SHM Converge Scientific Abstract ePoster Gallery-Refractory Hypercalcemia Secondary to Pneumocystis Jirovecii Pneumonia

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This case describes a 57-year-old renal transplant recipient on immunosuppressive therapy who presented with fever and malaise and was found to have severe, refractory hypercalcemia (15.6 mg/dL) with suppressed PTH. An extensive initial infectious workup was negative, and treatment with IV fluids, calcitonin, and bisphosphonates did not correct the calcium level. Further evaluation showed normal PTH-related protein, elevated 1,25-dihydroxyvitamin D, and normal 25-dihydroxy vitamin D, suggesting a calcitriol-mediated process. Because the patient remained febrile despite broad-spectrum antibiotics, additional testing for opportunistic infections was pursued, and Pneumocystis jirovecii PCR returned positive. He was treated with steroids and atovaquone for PJP, after which his serum calcium normalized.<br /><br />The poster highlights that hypercalcemia can be an important clue to Pneumocystis jirovecii pneumonia in kidney transplant recipients. In reported cases, hypercalcemia occurs in a substantial proportion of PJP patients and often resolves with treatment of the infection. The proposed mechanism is similar to granulomatous disease: activated macrophages in inflammatory lesions produce 1-alpha hydroxylase, increasing conversion of vitamin D to calcitriol. Elevated calcitriol increases intestinal and renal calcium absorption and promotes calcium release from bone, leading to hypercalcemia.<br /><br />The authors conclude that refractory hypercalcemia in a renal transplant patient should prompt consideration of PJP in the differential diagnosis, especially when routine hypercalcemia causes are excluded and fever persists despite empiric therapy.

Asset Subtitle

Lillian Sangha

Meta Tag

Author List Benjamin Ravichander, Irina Mishagina, Lillian Sangha

Category Clinical Vignettes

Concept Pneumocystis jirovecii pneumonia

Concept Hypercalcemia

Concept Calcitriol

Concept Refractory Hypercalcemia

Concept Renal Transplant Recipient

Distinguished Non-Finalist

Presenter Organization UPMC Harrisburg

Presenting Author Lillian Sangha

Track Adult

Keywords

renal transplant

hypercalcemia

Pneumocystis jirovecii pneumonia

immunosuppressive therapy

calcitriol-mediated

suppressed PTH

opportunistic infection

kidney transplant recipient

fever

atovaquone

Pneumocystis jirovecii pneumonia

Hypercalcemia

Calcitriol

Refractory Hypercalcemia

Renal Transplant Recipient