(1513) Cosmetic Gluteal Augmentation Causes Multiorgan Failure, Severe Hemolysis, and Death

Introduction: Cosmetic procedures of the buttocks and use of unapproved injectables for gluteal augmentation (GA) are increasingly popular. Injection of castor oil (CO) may lead to hemolysis and toxicity, and can be detected through the biomarker ricinine in blood or urine. We describe a case of suspected gluteal injection of CO, causing severe hemolysis, multi-organ failure, and death.

Description: A 26-year-old female presented as a transfer from a hospital in Mexico, with GCS 3T, following an injection for GA. Few details of the procedure are known, but she was found unresponsive at home. Physical exam revealed pupils fixed and dilated, epistaxis from oropharynx and nares, tachycardia, hypotension requiring high dose vasopressors, and healed needle and pen markings on bilateral hips and buttocks. She had significant edema and ecchymosis to the buttock, consistent with foreign material injection. CT of the head revealed bilateral subdural hematomas and subarachnoid hemorrhage. CT of the pelvis revealed diffuse subcutaneous infiltration of the gluteal region extending to the lower back.
Initial labs revealed anemia with hemoglobin 5.2g/dL, and severe hemolysis and coagulopathy due to suspected disseminated intravascular coagulation with D-dimer >7650ng/mL, INR 2.6, platelets 135k, and few schistocytes. She had severe lactic acidosis (LA) with pH 6.9 and lactic acid 8.4mmol/L. Triglycerides (TG) were 5472mg/dL. Many labs were rejected for lipemia and hemolysis.
The patient was admitted to the ICU. On day 2, her LA and coagulopathy improved, but hemolysis persisted. A urine sample sent to the AZ Department of Health showed trace levels of ricinine, although below the limit for a positive test. On day 3, plasmapheresis was performed with suspicion that plasma TGs represented CO. The patient rapidly deteriorated and formal brain death testing was conducted. Her family later elected for organ donation.

Discussion: To our knowledge, there has been only one other report of CO injection leading to severe hemolysis and multisystem organ failure. Trace levels of ricinine are not typically found in the general public, so it is likely that the patient’s serum and urine concentrations were higher following the initial injection. Unfortunately, the date of the procedure and injection volume remain unknown.