SHM Converge Scientific Abstract ePoster Gallery-Pneumocystis Jirovecii, Vitamin-D, and Hypercalcemia in a Renal Transplant Recipient

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A 55-year-old woman with a remote renal transplant and chronic kidney disease presented with one week of fatigue, fever, dry cough, and exertional dyspnea. She was immunosuppressed and taking daily vitamin D supplementation. Initial evaluation showed mild respiratory distress and CT chest with scattered ground-glass opacities. Infectious studies, including blood and respiratory cultures and urinary antigens, were negative, so antibiotics were initially withheld.<br /><br />Several days later, she worsened with hypoxemia, rising calcium, and acute kidney injury. Vitamin D was stopped and IV fluids were started. Bronchoscopy with lavage was negative for Pneumocystis jirovecii pneumonia (PJP), but the Fungitell assay was markedly elevated. Hypercalcemia workup showed elevated 1,25-dihydroxy vitamin D with low-normal PTH, suggesting non-parathyroid-mediated hypercalcemia. Based on the overall clinical picture, she was treated empirically with trimethoprim-sulfamethoxazole and high-dose steroids, leading to improvement in both hypercalcemia and kidney function. At one-week follow-up, calcium and creatinine had returned to baseline.<br /><br />The case highlights that PJP in renal transplant recipients may present atypically and can be complicated by hypercalcemia, especially in patients taking vitamin D supplements. A proposed mechanism is increased 1-alpha hydroxylase activity in pulmonary alveolar macrophages during granulomatous lung inflammation, which raises 1,25-dihydroxy vitamin D and suppresses PTH. Because vitamin D supplementation provides more substrate for this pathway, it may worsen hypercalcemia.<br /><br />Clinicians should maintain a high index of suspicion for PJP when renal transplant patients develop hypercalcemia, and management should include stopping calcium/vitamin D supplements and promptly initiating PJP-directed therapy.

Asset Subtitle

Margaret Liu

Meta Tag

Author List Margaret Liu, Meggan Forbes, Tatvam Choksi MD

Category Clinical Vignettes

Concept Pneumocystis jirovecii pneumonia

Concept Hypercalcemia

Concept Immunosuppression

Concept Calcitriol

Concept Trimethoprim-sulfamethoxazole

Distinguished Non-Finalist

Presenter Organization University of Chicago Pritzker School of Medicine

Presenting Author Margaret Liu

Track Adult

Keywords

pneumocystis jirovecii pneumonia

renal transplant

hypercalcemia

vitamin D supplementation

immunosuppression

acute kidney injury

ground-glass opacities

Fungitell assay

trimethoprim-sulfamethoxazole

high-dose steroids

Pneumocystis jirovecii pneumonia

Hypercalcemia

Immunosuppression

Calcitriol

Trimethoprim-sulfamethoxazole