Pneumocystis jirovecii Pneumonia-Induced Hypercalcemia
- AKI: Mechanisms - Case Reports
November 03, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 103 AKI: Mechanisms
- Thomas, Dominik, University of Utah Health, Salt Lake City, Utah, United States
- Abraham, Josephine, University of Utah Health, Salt Lake City, Utah, United States
A growing number of case reports demonstrate the relationship between non-parathyroid mediated hypercalcemia preceding or occurring in conjunction with a diagnosis of Pneumocystis jirovecii pneumonia (PJP). Most cases described in literature occur in kidney transplant patients. We present a patient with heart transplant with nonspecific symptoms, acute kidney injury and hypercalcemia.
63 year old female with history of breast cancer status post chemoradiation with anthracycline induced cardiomyopathy requiring orthotopic heart transplant two years earlier presented with fever, chills, weight loss and fatigue for two months. She reported in addition a dry cough with increasing shortness of breath. She presented with a serum creatinine (SCr) of 5.23mg/dl, up from a baseline of 2.2 mg/dl. Creatinine improved to 4.1mg/dl after intravenous hydration. Admission urinalysis unremarkable. Renal US was with increased bilateral echogenicity. Serum Calcium was 12.9 mg/dl on admission with PTH of 7 pmg/ML (15-65 pmg/mL) and 1,25 Vitamin D of 87pg/mL. (19.9-79.3 pg/mL). CT chest demonstrated patchy ground glass opacities throughout the lungs. Infectious work up revealed Beta-D-Glucan >500. A bronchoscopy with BAL was performed and returned positive for PJP on PCR. She was started on atovaquone with improvement in symptoms. Cr trended down to baseline with resolution of hypercalcemia.
Hypercalcemia related to PJP is thought to be associated via 1α-hydroxylase enzyme-dependent mechanism causing extra-renal production of 1α-hydroxylase. Some reports of PJP revealed the presence of inflammatory granulomas rich in macrophages and monocytes that are capable of vitamin D activation and thereby inducing hypercalcemia. The majority of cases are described in kidney transplant recipients possibly suggesting a susceptibility in these patients for developing PJP-related hypercalcemia but PJP can occur with any solid organ transplant.