Abstract: SA-PO508
Bad to the Bone: Refractory Hypercalcemia due to Limited Bone Marrow Sarcoidosis
Session Information
- Fluid, Electrolyte, and Acid-Base Disorders: Case Reports
November 05, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Fluid‚ Electrolyte‚ and Acid-Base Disorders
- 1002 Fluid‚ Electrolyte‚ and Acid-Base Disorders: Clinical
Authors
- Kondragunta, Kaushika, Brookwood Baptist Health, Birmingham, Alabama, United States
- Townsley, Erin, Brookwood Baptist Health, Birmingham, Alabama, United States
- Madonia, Phillip, Brookwood Baptist Health, Birmingham, Alabama, United States
- Vemulapalli, Uday, Brookwood Baptist Health, Birmingham, Alabama, United States
Introduction
Sarcoidosis limited to the bone marrow is a rare diagnosis.
Case Description
A 69 y.o. white woman with history of osteoporosis, chronic kidney disease stage 3, silicone breast implants presented with nausea, vomiting, and malaise. Vital signs on admission were stable. Labs were significant for an albumin of 3.3 g/dL, calcium of 14.1 mg/dL (corrected to 14.7mg/dL). She had two prior hospitalizations for volume depletion, with hypercalcemia to a level of 12-13mg/dL, and acute kidney injury which rapidly corrected with IV fluids. However, the recurrence of severe hypercalcemia necessitated further investigation. On admission, parathyroid hormone (PTH) was 55 pg/mL, PTH- related protein was 22 pg/mL, so PTH mediated hypercalcemia was unlikely. Vitamin D 25 level was 35 pg/mL, and angiotensin converting enzyme (ACE) levels were <5. Urine calcium was not low. Serum cortisol was normal. Mildly elevated vitamin D1,25 at a level of 81 pg/mL was noted. Differential diagnoses included sarcoidosis, multiple myeloma, foreign body granuloma and infectious granulomatosis. Skeletal survey showed no bony lesions. Myeloma panel showed an M spike of 0.5g/dL, immunofixation with IgM lambda, elevation of kappa/lambda light chains 5.12, and 9.19 mg/dl respectively, but total IgM kappa/lambda ratio was normal. A normal PET scan ruled out a silicone granuloma associated with her breast implants. Sarcoidosis was the final diagnosis considered. A bone marrow biopsy was performed, which was negative for polyclonal cells, malignancies, acid fast bacteria, and fungi. It showed scattered deep-seated non caseating granulomas consistent with sarcoidosis. She had complete resolution of hypercalcemia with 60 mg prednisone, tapered over 3 months.
Discussion
Diagnosing sarcoidosis from only hypercalcemia and elevated vitamin1,25 D without any other findings on imaging made this diagnosis clinically challenging. The step wise approach to rule out other etiologies led to a bone marrow biopsy, confirming the diagnosis. Chest X-ray and ACE levels are often used to screen for sarcoidosis, but are not very sensitive. Physicians should consider a bone marrow biopsy when there is high suspicion for granulomatous hypercalcemia. The tissue would need to be evaluated for infectious, hematologic, allergic, and other auto immune disorders causing granulomatous lesions.