1
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Gulhati V, Desy J, Thornton CS. A case of hypercalcemia from Pneumocystis jirovecii in an immunosuppressed non-HIV patient. BMC Pulm Med 2024; 24:204. [PMID: 38658913 PMCID: PMC11044281 DOI: 10.1186/s12890-024-03007-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/10/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The prevalence of non-HIV related Pneumocystis jirovecii pneumonia (PJP) is increasing with use of immunosuppressive therapies. There are case reports of solid organ transplant recipients on immunosuppressive therapy presenting with mild hypercalcemia, leading to a diagnosis of PJP. Recent studies have shown efficacy of PJP prophylaxis for patients treated with rituximab with a favourable adverse effect profile. CASE PRESENTATION A 78-year-old male with a history of PR3-ANCA vasculitis, chronic kidney disease and heart failure with reduced ejection fraction presented to our tertiary care hospital with a two-week history of confusion and non-productive cough. Background immunosuppression with rituximab was completed every six months. The patient was found to have hypercalcemia and new infiltrates and ground glass opacities on cross-sectional imaging. Bronchoscopy was performed that was positive for Pneumocystis jirovecii. He was treated with 21 days of trimethoprim-sulfamethoxazole and prednisone with resolution of symptoms and hypercalcemia. CONCLUSIONS Herein, we present a novel case of PJP in a non-transplant recipient preceded by hypercalcemia. Our case demonstrates the importance for a high suspicion for PJP in chronically immunosuppressed patients on rituximab presenting with PTH-independent hypercalcemia.
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Affiliation(s)
- Vishrut Gulhati
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, T2N 4N1, Calgary, AB, Canada
| | - Janeve Desy
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, T2N 4N1, Calgary, AB, Canada
| | - Christina S Thornton
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, T2N 4N1, Calgary, AB, Canada.
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary Cumming School of Medicine, Calgary, AB, Canada.
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2
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Hong L, Witton LD, Jolly EC. Pneumocystis jirovecii pneumonia presenting with severe, refractory hypercalcaemia in an immunosuppressed renal transplant patient: Review of the literature and novel biochemical insights. Clin Med (Lond) 2024; 24:100011. [PMID: 38377731 PMCID: PMC11024830 DOI: 10.1016/j.clinme.2023.100011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is a rare but serious complication of immunosuppression post-solid organ transplantation. We present a case of refractory, severe hypercalcaemia due to PJP in a renal transplant recipient. Treatment of PJP led to normalisation of the patient's calcium levels, and clinical improvement. To further explore the proposed calcitriol-driven mechanism leading to hypercalcaemia in PJP, we performed biochemical analysis on pre- and post-treatment serum and bronchoalveolar lavage sample at the time of PJP diagnosis. We confirmed high circulating and pulmonary levels of calcitriol in acute, untreated PJP with severe hypercalcaemia. PJP treatment led to reduction of circulating calcitriol to within normal range. We present this case, together with a literature review of similar reported cases, and the novel biochemical evidence supporting extra-renal production of calcitriol by activated pulmonary macrophages as the mechanism underpinning hypercalcaemia in PJP.
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Affiliation(s)
- Lucy Hong
- Medical student, University of Cambridge, Cambridge, UK
| | | | - Elaine C Jolly
- Consultant nephrologist, Cambridge University Hospitals NHS Trust, Cambridge, UK.
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3
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Koymen G, Celtik A, Cinkooglu A, Toz S, Asci G, Arda B, Toz H, Erdinc M. New-Onset Hypercalcemia After Renal Transplant: An Infectious Etiology Beyond Persistent Hyperparathyroidism. EXP CLIN TRANSPLANT 2021; 20:691-694. [PMID: 34142941 DOI: 10.6002/ect.2021.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pneumocystis jirovecii pneumonia is an opportunistic infection in kidney transplant recipients. It may be complicated by hypercalcemia. Here, we discuss a 59-year-old man who presented with respiratory symptoms and hypercalcemia. He had undergone a deceased donor kidney transplant 2 years previously. The patient had persistent hyperparathyroidism, but his serum calcium level was normal. At the time of admission, his serum calcium level had increased and his parathyroid hormone level was suppressed. He was diagnosed with Pneumocystis jirovecii pneumonia. Serum calcium and parathyroid hormone levels returned to baseline values after treatment. Pneumocystis jirovecii pneumonia is an important infection that can present with hypercalcemia among kidney transplant recipients.
