High-dose Vitamin D supplementation precipitating hypercalcemic crisis in granulomatous disorders

Abstract

Background:Vitamin D supplementation precipitating hypercalcemic crisis is often the first manifestation in patients with granulomatous disorders.Methods:We report our experience on patients presenting with hypercalcemic crisis due to granulomatous disorder and the role of Vitamin D supplementation in the precipitation of hypercalcemic crisis in them.Results:The study included five patients with granulomatous disorders who presented with hypercalcemic crisis. All patients initially presented with nonspecific constitutional symptoms to other health-care centers to receive high-dose Vitamin D supplementation (60,000 U/week or 600,000 U intramuscular single dose). All of these patients presented with hypercalcemic crisis (serum calcium: 16.04 ± 0.3 mg/dl) to our centers after a period of 32.8 ± 9.62 days. Three patients were diagnosed to have sarcoidosis, and two were diagnosed to have tuberculosis. All five patients had parathyroid hormone-independent hypercalcemia with elevated serum 1,25-dihydroxy Vitamin D. Serum angiotensin-converting enzyme level was elevated in all the three patients with sarcoidosis. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography was performed in two patients with sarcoidosis which demonstrated diffusely increased tracer uptake in liver. In these two patients, liver biopsy confirmed the diagnosis.Conclusions:High-dose Vitamin D supplementation is most often the underlying cause of hypercalcemic crisis in patients with granulomatous disorders. Hence, high-dose Vitamin D supplementation should be used judiciously.

Sarcoidosis and calcium homeostasis disturbances—Do we know where we stand?

“…80–82 This is an important issue because there is currently a discussion about supplementation with vitamin D and calcium and its potential in bringing about hypercalcemia and hypercalciuria. 36,62,83,84 Two retrospective studies of patients visiting the outpatient clinic stand in opposition to each other. In a cohort analysis of almost 400 patients (randomly chosen, divided in two equal groups) Sodhi and Aldrich showed that the group of patients, who at least once had vitamin D prescribed, had an almost two times higher risk of developing hypercalcemia in a 2-year follow-up.…”

Hypercalcaemia in an idiopathic hypoparathyroidism patient, due to sarcoidosis

“…In our case, sACE was elevated, directing investigation towards sarcoidosis, since other causes were excluded. Bronchial lavage is useful in the diagnosis, especially when CD4/CD8 ratio is over 3.5 6 as was the case in this patient. Gold-standard for the diagnosis however is histopathological findings of noncaseating granulomas on biopsy from affected organs in a patient with compatible clinical and radiological findings, provided that other diagnosis was excluded 7 .…”

“…Cases of concomitant hypoparathyroidism and sarcoidosis are scarce in literature and all cases have been described more that 40 years prior, and most cases refer to hypoparathyroidism due to surgical removal of the glands during thyroidectomy [1][2][3][4] . In known hypoparathyroidism patients, most cases of hypercalcaemia are attributed to inappropriate excessive Concomitant hypoparathyroidism and sarcoidosis JRPMS calcium intake 5 or poisoning from vitamin D supplementation 6 . In such patients, diagnosis of an underlying disease causing hypercalcaemia can be challenging.…”

A severe Case of Hypercalcemia due to Pulmonary Tuberculosis Reactivation

“…Recent guidelines suggest maintaining a 25(OH)D level of between 20 and 30 ng/ml in patients with granulomatous disorders, although in doing so, the close monitoring of 25(OH)D levels is recommended, and levels of more than 30 ng/ml should be avoided, being associated with hypercalcemia and hypercalciuria. Serious hypercalcemic crises can occur during treatment (12).…”