Abstract: SA-PO530
Stepwise Teamwork Approach Saves Patients Extensive Work-Up
Session Information
- Acid-Base, Calcium, Potassium, and Magnesium Disorders: Clinical
October 26, 2024 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Fluid, Electrolytes, and Acid-Base Disorders
- 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical
Authors
- Alshwayat, Anas Radi Issa, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
- Karakala, Nithin, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
- Abdallah, Ahmed, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
Introduction
Hypercalcemia is a relatively common clinical entity that can arise from a variety of etiologies, including primary hyperparathyroidism, malignancies or medications. In most of these cases, the underlying cause can be determined through a thorough clinical evaluation, including a detailed patient history, physical examination and targeted laboratory testing. We present a case with significant hypercalcemia, highlighting the diagnostic approach taken to identify the underlying cause through systematic analysis of the patient's symptoms, laboratory results and imaging studies
Case Description
77-year-old male with past medical history of hypertension, prostate cancer status post-excision and CKD stage IIIB, was transferred from an outside hospital for evaluation of suspected multiple myeloma.
Physical exam was stable but initial laboratory work up showed a serum calcium level of 15.3 mg/dL. He was started on IV fluids with a slight improvement in serum calcium level to 12 mg/dl however it rebounded to 13 g/dl the next day prompting a consultation for Nephrology for management of acute kidney injury and hypercalcemia.
A bone marrow biopsy ruled out for multiple myeloma, leading to consideration of other differentials. Parathyroid hormone (PTH) was appropriately low, and 25-Hydroxyvitamin D level was normal, but 1,25-Dihydroxyvitamin D was elevated at 108 pg/mL. This raised the suspicion of hypervitaminosis D due to granulomatous disease (sarcoidosis vs. infection). Detailed history revealed that the patient lived on a farm with various animals, including birds raising suspicion for an inhalational insult.
CT scan of the lung that showed a left lung nodule. This was followed by a bronchoscopy that revealed high beta-D-glucan levels and fungal culture showed growth of Pneumocystis Carinii pneumonia.
The patient was subsequently treated for PCP. After two months, his hypercalcemia was completely resolved.
Discussion
Pneumocystis pneumonia is recognized for triggering a granulomatous response that stimulates the overproduction of 1,25-dihydroxyvitamin D, resulting in hypercalcemia and a range of complications, including AKI. Hypercalcemia associated with PCP proves resistant to standard treatments and should trigger a thorough patient history inquiry. In many cases, a comprehensive history and examination offer vital diagnostic insights even for non-immunocompromised patients.