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Abstract: PO1191

Disseminated Histoplasmosis Presenting as Severe Hypercalcemia

Session Information

Category: Fluid, Electrolyte, and Acid-Base Disorders

  • 902 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Medikayala, Sushma, Cleveland Clinic Florida, Weston, Florida, United States
  • Mcwilliams, Carla S., Cleveland Clinic Florida, Weston, Florida, United States
  • Bobart, Shane A., Cleveland Clinic Florida, Weston, Florida, United States
  • Bunting, Silvia T., Cleveland Clinic Florida, Weston, Florida, United States
  • Sandy, Dianne T., Cleveland Clinic Florida, Weston, Florida, United States
  • Braun, Mauro, Cleveland Clinic Florida, Weston, Florida, United States
  • Gebreselassie, Surafel K., Cleveland Clinic Florida, Weston, Florida, United States
Introduction

Hypercalcemia (HC) is a significant complication of Disseminated Histoplasmosis (DH). While there are case reports on DH causing HC in immunosuppressed patients including HIV and chemotherapy, there are very rare case reports on DH causing HC in Non-immunosuppressed hosts. The diagnosis of DH in HC may be delayed due to other differential diagnoses such a Sarcoidosis leading to prolonged and worsening hypercalcemia and subsequent renal failure. We report a case of HC in a patient who presented with generalized skin ulcers and bilateral adrenal masses. The initial manifestation of DH with HC, painful skin ulcers, bilateral large lobulated adrenal masses, prompted an initial concern for sarcoidosis. After presenting to our institution 5 months later, a diagnosis of DH was made as the cause of his Hypercalcemia.

Case Description

A 58-year-old male with new onset generalized skin rash was diagnosed with HC, empirically treated with prednisone for sarcoidosis due to elevated 1,25 di hydroxy Vitamin D, 5 months ago at an outside hospital. After starting prednisone, his skin lesions progressed to disseminated painful ulcers and was referred to our institution after developing AKI with a serum creatinine of 4.6mg/dl (Cr 1.6mg/dl, 5 months ago) calcium 14mg/dl, PTH 2pg/ml. CT abdomen revealed large lobulated bilateral adrenal masses. Bone marrow biopsy revealed non-necrotizing granulomas with yeast form fungal organisms on GMS stain. A Shave skin biopsy of an abdominal ulcer revealed Fungal yeast forms consistent with histoplasmosis, associated with ulcers on GMS stain. Urine Histoplasma antigen positive. Adrenal mass biopsy revealed necrotic material and fibroconnective tissue. DH was initially treated with IV liposomal amphotericin and transitioned to oral Itraconazole. At the time of discharge, calcium was 9.8 mg/dl and serum creatinine was 2.9mg/dl.

Discussion

Hypercalcemia, in the setting of elevated 1,25 di hydroxy Vitamin D levels, prompts concern for granulomatous disease. Sarcoidosis is a common etiology, however, other causes must be entertained. The cluster of findings of adrenal non caseating granulomas coupled with diffuse skin ulcers with hypercalcemia should prompt the provider to consider infectious etiologies such as disseminated histoplasmosis as early diagnosis and prompt treatment can result in improved outcomes