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Affiliation(s)
- Gorkem Koymen
- From the Department of Internal Medicine, School of Medicine, Ege University, Izmir, Turkey
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4
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Chen J, He T, Li X, Wang X, Peng L, Ma L. Metagenomic Next-Generation Sequencing in Diagnosis of a Case of Pneumocystis jirovecii Pneumonia in a Kidney Transplant Recipient and Literature Review. Infect Drug Resist 2020; 13:2829-2836. [PMID: 32884306 PMCID: PMC7431457 DOI: 10.2147/idr.s257587] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite the increasing incidences of Pneumocystis jirovecii pneumonia (PCP) in renal transplant recipients, diagnosis of PCP remains challenging due to its nonspecific clinical presentation and the inadequate performance of conventional diagnostic methods. There is a need for novel diagnostic methods. CASE PRESENTATION A 27-year-old woman developed acute pneumonia 4 months after renal transplantation. Blood tests revealed a low CD4 count, a normal 1,3-beta-D-glucan level and other changes typical of inflammatory responses. Chest imaging showed bilateral diffuse infiltrates. Microscopic examination of stained sputum and bronchoalveolar lavage fluid (BALF) smear specimens did not find Pneumocystis organisms. There was also no evidence for other pathogens known to cause pneumonia in various antibody and culture tests. Direct metagenomic next-generation sequencing (mNGS) analysis of a BALF specimen identified a large number of P. jirovecii reads, allowing to confirm the diagnosis of PCP. Following treatment with trimethoprim-sulfamethoxazole for two weeks, the patient was cured and discharged. CONCLUSION This case report supports the value of mNGS in diagnosing PCP, highlights the inadequate sensitivity of conventional diagnostic methods for PCP, and calls for the need to add PCP prophylaxis to the current Diagnosis and Treatment Guideline of Invasive Fungal Infections in Solid Organ Transplant Recipients in China.
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Affiliation(s)
- Jie Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Ting He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xiujun Li
- Department of Pathology, College of Basic Medicine, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xue Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Li Peng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
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5
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Giordani MC, Villamil Cortez SK, Diehl M, Barcan LA, Rosa-Diez G, Groppa SR, Schreck C, Mombelli C, Imperiali N. Hypercalcemia as an Early Finding of Opportunistic Fungal Pneumonia in Renal Transplantation: A Case Series Report. Transplant Proc 2020; 52:1178-1182. [PMID: 32340747 DOI: 10.1016/j.transproceed.2020.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pneumonia caused by opportunistic fungi is a serious complication in immunocompromised patients. Hypercalcemia has been described in renal transplantation associated with Pneumocystis jirovecii (PJP) or Histoplasma capsulatum (HCP) pneumonia. METHODS We describe 5 patients who underwent kidney transplant between 2014 and 2019 and developed hypercalcemia before the diagnosis of pulmonary fungal infection: 4 patients with PJP and 1 with HCP. We assessed calcium metabolism and kidney function by total and ionized calcium, phosphorus, intact parathormone (iPTH), 25-OH vitamin D, 1,25(OH)2 vitamin D, and serum creatinine levels. RESULTS Mean albumin-corrected calcium and ionized calcium were 12.56 mg/dL (range, 10.8-13.8 mg/dL) and 1.57 mmol/L (range, 1.43-1.69 mmol/L). Patients were normocalcemic, at 10.12 mg/dL (range, 9.6-10.5 mg/dL), before diagnosis and resolved hypercalcemia after antifungal treatment, at 8.86 mg/dL (range, 8.0-9.5 mg/dL). All patients had low or normal iPTH values, at 29.1 pg/mL (range, <3-44 pg/mL), with higher PTH levels 3 months before diagnosis and after treatment, at 147.3 pg/mL (range, 28.1-479 pg/mL) and 117.5 pg/mL (range, 18.2-245 pg/mL), respectively. The mean value for 25-OH vitamin D was 30.8 ng/mL (range, 14.6-62.8 ng/mL). This supports a PTH-independent mechanism, and we postulated an extrarenal production of 1,25(OH)2 vitamin D. CONCLUSION In kidney transplant patients, hypercalcemia independent of PTH and refractory to treatment should alert for the possibility of opportunistic fungal pneumonia.
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Affiliation(s)
- María Cora Giordani
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | | | - María Diehl
- Department of Endocrinology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Laura A Barcan
- Department of Infectology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Rosa-Diez
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - S Rosana Groppa
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Schreck
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - César Mombelli
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Nora Imperiali
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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6
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Garo F, Aglae C, Ahmadpoor P, Moranne O. Pneumocystis jirovecii pneumonitis: cause of acute hypercalcaemia in chronic haemodialysis patient. BMJ Case Rep 2020; 13:13/1/e231334. [PMID: 31988055 DOI: 10.1136/bcr-2019-231334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 76-year-old renal transplant patient due to autosomal dominant polycystic kidney disease who resumed chronic haemodialysis was admitted to our hospital for confusion and lassitude. He was afebrile and physical examination revealed diffuse bilateral rales with decreased respiratory sounds in lower right lung. Laboratory data showed hypercalcaemia (total calcium 3.92 mmol/L (normal range 2.2-2.6 mmol/L), ionised calcium 1.87 mmol/L (1.15-1.35 mmol/L)), low intact parathyroid hormone (iPTH) 15 ng/L, (15-65 ng/L) and high 1,25(OH)2D3 128.9 pg/mL, (15.2-90.1 pg/mL). Chest CT-scan revealed bilateral apical lung lesions after 15 days of antibiotics. Bronchoalveolar sample was PCR positive for Pneumocystis jirovecii He was treated with an extra session of haemodialysis with 1.25 mmol/L dialysate calcium concentration, oral trimethoprim-sulfamethoxazole was started and oral corticosteroid dose increased to 1 mg/kg for 1 week. Hypercalcaemia decreased progressively after initiation of these treatments. We concluded a case of hypercalcaemia secondary to P. jirovecii infection.
