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Kidney Week

Abstract: PO2208

Hypercalcemia in Immunocompromised Host: Beware of Zebras

Session Information

Category: Transplantation

  • 1902 Transplantation: Clinical

Authors

  • Rizvi, Ali Waris, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
  • Chopra, Bhavna, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
  • Marshall, Cody, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
  • Sureshkumar, Kalathil K., Allegheny Health Network, Pittsburgh, Pennsylvania, United States

Group or Team Name

  • AHN Nephrology
Introduction

Hypercalcemia has varied etiology with treatment dictated by underlying cause. We present an immunocompromised host with weight loss, lymphadenopathy and hypercalcemia masquerading as malignancy.

Case Description

A 74 year old male construction worker with deceased donor liver transplant 4 months earlier on tacrolimus/mycophenolic acid (MPA) maintenance and stage 4 chronic kidney disease presented with constitutional symptoms and 20 pound weight loss. Serum creatinine was 2.5 mg/dl and corrected calcium 11.9 mg/dl. CT scan showed mediastinal and bilateral axillary lymphadenopathy. Serum EBV and CMV PCR were negative. Work up for hypercalcemia revealed: intact PTH 6.8 picogram/ml (11.0-68.0) , 25 OH vitamin D 44.6 ng/ml (30-100), κ:λ ratio 1.45 (0.26-1.65) and absent M-spike on serum protein electrophoresis. Blood culture grew Cryptococcus neoformans and serum Cryptococcal antigen titer was positive at 1:4096. Lumbar puncture revealed CSF lymphocytic pleocytosis and positive cryptococcal antigen titer at 1:32. Axillary lymph node biopsy showed cryptococcal lymphadenitis with diffuse involvement by encapsulated yeast forms within non-necrotizing granulomatous inflammation (fig 1). Patient was started on induction treatment with intravenous liposomal amphotericin B and oral flucytosine till 2 weeks after negative blood cultures followed by 8 weeks of consolidative therapy with oral fluconazole. MPA was stopped and tacrolimus continued. Hypercalcemia resolved a week after initiating antifungal therapy. Patient doing well 4 months later on maintenance fluconazole.

Discussion

Hypercalcemia is a rare manifestation of disseminated fungal infection. The exact etiology is unclear but 1, 25 di (OH) vitamin D and PTHrp are implicated. Weight loss and lymphadenopathy in our immunosuppressed patient raised concern for malignancy. However, blood culture and lymph node histology clinched the diagnosis enabling prompt therapy with resolution of the symptoms and hypercalcemia.