Abstract: SA-PO996

Hypercalcemia: Lung Nodules with a Pathological Fracture Are Not Always Indicative of Malignancy

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Alrawi, Omer, Wayne State University, Detroit, Michigan, United States
  • Thimmisetty, Ravi K., Wayne State University, Detroit, Michigan, United States
  • Altaie, Nehal, Detroit medical center, Detroit, Michigan, United States
  • Ibrahim, Walid, Wayne State University/DMC, Dearborn, Michigan, United States
  • Osman Malik, Yahya M., Wayne State University Medical School, Detroit, Michigan, United States
  • Imran, Nashat Burhan, Wayne State University, Detroit, Michigan, United States
Background

Hypercalcemia is a relatively common clinical problem.The initial goal of the laboratory evaluation is to differentiate parathyroid hormone (PTH)-mediated hypercalcemia from non-PTH mediated hypercalcemia.
Although malignancy is the most common cause of non-PTH mediated hypercalcemia, other differentail should be considered specially in immunocompromised patients.

Methods

A 60-year old Asian female with past medical history inclusive for diabetes type 2, hypertension, chronic kidney disease stage 3, hepatitis B on treatment, myasthenia gravis on immunosuppressive treatment (prednisone, mycophenolate mofetil), and osteoporosis presented following a fall. Her x-ray showed a fracture of the left forearm and an incidental small left upper lobe lesion adjacent to the aorta. Chest CT scan confirmed the lesion and PET scan was suspicious for malignancy.
Initial workup was remarkable for hypercalcemia at 11 mg/dl with inappropriate normal PTH (due to CKD 3).
Left lobectomy with excision of 11 lymph nodes was done. Final report revealed giant cell granulomas and fungus consistent with cryptococcal infection. All lymph nodes were negative for malignancy and were sterile for anaerobic, aerobic, TB and other fungal culture. A serum cryptococcal antigen was positive at 1:4 titer. Brain imaging and CSF exam were negative for cryptococcal involvement. HIV testing was negative. Other workup showed High 1,25 Vitamin D at 148 pg/ml (normal range 15-75 pg/ml ) with normal Vitamin D 25 at 42 ng/ml that is consistent with granulomatous process. She was started on fluconazole. Consequently, her calcium and cryptococcal antigen were normalized following 9 months of therapy.

Conclusion

This case demonstrates the importance of considering all differential diagnoses of non-PTH mediated hypercalcemia, which include granulomatous disorders, vitamin D intoxication, and malignancy. Before committing the patient to unnecessary procedures; it is imperative to have a tissue diagnosis to guide further surgical and medical management, especially in immunocompromised patients were infection is more common.