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Affiliation(s)
- Florian Garo
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France
| | - Cedric Aglae
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France.,Faculte de Medecine, Universite de Montpellier, Montpellier, France
| | - Pedram Ahmadpoor
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France
| | - Olivier Moranne
- Departement of Nephrology, Dialysis and Apheresis, Centre Hospitalier Universitaire de Nimes, Nimes, France.,Faculte de Medecine, Universite de Montpellier, Montpellier, France
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7
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Binet Q, Mairesse J, Vanthuyne M, Marot JC, Wieers G. Hypercalcemia Heralding Pneumocystis jirovecii Pneumonia in an HIV-Seronegative Patient with Diffuse Cutaneous Systemic Sclerosis. Mycopathologia 2019; 184:787-793. [PMID: 31729682 DOI: 10.1007/s11046-019-00397-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022]
Abstract
Pneumocystis pneumonia (PCP) is a life-threatening fungal infection occurring in immunocompromised patients such as HIV-positive patients with low CD4 cell count or patients under heavy immunosuppressive therapy. We report the case of a 59-year-old male with severe diffuse cutaneous systemic sclerosis presenting with asthenia, dry cough and worsening shortness of breath for the last 15 days. Biological studies were remarkable for PTH-independent severe hypercalcemia with low 25-hydroxyvitamin D and a paradoxically elevated 1,25-dihydroxyvitamin D. Early bronchoalveolar lavage allowed for PCP diagnosis and targeted treatment. We discuss the underlying physiopathology and difficulties regarding prophylaxis and treatment.
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Affiliation(s)
- Quentin Binet
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium.
| | - Jacques Mairesse
- Division of Clinical Biology and Cytology, Clinique St-Pierre Ottignies, Ottignies, Belgium
| | - Marie Vanthuyne
- Division of Rheumatology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium.,Division of Rheumatology, Grand Hôpital de Charleroi, Gilly, Belgium
| | - Jean-Christophe Marot
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium
| | - Grégoire Wieers
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium
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8
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Coche S, Cornet G, Morelle J, Labriola L, Kanaan N, Demoulin N. Hypercalcemia associated with Pneumocystis jirovecii pneumonia in renal transplant recipients: case report and literature review. Acta Clin Belg 2019; 76:75-78. [PMID: 31470765 DOI: 10.1080/17843286.2019.1655233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Pneumocystis jirovecii associated pneumonia is a potentially life-threatening opportunistic infection, occurring most frequently in the first year after renal transplantation, and may be associated with hypercalcemia. Clinical presentation:We report the case of a renal transplant recipient presenting with Pneumocystis jirovecii associated pneumonia and hypercalcemia due to ectopic production of 1,25-dihydroxyvitamin D, 6 years after renal transplantation. Calcemia and 1-25 hydroxyvitamin D levels normalized after our patient was treated by trimethoprim-sulfamethoxazole. Discussion: We review similar cases to delineate the clinical and biological profile of patients with Pneumocystis jirovecii pneumonia associated hypercalcemia. Conclusion:Physicians should evoke this diagnosis in renal transplant recipients presenting with pulmonary infection associated with hypercalcemia.
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Affiliation(s)
- Sophie Coche
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium
| | - Georges Cornet
- Division of Nephrology, Centre Hospitalier Peltzer-La Tourelle , Verviers, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Laura Labriola
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Nada Kanaan
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Nathalie Demoulin
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
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9
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Hypercalcemia is common during Pneumocystis pneumonia in kidney transplant recipients. Sci Rep 2019; 9:12508. [PMID: 31467367 PMCID: PMC6715728 DOI: 10.1038/s41598-019-49036-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/14/2019] [Indexed: 12/27/2022] Open
Abstract
A few cases of hypercalcemia related to Pneumocystis jirovecii pneumonia (PJP) have previously been described, supposedly associated with an 1α-hydroxylase enzyme-dependent mechanism. The prevalence and significance of hypercalcemia in PJP remain unclear, especially in kidney transplant recipients (KTR) who frequently display hypercalcemia via persisting hyperparathyroidism. We here retrospectively identified all microbiologically-proven PJP in adult KTR from 2005 to 2017 in the Lille University Hospital, and studied the mineral and bone metabolism parameters during the peri-infectious period. Clinical features of PJP-patients were analyzed according to their serum calcium level. Hypercalcemia (12.6 ± 1.6 mg/dl) was observed in 37% (18/49) of PJP-patients and regressed concomitantly to specific anti-infectious treatment in all cases. No other cause of hypercalcemia was identified. In hypercalcemic patients, serum levels of 1,25-dihydroxyvitamin D were high at the time of PJP-diagnosis and decreased after anti-infectious treatment (124 ± 62 versus 28 ± 23 pg/mL, p = 0.006) while PTH serum levels followed an inverse curve (35 ± 34 versus 137 ± 99 pg/mL, p = 0.009), suggesting together a granuloma-mediated mechanism. Febrile dyspnea was less frequent in hypercalcemic PJP-patients compared to non-hypercalcemic (29 versus 67%). In summary, hypercalcemia seems common during PJP in KTR. Unexplained hypercalcemia could thus lead to specific investigations in this particular population, even in the absence of infectious or respiratory symptoms.
