SHM Converge Scientific Abstract ePoster Gallery-Hypercalcemia: Sarcoidosis Hiding in Plain Sight

Pdf Summary

This case describes an 83-year-old man with a history of prostate cancer in remission, chronic kidney disease, and recently treated Strongyloides stercoralis infection who presented with recurrent severe hypercalcemia and acute kidney injury. On his initial admission, calcium was 14 mg/dL and creatinine 2.71 mg/dL. He was treated with aggressive IV fluids, calcitonin, and zoledronic acid, improving to calcium 8.7 mg/dL and creatinine 1.9 mg/dL, but the cause remained unclear. His PSA was elevated, raising concern for malignancy.<br /><br />Two months later, he was readmitted with recurrent hypercalcemia. Management again included IV hydration, calcitonin, furosemide, and pamidronate. Because his prior malignancy history made cancer-related hypercalcemia a concern, a thorough workup was pursued. PET/CT and tissue biopsy ultimately confirmed sarcoidosis with granulomatous disease as the cause. The case highlights that sarcoidosis can hide in plain sight and should be considered in patients with low PTH hypercalcemia, especially when vitamin D-related mechanisms are suspected.<br /><br />The proposed mechanism is granulomatous overproduction of 1,25-dihydroxyvitamin D, which increases intestinal calcium absorption and decreases renal calcium excretion. Although 1,25-dihydroxyvitamin D is often elevated in sarcoidosis, it was only high-normal in this patient, making diagnosis less straightforward.<br /><br />Treatment posed an additional challenge because corticosteroids, the cornerstone of sarcoidosis therapy, could increase infection risk in someone with a recent Strongyloides infection. A multidisciplinary team carefully balanced this risk, initially withholding steroids before later starting prednisone 20 mg daily with parasitic monitoring. This led to resolution of hypercalcemia.<br /><br />Key lessons include using a systematic approach to hypercalcemia, distinguishing malignancy from granulomatous disease, relying on tissue diagnosis in atypical cases, and coordinating multidisciplinary care when immunosuppression is needed.

Asset Subtitle

Kengo Z. Soghoyan

Meta Tag

Author List Adina Voiculescu, Kengo Z. Soghoyan

Category Clinical Vignettes

Concept Hypercalcemia

Concept Sarcoidosis

Concept Calcitriol

Concept Diagnostic Approach

Concept Malignancy

Distinguished Non-Finalist

Presenter Organization Brigham and Women's Hospital

Presenting Author Kengo Z. Soghoyan

Track Adult

Keywords

hypercalcemia

acute kidney injury

sarcoidosis

granulomatous disease

prostate cancer

Strongyloides stercoralis

1,25-dihydroxyvitamin D

corticosteroid therapy

PET/CT

tissue biopsy

Hypercalcemia

Sarcoidosis

Calcitriol

Diagnostic Approach

Malignancy