7 ng/mL, 1,25-OH vitamin D 17 pg/mL, positive ANA 1:1280, positive anti-SSA, weakly positive RF, ACE 203 U/L. HRCT chest showed no nodules or interstitial lung disease. BAL had CD4/CD8 ratio 0.72. Right heart catheterization found mPAP 32 mmHg, PCWP 6 mmHg and PVR 6.8 WU, compatible with precapillary PH. Left buttock skin biopsy noted small empty vacuoles but no granulomas. Kidney biopsy revealed glomeruli and peritubular capillaries with faint oil red O positive empty vacuoles; surrounded by CD68 staining corresponding to macrophages on EM. Discussion: The oil red O positive vacuoles on skin and kidney biopsy indicate particle migration from the gluteal implants or injections. Macrophage involvement, hypercalcemia, high 1,25/25 vitamin D ratio, elevated ACE and precapillary PH reflect underlying granulomatous disease from particle migration to the lungs and pulmonary arterial system. No granulomas were found on biopsy. Autoimmune serology was nonspecific. Our patient had no features of systemic sclerosis, SLE, Sjogren's or sarcoidosis. To conclude, we present a unique case of systemic foreign particle embolization resulting in renal dysfunction, PH and autoimmunity as proven by kidney biopsy.