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10
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Yau AA, Farouk SS. Severe hypercalcemia preceding a diagnosis of Pneumocystis jirovecii pneumonia in a liver transplant recipient. BMC Infect Dis 2019; 19:739. [PMID: 31438872 PMCID: PMC6704494 DOI: 10.1186/s12879-019-4370-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/11/2019] [Indexed: 11/21/2022] Open
Abstract
Background Incidence of the opportunistic infection Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant patients ranges from 5 to 15% with a mortality of up to 38%. Case presentation We present a liver transplant recipient who developed hypoxemic respiratory failure related to PJP soon after treatment for allograft rejection. His presentation was preceded by severe hypercalcemia of 14.6 mg/dL and an ionized calcium of 1.7 mmol/L which remained elevated despite usual medical management and eventually required renal replacement therapy. As approximately 5% of PJP cases have granulomas, here we review the role of pulmonary macrophages and inflammatory cytokines in the pathophysiology of granuloma-mediated hypercalcemia. We also discuss the interpretation of our patient’s laboratory studies, response to medical therapy, and clinical risk factors which predisposed him to PJP. Conclusions It is important for clinicians to consider PJP as an etiology of granulomatous pneumonia and non-parathyroid hormone mediated hypercalcemia in chronically immunosuppressed organ transplant recipients for timely diagnosis and management.
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Affiliation(s)
- Amy A Yau
- Division of Nephrology, Department of Medicine, Icahn School of Medicine, Mount Sinai, 1 Gustave Levy Place, New York, NY, 10029, USA
| | - Samira S Farouk
- Division of Nephrology, Department of Medicine, Icahn School of Medicine, Mount Sinai, 1 Gustave Levy Place, New York, NY, 10029, USA.
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11
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Taylor LN, Aesif SW, Matson KM. A case of Pneumocystis pneumonia, with a granulomatous response and vitamin D-mediated hypercalcemia, presenting 13 years after renal transplantation. Transpl Infect Dis 2019; 21:e13081. [PMID: 30892756 DOI: 10.1111/tid.13081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/01/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022]
Abstract
Vitamin D-mediated hypercalcemia is an uncommon complication of Pneumocystis infection. A granulomatous response resulting from Pneumocystis infection is also atypical. In this report, we describe an exceptional case of granulomatous Pneumocystis pneumonia associated with vitamin D-mediated hypercalcemia, in a patient who presented unusually late after renal transplantation. The patient's hypercalcemia resolved with treatment of the infection.
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Affiliation(s)
- Lindsay N Taylor
- Department of Internal Medicine, Division of Infectious Disease, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Scott W Aesif
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kristine M Matson
- Department of Internal Medicine, Division of Infectious Disease, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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12
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Mascia G, Argiolas D, Carta E, Michittu MB, Piredda GB. Acute Kidney Injury Secondary to Hypercalcemia in a Kidney Transplant Patient With Pneumocystis jirovecii Pneumonia: A Case Report. Transplant Proc 2018; 51:220-222. [PMID: 30736974 DOI: 10.1016/j.transproceed.2018.04.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Persistent hyperparathyroidism is one of the main causes of hypercalcemia following kidney transplantation; differential diagnosis is required. CASE PRESENTATION We report the case of a 61-year-old kidney transplant recipient who underwent transplant in September 2016. She was admitted in March 2017 presenting with a 3-week history of asthenia, hypotension, and cough. Laboratory analysis showed acute kidney injury with hypercalcemia and elevation of inflammatory markers. She was initially treated with hydration therapy. A few days after admission she developed respiratory failure: chest computed tomography showed a ground-glass pattern. A diagnosis of Pneumocystis jirovecii was made on bronchoalveolar lavage. A subsequent graft biopsy was performed that revealed intratubular calcium deposition without signs of rejection. The patient was given trimethoprim/sulfamethoxazole, with improvement in pulmonary and renal function as well as improvement in hypercalcemia. CONCLUSIONS P jirovecii infection can trigger activation of intra-alveolar macrophages that leads to extrarenal vitamin D production with subsequent hypercalcemia. This rare event should be considered in renal transplant patients with pulmonary infection accompanied by hypercalcemia. In our case, hypercalcemia also provoked acute kidney injury.
