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Kidney Week

Abstract: PO2478

Hypercalcemia: A Prodromal Feature of Pneumocystis jirovecii Pneumonia in Kidney Transplant Recipients

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Chen, Joy C. Y., University of Michigan, Ann Arbor, Michigan, United States
  • Isaac, Johanan Nithilan, University of Michigan, Ann Arbor, Michigan, United States
  • Parasuraman, Raviprasenna K., University of Michigan, Ann Arbor, Michigan, United States
Introduction

Hypercalcemia in transplant recipients (KTRs) is frequently caused by persisting hyperparathyroidism. However, hypercalcemia can also be a prodromal feature of serious underlying infections and malignancy. We present 2 cases of parathyroid hormone (PTH) independent hypercalcemia that preceded Pneumocystis jirovecii pneumonia (PJP) diagnosis.

Case Description

Case1. A 21y.o. male with end-stage kidney disease (ESKD) from FSGS presented with 3 weeks of dyspnea and cough 8 months after transplant (Tx). Chest x-ray (CXR) showed interstitial opacities. Lab revealed acute kidney injury and severe hypercalcemia (Table 1). He was treated with IV fluid and calcitonin, and hypercalcemia improved (Figure 1). Workup showed significant elevation in 1,25 dihydroxyvitamin D (1,25(OH)2 VitD)and low PTH level, and his sputum was positive for PJP by DNA PCR. Case2. A 26-y.o. male with ESKD from nephronophthisis presented with 2 weeks of cough and dyspnea 10 yrs after Tx. He had severe hypercalcemia, and CXR showed nodular interstitial opacities. He was diagnosed with PJP by sputum DNA PCR. His hypercalcemia workup also revealed elevated 1,25(OH)2 VitD and low PTH.

Discussion

PJP occurs in 5–15% of KTRs without prophylaxis with significant morbidity and mortality. A timely diagnosis is challenging given its indolent presentation. Since hypercalcemia can occur in 20-30% of cases during early stages of PJP from increased production of 1,25(OH)2 VitD via 1-α-hydroxylase from alveolar macrophages, its presence should alert clinicians of its diagnosis. In 2019, 2 out of 5 PJP cases at our center had hypercalcemia at least 2 weeks prior to PJP diagnosis with high 1,25(OH)2 VitD and low PTH. In both cases, hypercalcemia resolved after treatment of PJP. These 2 cases illustrate hypercalcmia could be a prodromal feature in PJP. Early recognition with appropriate treatment would significantly reduce its morbidity and mortality.

Clinical characteristics
CaseTotal Calcium (ref: 8.6-10.3 mg/dL)Ionized calcium (ref: 1.12-1.30 mmol/L)PTH (ref: 10-65 pg/mL)1,25(OH)2 VitD (ref: 18-78 pg/mL)Treatment
114.92.0223129IV fluid, calcitonin, TMP-SMX
2142.36<6141IV fluid, calcitonin, pamidronate, clinadmycin, primaquine

Calcium trend