Mycobacterium avium-intracellulare and the unpredictable course of hypercalcemia in an AIDS patient

Ayoubieh, Houriya; Alkhalili, Eyas

doi:10.1016/j.bjid.2016.08.002

Cited by 6 publications

(9 citation statements)

References 11 publications

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“…There are five reported cases of hypercalcemia in patients who were undergoing treatment for MAI and/or HIV, soon after starting or changing therapy. [16][17][18] Hypercalcemia with low level of vitamin D also has been described in a case of cutaneous granulomatous disease caused by Mycobacterium marinum four weeks after starting ART. PTH and both 25 Hydroxyvitamin D and 1,25(OH) 2 D 3 were all suppressed [19].…”

Section: Discussionmentioning

confidence: 95%

Severe hypercalcemia in a patient with extrapulmonaryMycobacterium abscessus: granuloma or immune reconstitution inflammatory syndrome? First case ofMycobacterium abscessuspresenting as retroperitoneal lymphadenopathy with severe hypercalcemia: a case report and literature review

Abdulfattah

Rahman

Shweta

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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Background: Nontuberculous mycobacterium is a recognized cause of hypercalcemia, particularly in patients with acquired immunodeficiency syndrome (AIDS). Here we describe a case of severe hypercalcemia secondary to Mycobacterium abscessus (M. abscessus) in a patient with AIDS. To the best of our knowledge this is the first case report describing a case of M. abscessus presenting as retroperitoneal lymphadenopathy and severe hypercalcemia.Case description: A 56-year-old man with AIDS presented with altered mental status and somnolence for four days. Laboratory investigations were significant for calcium 16.49 mg/dL (RI 8.9–10.3 mg/dL), 1,25 dihydroxyvitamin D level 44.1 pg/ml (RI 19.9–79.3 pg/ml) and parathyroid hormone (PTH) 4 pg/mL (RI 15–65 pg/mL). CT scan of Abdomen and Pelvis showed hepatosplenomegaly with large retroperitoneal, retrocrural, and mesenteric lymphadenopathy which had an intense focal uptake on Gallium scan. Bone marrow biopsy revealed mild plasmacytosis (5%) with no evidence of myelodysplasia, acute leukemia or lymphoma. A subsequent lymph node biopsy showed fragments of fibrous tissue with lymphohistiocytic infiltrate and many acid-fast bacilli. Pre-antibiotic blood cultures grew Mycobacterium which was identified later as M. abscessus at four weeks.Conclusion: hypercalcemia in HIV-infected patients may suggest malignancy or infectious etiology, among other causes. Clinicians should be aware of the risk of hypercalcemia with nontuberculous mycobacterium (NTM) infection, whether as first manifestation or a late presenter in the disease course after initiating antiretroviral therapy (ART). We suggest careful monitoring of serum calcium level upon diagnosis of NTM infection and after initiation of ART, NTM therapy or vitamin D supplementation.

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Section: Discussionmentioning

confidence: 95%

Severe hypercalcemia in a patient with extrapulmonaryMycobacterium abscessus: granuloma or immune reconstitution inflammatory syndrome? First case ofMycobacterium abscessuspresenting as retroperitoneal lymphadenopathy with severe hypercalcemia: a case report and literature review

Abdulfattah

Rahman

Shweta

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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“…An increase in granuloma formation can cause hypercalcemia due to overproduction of calcitriol via increased 1 -hydroxylase activity from macrophages [5]. This observation has been noted in isolated case reports in HIV-infected individuals with a variety of infectious and noninfectious processes including mycobacterium [3,[7][8][9][10], cryptococcal [11], and lymphoma [12].…”

Section: Discussionmentioning

confidence: 93%

Hypercalcemia Secondary to Immune Reconstitution Inflammatory Syndrome in an HIV-Infected Individual With Mycobacterium avium Complex

Awasty

Jafri

Manzoor

et al. 2021

Cureus

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Immune reconstitution inflammatory syndrome (IRIS) is an uncommon cause of hypercalcemia in HIVinfected patients recently started on highly active antiretroviral therapy (HAART). It is hypothesized that increased granulomatous formation due to IRIS leads to an overproduction of calcitriol. High levels of calcitriol, then, can lead to significant hypercalcemia.We present the case of a 63-year-old male with HIV off HAART presented to the emergency room for confusion, frequent falls, and cough. His CD-4 count was noted to be below 35 cells/µL 496). Over the course of the hospitalization, the patient wasfound to havedisseminatedMycobacterium avium complex (MAC)infectionand was initiated on HAART. Initiation of HAART was followed by an increase in calcium up to 14.1 mg/dL. The hypercalcemia did not respond to either Calcitonin or Pamidronate. Consideration was then given to IRIS in the setting of MAC infection leading to increased granulomatous formation. Calcium levels normalized within three days of therapy after initiation of prednisone for the treatment of IRIS.It is thought that an increase in CD-4 counts leads to the recovery of an immune response. This can lead to granulomatous inflammation. An increase in granuloma formation can cause hypercalcemia due to overproduction of calcitriol via increased 1 -hydroxylase activity from macrophages. Our case report describes IRIS-mediated hypercalcemia in an HIV-infected individual with MAC infection. This unusual cause of severe hypercalcemia should be considered in differential diagnoses for immunocompromised patients in the appropriate setting. Prompt treatment of IRIS with glucocorticoids can lead to the resolution of hypercalcemia.

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“…We reviewed several publications that stress that atypical diagnoses are often missed, especially since hypercalcemia frequency may be as low as 6% of sarcoidosis cases [12]. Cardiac sarcoidosis, ocular and neuro sarcoidosis may not have the classic presentation of hilar lymphadenopathy [3].…”

Section: Discussionmentioning

confidence: 99%

“…Mycobacterium avium intracellulare (MAI, previously Mycobacterium avium complex) is one rare reported cause of hypercalcemia due to 1,25-dihydroxy vitamin D levels dysregulation due to granuloma formation [12]. Additionally, beryllosis and lymphoma are unusual causes of granulomatous disease [4, 13].…”

Section: Discussionmentioning

confidence: 99%

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

Hanna¹,

Kaldas

Arman³

et al. 2018

CNCS

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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.

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Mycobacterium avium-intracellulare and the unpredictable course of hypercalcemia in an AIDS patient

Cited by 6 publications

References 11 publications

Severe hypercalcemia in a patient with extrapulmonaryMycobacterium abscessus: granuloma or immune reconstitution inflammatory syndrome? First case ofMycobacterium abscessuspresenting as retroperitoneal lymphadenopathy with severe hypercalcemia: a case report and literature review

Severe hypercalcemia in a patient with extrapulmonaryMycobacterium abscessus: granuloma or immune reconstitution inflammatory syndrome? First case ofMycobacterium abscessuspresenting as retroperitoneal lymphadenopathy with severe hypercalcemia: a case report and literature review

Hypercalcemia Secondary to Immune Reconstitution Inflammatory Syndrome in an HIV-Infected Individual With Mycobacterium avium Complex

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

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