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Affiliation(s)
- G Mascia
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - D Argiolas
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - E Carta
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy.
| | - M B Michittu
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - G B Piredda
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
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13
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Ling J, Anderson T, Warren S, Kirkland G, Jose M, Yu R, Yew S, Mcfadyen S, Graver A, Johnson W, Jeffs L. Hypercalcaemia preceding diagnosis of Pneumocystis jirovecii pneumonia in renal transplant recipients. Clin Kidney J 2017; 10:845-851. [PMID: 29225815 PMCID: PMC5716089 DOI: 10.1093/ckj/sfx044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/19/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The overall incidence of Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant recipients is 5-15%. A timely diagnosis of PJP is difficult and relies on imaging and detection of the organism. METHODS We present a case series of four patients displaying hypercalcaemia with an eventual diagnosis of PJP and document the management of the outbreak with a multidisciplinary team approach. We discuss the underlying pathophysiology and previous reports of hypercalcaemia preceding a diagnosis of PJP. We also reviewed the evidence concerning PJP diagnosis and treatment. RESULTS Within our renal transplant cohort, four patients presented within 7 months with hypercalcaemia followed by an eventual diagnosis of PJP. We measured their corrected calcium, parathyroid hormone (PTH), 1,25-dihydroxycholecalciferol [1,25-(OH)2D3] and 25-hydroxycholecalciferol [25(OH)D] levels at admission and following treatment of PJP. All four patients diagnosed with PJP were 4-20 years post-transplantation. Three of the four patients demonstrated PTH-independent hypercalcaemia (corrected calcium >3.0 mmol/L). The presence of high 1,25(OH)2D3 and low 25(OH)D levels suggest negation of the negative feedback mechanism possibly due to an extrarenal source; in this case, the alveolar macrophages. All four patients had resolution of their hypercalcaemia after treatment of PJP. CONCLUSIONS Given the outbreak of PJP in our renal transplant cohort, and based on previous experience from other units nationally, we implemented cohort-wide prophylaxis with trimethoprim-sulphamethoxazole for 12 months in consultation with our local infectious diseases unit. Within this period there have been no further local cases of PJP.
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Affiliation(s)
- Jonathan Ling
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Tara Anderson
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Sanchia Warren
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Geoffrey Kirkland
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Matthew Jose
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Richard Yu
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Steven Yew
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Samantha Mcfadyen
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Alison Graver
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - William Johnson
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Lisa Jeffs
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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14
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Abstract
Hypercalcemia occurs in up to 4% of the population in association with malignancy, primary hyperparathyroidism, ingestion of excessive calcium and/or vitamin D, ectopic production of 1,25-dihydroxyvitamin D [1,25(OH)2D], and impaired degradation of 1,25(OH)2D. The ingestion of excessive amounts of vitamin D3 (or vitamin D2) results in hypercalcemia and hypercalciuria due to the formation of supraphysiological amounts of 25-hydroxyvitamin D [25(OH)D] that bind to the vitamin D receptor, albeit with lower affinity than the active form of the vitamin, 1,25(OH)2D, and the formation of 5,6-trans 25(OH)D, which binds to the vitamin D receptor more tightly than 25(OH)D. In patients with granulomatous disease such as sarcoidosis or tuberculosis and tumors such as lymphomas, hypercalcemia occurs as a result of the activity of ectopic 25(OH)D-1-hydroxylase (CYP27B1) expressed in macrophages or tumor cells and the formation of excessive amounts of 1,25(OH)2D. Recent work has identified a novel cause of non-PTH-mediated hypercalcemia that occurs when the degradation of 1,25(OH)2D is impaired as a result of mutations of the 1,25(OH)2D-24-hydroxylase cytochrome P450 (CYP24A1). Patients with biallelic and, in some instances, monoallelic mutations of the CYP24A1 gene have elevated serum calcium concentrations associated with elevated serum 1,25(OH)2D, suppressed PTH concentrations, hypercalciuria, nephrocalcinosis, nephrolithiasis, and on occasion, reduced bone density. Of interest, first-time calcium renal stone formers have elevated 1,25(OH)2D and evidence of impaired 24-hydroxylase-mediated 1,25(OH)2D degradation. We will describe the biochemical processes associated with the synthesis and degradation of various vitamin D metabolites, the clinical features of the vitamin D-mediated hypercalcemia, their biochemical diagnosis, and treatment.
