Abstract: SA-PO847
An Unusual Presentation of Hypercalcemia in a Patient With Kidney Transplant
Session Information
- Transplantation: Clinical - Case Reports
November 05, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Pujar, Thejeswi, Saint Louis University, Saint Louis, Missouri, United States
- Caliskan, Yasar, Saint Louis University, Saint Louis, Missouri, United States
- Abu Al Rub, Fadee, Saint Louis University, Saint Louis, Missouri, United States
- Bastani, Bahar, Saint Louis University, Saint Louis, Missouri, United States
Introduction
Hypercalcemia in kidney transplant patients is not uncommon. Persistent hyperparathyroidism is reported to occur in approximately 15 to 50% of patients following transplantation causing hypercalcemia. A rise in calcium level on the background of previously stable calcium levels with stable elevated parathyroid hormone (PTH) should prompt investigating malignant etiology. We present the case of a 67-year-old man who was hospitalized With an unusual case of hypercalcemia.
Case Description
A 67-year-old male with history of kidney transplant [YC1] 3.5 years prior presented with progressive weakness and fatigue. On admission he had acute kidney injury (AKI) and hypercalcemia with a corrected calcium of 14.5 mg/dl. He had history of tertiary hyperparathyroidism controlled on cinacalcet, with calcium level in range of (9-10 mg/dl) in the previous year. Workup revealed a mildly elevated PTH 130 pg/ml, normal 25 hydroxy Vit D and normal PTH related protein levels. Serum and urine electrophoresis with immunofixation revealed IgG monoclonal gamma restriction. A bone marrow biopsy ruled out plasma cell dyscrasia. A whole-body PET CT revealed marked splenomegaly with intense Fluorodeoxyglucose (FDG) uptake. Epstein Barr Virus (EBV) PCR was 407,000 IU/ml raising the suspicion for post transplant lymphoproliferative disorder (PTLD).
A subsequent splenic biopsy revealed: Diffuse Large B Cell Lymphoma and EBER ISH (Epstein-Barr Encoding Region in Situ Hybridization) test was positive.
Hypercalcemia was treated successfully with intravenous fluids and pamidronate, then the patient was initiated on rituximab. However, due to lack of response, this was changed to rituximab, cyclophosphamide, doxorubicin and prednisone (R-CHOP) therapy. The patient maintained normal calcium Level in the range pf (8-9 mg/dl).
Discussion
This is a unique presentation of an EBV induced PTLD involving the spleen in a renal transplant patient. Hypercalcemia by extrarenal overproduction of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) is seen in < 1% of hypercalcemia of malignancy and is usually found in lymphomas. It is more common in granulomatous disease like Tuberculosis and Sarcoidosis.
The extra renal production of calcitriol by these cells results in substantial increase in the absorption of calcium. In this case hyperparathyroidism probably aggravated the condition.