Abstract: PO0321
Recreation with a Concerning Diagnosis
Session Information
- AKI: Clinical Case Reports
November 04, 2021 | Location: On-Demand, Virtual Only
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 103 AKI: Mechanisms
Authors
- Khan, Sobia N., Stonybrook University Hospital, Stony Brook, New York, United States
- Suh, Heesuck, Stonybrook University Hospital, Stony Brook, New York, United States
Introduction
Sarcoidosis is a systemic granulomatous disease of unknown etiology, characterized by non-necrotizing/non-caseating granuloma. The diagnosis of sarcoidosis requires stepwise approach to identify organs that may be affected and are amenable to biopsy, exclusion of other causes of granulomatous histopathology with special stains for mycobacteria and fungi, documentation of involvement of at least one additional organ system, and exclusion of other multisystem granulomatous diseases.
Case Description
A 73-year-old male with history of chronic kidney disease stage II serum creatinine 1.4mg/dl, T2DM, hypertension, history of lymphoma presented to the clinic. He was noted to have a black ink tattoo on his shoulder, present for > 40 years. Blood work showed wbc 8.66, H/H 12.8/39.8, platelets 210, BUN/Cr 34/2.86, GFR 21, Na 139, K 3.6, Hco 26, Ca 10.9, P 3.5, Mg 2.2, Hgba1c 6.3%, Ua +protein.
Follow up:
Further work up for hypercalcemia and acute kidney injury showed Ca 11.2, iPTH 10.2, PTHrP 4.7, 1, 25 vit D 78.2, vit D 41, ACE 84, SPEP/UPEP: no monoclonal gammopathy. CXR negative for hilar lymphadenopathy. Renal ultrasound normal size kidneys with mild echogenicity. Chest CT showed calcified enlarged left lower cervical, supraclavicular, chest wall and axillary lymph nodes and reticular asymmetric mild pleural thickening. He underwent axillary lymph node biopsy which showed granulomatous lymphadenitis, with extensive infiltration by pigment laden macrophages, multiple non-caseating granuloma with foreign body type giant cell, some with intracellular pigment particles staining. Staining was negative for any mycobacterial or fungal organism, melanoma cocktail had negative staining, the immunostains showed increased background due to pigment. The differential included non-infectious granulomatous lymphadenitis and sarcoidosis.
Discussion
Our patient had a tattoo placed > 40 year ago and developed non-caseating granuloma with extensive infiltration by pigment laden granuloma.
In an unexplained case of hypercalcemia in the setting of granulomatous histopathologic finding containing tattoo pigment, it is prudent to consider the diagnosis of sarcoidosis. Granulomatous reaction to tattoo pigment histologically can be sarcoidal or foreign body type. These sarcoidal granuloma usually involve the tattooed skin and may represent first manifestation of systemic sarcoidosis.