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Affiliation(s)
- Peter J Tebben
- Divisions of Endocrinology (P.J.T., R.K.) and Nephrology and Hypertension (R.K.), and Departments of Pediatric and Adolescent Medicine (P.J.T.), Internal Medicine (P.J.T., R.K.), Laboratory Medicine and Pathology (R.J.S.), and Biochemistry in Molecular Biology (R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota 55905
| | - Ravinder J Singh
- Divisions of Endocrinology (P.J.T., R.K.) and Nephrology and Hypertension (R.K.), and Departments of Pediatric and Adolescent Medicine (P.J.T.), Internal Medicine (P.J.T., R.K.), Laboratory Medicine and Pathology (R.J.S.), and Biochemistry in Molecular Biology (R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota 55905
| | - Rajiv Kumar
- Divisions of Endocrinology (P.J.T., R.K.) and Nephrology and Hypertension (R.K.), and Departments of Pediatric and Adolescent Medicine (P.J.T.), Internal Medicine (P.J.T., R.K.), Laboratory Medicine and Pathology (R.J.S.), and Biochemistry in Molecular Biology (R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota 55905
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Nordholm A, Mace ML, Gravesen E, Olgaard K, Lewin E. A potential kidney-bone axis involved in the rapid minute-to-minute regulation of plasma Ca2+. BMC Nephrol 2015; 16:29. [PMID: 25885328 PMCID: PMC4377030 DOI: 10.1186/s12882-015-0019-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/19/2015] [Indexed: 12/22/2022] Open
Abstract
Background Understanding the regulation of mineral homeostasis and function of the skeleton as buffer for Calcium and Phosphate has regained new interest with introduction of the syndrome “Chronic Kidney Disease-Mineral and Bone Disorder”(CKD-MBD). The very rapid minute-to-minute regulation of plasma-Ca2+ (p-Ca2+) takes place via an exchange mechanism of Ca2+ between plasma and bone. A labile Ca storage pool exists on bone surfaces storing excess or supplying Ca when blood Ca is lowered. Aim was to examine minute-to-minute regulation of p-Ca2+ in the very early phase of acute uremia, as induced by total bilateral nephrectomy and to study the effect of absence of kidneys on the rapid recovery of p-Ca2+ from a brief induction of acute hypocalcemia. Methods The rapid regulation of p-Ca2+ was examined in sham-operated rats, acute nephrectomized rats(NX), acute thyroparathyrectomized(TPTX) rats and NX-TPTX rats. Results The results clearly showed that p-Ca2+ falls rapidly and significantly very early after acute NX, from 1.23 ± 0.02 to 1.06 ± 0.04 mM (p < 0.001). Further hypocalcemia was induced by a 30 min iv infusion of EGTA. Control groups had saline. After discontinuing EGTA a rapid increase in p-Ca2+ took place, but with a lower level in NX rats (p < 0.05). NX-TPTX model excluded potential effect of accumulation of Calcitonin and C-terminal PTH, both having potential hypocalcemic actions. Acute TPTX resulted in hypercalcemia, 1.44 ± 0.02 mM and less in NX-TPTX rats,1.41 ± 0.02 mM (p < 0.05). Recovery of p-Ca2+ from hypocalcemia resulted in lower levels in NX-TPTX than in TPTX rats, 1.20 ± 0.02 vs.1.30 ± 0.02 (p < 0.05) demonstrating that absence of kidneys significantly affected the rapid regulation of p-Ca2+ independent of PTH, C-PTH and CT. Conclusions P-Ca2+ on a minute-to-minute basis is influenced by presence of kidneys. Hypocalcemia developed rapidly in acute uremia. Levels of p-Ca2+, obtained during recovery from hypocalcemia resulted in lower levels in acutely nephrectomized rats. This indicates that kidneys are of significant importance for the ‘set-point’ of p-Ca2+ on bone surface, independently of PTH and calcitonin. Our results point toward existence of an as yet unknown factor/mechanism, which mediates the axis between kidney and bone, and which is involved in the very rapid regulation of p-Ca2+.
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Affiliation(s)
- Anders Nordholm
- Nephrological Department B, Herlev Hospital, DK 2730, Copenhagen, Denmark.
| | - Maria L Mace
- Nephrological Department B, Herlev Hospital, DK 2730, Copenhagen, Denmark.
| | - Eva Gravesen
- Nephrological Department P, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Klaus Olgaard
- Nephrological Department P, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Ewa Lewin
- Nephrological Department B, Herlev Hospital, DK 2730, Copenhagen, Denmark. .,Nephrological Department P, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Ramalho J, Bacelar Marques ID, Aguirre AR, Pierrotti LC, de Paula FJ, Nahas WC, David-Neto E. Pneumocystis jirovecii pneumonia with an atypical granulomatous response after kidney transplantation. Transpl Infect Dis 2014; 16:315-9. [PMID: 24621124 DOI: 10.1111/tid.12198] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/09/2013] [Accepted: 10/12/2013] [Indexed: 12/11/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) continues to be a leading cause of morbidity and mortality in kidney transplant recipients. Granulomatous PCP is an unusual histological presentation that has been described in a variety of immunosuppressive conditions. Previous studies have demonstrated an association between granulomatous disorders and hypercalcemia, the purported mechanism of which is extrarenal production of 1,25-dihydroxyvitamin D by activated macrophages. Here, we report a case of granulomatous formation in a kidney transplant recipient with PCP who presented with hypercalcemia and suppressed parathyroid hormone, both of which resolved after successful treatment of the pneumonia. In immunocompromised patients, pulmonary infection associated with hypercalcemia should raise the suspicion of PCP and other granulomatous disorders.
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Affiliation(s)
- J Ramalho
- Nephrology Division, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Chatzikyrkou C, Clajus C, Haubitz M, Hafer C. Hypercalcemia and pneumocystis Pneumonia after kidney transplantation: report of an exceptional case and literature review. Transpl Infect Dis 2011; 13:496-500. [PMID: 21414118 DOI: 10.1111/j.1399-3062.2011.00623.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pneumocystis jirovecii remains an important pathogen in solid organ transplant recipients. Although the overall incidence may be decreasing, after the adoption of effective prophylactic measures, the risk has not been abolished, and pneumocystis pneumonia (PCP) can be observed even many years after successful transplantation. Hypercalcemia develops frequently after renal transplantation and is commonly associated with preexisting secondary hyperparathyroidism. But the pathogenesis of hypercalcemia occurring later in the course of transplantation may be different, and other disease states, such as malignancy and opportunistic infections, must be considered. Hypercalcemia in conjunction with PCP is being increasingly reported in renal transplant patients. In all the cases, respiratory symptoms were prominent, hypercalcemia was of mild-to-moderate severity, parathyroid hormone concentration was decreased, and 1,25(OH)(2) D levels were extraordinarily or inappropriately high. We report the first case to our knowledge of severe hypercalcemia accompanying PCP, in a patient with previous total parathyroidectomy.
