Hypercalcemia-induced acute kidney injury in a Caucasian female due to radiographically silent systemic sarcoidosis

Abstract

Abstract. Sarcoidosis is a rare autoimmune disease resulting in formation of non-necrotizing “non-caseating” granulomas generally in the lung. The disease classically strikes African American females in their fourth and fifth decades. The resulting hypercalcemia is a result of 1-α hydroxylase overexpression in granulomas with increased 1,25-dihydroxy vitamin D levels. This phenomenon can also be observed in mycobacterial and fungal infections that produce granulomas in infected patients. Thus, chronic infectious diseases are part of differential diagnosis of granulomatous processes. We present an elderly Caucasian female who presented with hypercalcemia with serum calcium of 11 – 14 mg/dL and an elevated ionized calcium of 1.4 – 1.5 mmol/L. Initially cholecalciferol supplements were stopped, but hypercalcemia persisted for more than 2 months. 1,25-dihydroxy vitamin D levels were markedly elevated with low normal 25-hydroxy vitamin D levels, angiotensin-converting enzyme levels were also high, and chest computed tomography (CT) imaging was negative for any lymphadenopathy (including perihilar lymphadenopathy). Malignancy and infectious workups were negative for fungal and mycobacterial infections. Positron emission tomography revealed several small lymph nodes in right upper lobe of lung, and biopsy of bone marrow and lung lymph-nodes revealed non-caseating granulomata. We present an atypical case of occult sarcoidosis presenting mainly with biochemical findings without any definitive imaging findings, making diagnosis a clinical challenge.

Osseous manifestations of sarcoidosis

“…The main cause is medication with glucocorticoids. Endogenous overproduction of calcitriol can be accompanied by vitamin D deficiency [40,41]. Kiani et al [42] reported a negative correlation between vitamin D deficiency and pulmonary functional state in patients with sarcoidosis.…”

Hypercalcemia and a “no observed adverse effect level” intake of vitamin D

“…The high serum 1,25-dihydroxyvitamin D levels, hypercalcemia-related renal impairment and recent onset are entirely consistent with published case reports on sarcoidosis. 13,14 The only difference was that, in those cases, serum 25-hydroxyvitamin D levels were normal. The high 1,25-dihydroxyvitamin D in the case report of Auguste and colleagues 1 is not a sign of vitamin D toxicity and is likely a consequence of sarcoidosis.…”

“…The high 1,25-dihydroxyvitamin D in the case report of Auguste and colleagues 1 is not a sign of vitamin D toxicity and is likely a consequence of sarcoidosis. [13][14][15] The renal biopsy used by Auguste and colleagues does not rule out sarcoidosis. 16 The hydroxychloroquine they used to treat the patient is not a conventional treatment for vitamin D toxicity, but it is a first-line treatment for sarcoidosis.…”

“…16 The hydroxychloroquine they used to treat the patient is not a conventional treatment for vitamin D toxicity, but it is a first-line treatment for sarcoidosis. [13][14][15] Although the case reported by Auguste and colleagues was probably not a primary disease of vitamin D toxicity, it is important to limit sources of vitamin D in patients with sarcoidosis.…”

Effect of Parathyroid Function After Thyroidectomy and Radioactive-Iodine Therapy for Thyroid Disease

“…Low calcium can lead to circumoral or peripheral paranesthesia, tetany, carpopedal spasm, laryngospasm, and ECG changes from long QT interval to VT arrest [1,2]. While high calcium can cause fatigue, polyuria, polydipsia, nephrolithiasis, peptic ulcer disease, altered mental status, gait instability [3][4][5], myalgia, arthralgia, abdominal pain [4], rare submandibular gland atrophy and sialolithiasis, metastatic pulmonary calcification [6,7], sometimes even inducing acute kidney injury or acute pancreatitis [8][9][10][11][12][13], or being life-threatening [14,15]. The parathyroid gland is an adjacent organ of the thyroid.…”