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Affiliation(s)
- C Chatzikyrkou
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany.
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Bency R, Roger SD, Elder GJ. Hypercalcaemia as a prodromal feature of indolent Pneumocystis jivorecii after renal transplantation. Nephrol Dial Transplant 2011; 26:1740-2. [PMID: 21378150 DOI: 10.1093/ndt/gfr051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Following renal transplantation, hypercalcaemia is frequently caused by persisting hyperparathyroidism. Unregulated extrarenal 1,25-dihydroxyvitamin D (1,25(OH)(2)D) synthesis, which is well recognized as a cause of hypercalcaemia in granulomatous diseases, may also occur after kidney transplantation. This mechanism is also likely to be responsible for hypercalcaemia reported during treatment of cytomegalovirus and associated with acute symptomatic pneumocystis jivorecii pneumonia (PCP). Hypercalcaemia as a prodromal feature of indolent PCP has not been described. We report a renal transplant recipient who developed hypercalcaemia 30 months post-transplant due to extrarenal production of 1,25(OH)(2)D. Two months later, PCP was diagnosed and hypercalcaemia resolved after initiation of treatment.
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Affiliation(s)
- Rosamma Bency
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.
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20
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Lowe H, Cusano NE, Binkley N, Blaner WS, Bilezikian JP. Vitamin D toxicity due to a commonly available "over the counter" remedy from the Dominican Republic. J Clin Endocrinol Metab 2011; 96:291-5. [PMID: 21123442 DOI: 10.1210/jc.2010-1999] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Hypercalcemia in ambulatory patients is occasionally caused by vitamin D toxicity. OBJECTIVE We report nine patients presenting to Columbia University Medical Center with hypercalcemia due to a supplement from the Dominican Republic containing massive amounts of vitamin D. METHODS Case histories and laboratory evaluation (calcium, PTH, vitamin D metabolites) are discussed in the context of other published cases of vitamin D toxicity. The supplement was analyzed by HPLC to quantitate vitamin D and A content. RESULTS Nine patients presented with hypercalcemia (range, 10.8-17.2 mg/dl; normal, 8.4-9.8 mg/dl), suppressed PTH (range, <3 to 11 pg/ml), and elevated 25-hydroxyvitamin D (range, 94-525 ng/ml; normal, 30-80 ng/ml) levels. All reported recently taking an over-the-counter vitamin supplement called Soladek readily available in the Dominican Republic and in Upper Manhattan. Although serum calcium values before the ingestion of Soladek were not elevated (baseline serum calcium range, 8.7-9.2 mg/dl), most had a disorder that can be associated with hypercalcemia [squamous cell cancer (n = 1), Pneumocystis or mycobacterial infection (n = 3), lymphoma (n = 1), granulomatous disease (n = 1), hyperthyroidism (n = 2)]. According to the manufacturer's label, each 5-ml vial of Soladek contains vitamin D (600,000 IU), vitamin A (120,000 IU), and vitamin E (5 mg). Laboratory analysis by HPLC revealed that the supplement actually contained vitamin D(3) (864,000 IU) and vitamin A (predominantly retinyl palmitate 123,500 IU) per vial. CONCLUSION Although hypercalcemia due to exogenous use of vitamin D is unusual, it is important to consider it in the differential diagnosis, particularly among individuals with access to Soladek.
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Affiliation(s)
- Hyesoo Lowe
- Division of Endocrinology, Department of Medicine, Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, New York 10032, USA
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Vitamin D Metabolite–Mediated Hypercalcemia With Suppressed Parathormone Concentration in Pneumocystis jiroveci Pneumonia After Kidney Transplantation. Transplant Proc 2009; 41:3320-2. [DOI: 10.1016/j.transproceed.2009.08.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ramezani M, Einollahi B, Asl MA, Nafar M, Pourfarziani V, Moradi M, Samadpour A, Alghasi M, Davoudi F. Calcium and Phosphorus Metabolism Disturbances After Renal Transplantation. Transplant Proc 2007; 39:1033-5. [PMID: 17524884 DOI: 10.1016/j.transproceed.2007.03.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Several studies have noted that, despite beneficial correction of abnormalities of mineral metabolism after successful renal transplantation, renal functional recovery is incomplete. Also, persistence of hyperparathyroidism and metabolic acidosis among patients with chronic impairment of graft function together with the use of loop diuretics and immunosuppressive drugs with adverse effects may alter mineral metabolism. We determined calcium and phosphorus levels in recipients. METHODS This cross-sectional study enrolled 398 recipients in 2 medical centers in Iran from 1988 to 2004 to evaluate serum calcium and phosphorus levels after 1 month in relation to graft and patient survivals. Cyclosporine was the constant part of the immunosuppressive treatment in all study subjects. RESULTS The median follow-up time was 8 months (range, 1-180 months). One and 10-year survival rates of patients were 97.9% and 91.1%. Mean (SD) serum calcium levels before and after transplantation were 8.79 (1.26) and 8.50 (1.39) mg/dL, respectively (P=.020). The mean (SD) phosphate levels before and after transplantation were 6.43 (2.42) and 3.64 (1.71) mg/dL, respectively (P=.000). There was no significant difference in survival considering changes in serum calcium and phosphorus levels. There was no correlation between serum calcium and phosphorus level changes among study patients. CONCLUSIONS Despite reports suggesting hypercalcemia as a posttransplantation finding, we did not observe this condition, but, consistent with other reports in this field, we observed a significant decrease in serum phosphorus levels showing correction of this mineral level.
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Affiliation(s)
- M Ramezani
- Department of Internal Medicine, Baqyiatollah University of Medical Sciences, Tehran, Iran
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Abstract
The diagnosis of fungal disease is a challenge that requires diligent attention to history and clinical signs as well as an astute ability to interpret laboratory data. Because fungal disease can mimic other infectious and neoplastic diseases in clinical presentation, the clinician has to be aware of fungal diseases common locally as well as in other regions of the country. A global approach to the diagnosis of fungal disease that correlates clinical signs as well as physical examination, clinical pathology, and histopathology findings with serology, culture, and the newer immunohistochemical and molecular techniques, where available, is the best approach to optimize the identification of the underlying agent.
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Affiliation(s)
- Sharon M Dial
- Department of Veterinary Science and Microbiology, Arizona Veterinary Diagnostic Laboratory, University of Arizona, 2831 North Freeway, Tucson, AZ 85705, USA.
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Shahnaz S, Reich D, Arévalo-Valencia D, Kucinska S, Tulczynska J, Fleischman J. HTLV-1-associated adult T cell leukemia lymphoma presenting as granulomatous pneumocystis jiroveci pneumonia (PJP) and hypercalcemia. J Gen Intern Med 2007; 22:420-3. [PMID: 17356979 PMCID: PMC1824742 DOI: 10.1007/s11606-006-0047-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Since the initial description of human T cell lymphotropic virus (HTLV-1), clusters of this infection have been detected globally. Unlike HIV infection, most patients infected with HTLV-1 remain asymptomatic throughout their lifetime. CASE REPORT We report the case of a 39-year-old Afro-Caribbean man with HTLV-1 infection presenting as hypercalcemia and granulomatous pneumocystis jiroveci pneumonia. RESULTS Interestingly, the hypercalcemia presented with normal parathyroid hormone-related protein and low 1,25 dihydroxyvitamin D levels, and the presence of pneumocystis jiroveci in the granulomas was diagnosed with transbronchial biopsy taken during bronchoscopy. HTLV-1-associated adult T cell leukemia lymphoma (ATLL) was diagnosed in this patient by bone marrow and lymph node biopsy. CONCLUSION Increased bone resorption, likely cytokine-mediated, is the most likely mechanism of hypercalcemia in this patient. This is believed to be the first description of this type of reaction to pneumocystis jiroveci in a HTLV-1-infected ATLL patient.
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Affiliation(s)
- Sabiha Shahnaz
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - David Reich
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Diana Arévalo-Valencia
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Slavka Kucinska
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Joanna Tulczynska
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
| | - Jean Fleischman
- Department of Medicine, Mount Sinai Services, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432 USA
- Mount Sinai School of Medicine, New York, NY USA
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Hung YM. Pneumocystis carinii Pneumonia with Hypercalcemia and Suppressed Parathyroid Hormone Levels in a Renal Transplant Patient. Transplantation 2006; 81:639. [PMID: 16495820 DOI: 10.1097/01.tp.0000185461.21901.5b] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Hypercalcemia has been described in patients with a number of granulomatous diseases, including sarcoidosis and mycobacterial infection. Disordered vitamin D metabolism is the root cause for the elevated serum calcium levels. A similar mechanism of abnormal vitamin D metabolism explained the hypercalcemia occurring in patients with lymphoma. Crohn's disease is a granulomatous disorder that is more commonly associated with hypocalcemia caused by poor calcium intake and decreased intestinal calcium absorption related to vitamin D deficiency as a consequence of malabsorption. A man with Crohn's disease who presented with hypercalcemia and acute renal failure is described. Biochemical parameters showed an elevated 1,25-dihydroxyvitamin D level, with a low-normal 25-hydroxyvitamin D level and decreased parathyroid hormone level. Inflammatory bowel disease had been clinically active during the preceding 2 months. With resolution of gastrointestinal symptoms, serum calcium, vitamin D, and parathyroid hormone levels returned to normal. Serum creatinine levels decreased toward normal. Angiotensin-converting enzyme (ACE) levels have been reported to be elevated in patients with sarcoidosis, particularly in the setting of active disease with hypercalcemia. Controversy exists about ACE levels in the face of active Crohn's disease: 1 report noted elevated levels, whereas other publications reported depressed levels. Our patient had an elevated ACE level in the setting of active bowel disease and hypercalcemia, and ACE levels returned to normal with resolution of gastrointestinal symptoms.
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Affiliation(s)
- Kathryn A Tuohy
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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