Hypercalcemia in two patients with sarcoidosis and Mycobacterium avium intracellulare not mediated by elevated vitamin D metabolites

Hypercalcaemia in Mycobacterium kansasii pulmonary infection

A gentleman in his 60s with end-stage kidney disease status post kidney transplantation on prednisone and tacrolimus presented with generalised weakness for 7 days, associated with altered mental status. Investigations revealed pancytopenia, acute kidney injury, hypercalcaemia, decreased parathyroid hormone (PTH) and normal calcitriol levels. CT of the chest showed multifocal lung opacities suspicious for malignancy. Bronchoscopy with biopsy yielded no malignant cells, and bronchoalveolar lavage specimens grew Mycobacterium kansasii The patient was treated with bisphosphonates, calcitonin and antibiotics for non-tuberculous mycobacteria pulmonary infection, with improvement in serum calcium levels, and was discharged after 5 weeks of hospitalisation.The work-up for hypercalcaemia begins with PTH measurement, and low PTH levels are consistent with malignancy, immobilisation and granulomatous diseases. Hypercalcaemia in the lattermost is classically caused by overproduction of calcitriol by activated macrophages. However, there are case reports of mycobacterial infections with hypercalcaemia despite normal calcitriol levels, supporting the existence of an additional mechanism of hypercalcaemia in granulomatous infections.

Mycobacterium avium complex: An unusual cause of hypercalcemia

Mycobacterium avium-complex (MAC) is an infectious granulomatous disease which is associated with hypercalcemia especially in immunocompromised patients. We present an unusual case of MAC infection in an immunocompetent patient presenting as hypercalcemia.A 76-year-old immunocompetent male was admitted for hypercalcemia of 12.6 mg/dl found on outpatient evaluation for fatigue. PTH level was low 8 pmol/L, Vitamin D 25hydroxy was 29 ng/ml, 1,25 dihydroxy vitamin D (1,25(OH)2 vitamin D) levels was low at 11 pg/ml, PTH related peptide was 1.1 pmol/L. Hypercalcemia resolved with intravenous hydration and bisphosphonate administration. CT chest identified a nodule with central cavity in the right upper lobe. Pathology from percutaneous biopsy of thenodule demonstrated granulomatous inflammation. AFB culture came positive for MAC. Patient was treated with Azithromycin, Rifabutin and Ethambutol for twelve months.Granulomatous diseases like MAC cause hypercalcemia via activation of macrophages which express extrarenal 1- alpha -hydroxylase. It converts vitamin D to its active form 1,25(OH)2 vitamin D causing its excess, leading to hypercalcemia. Interestingly, in our patient calcium level was elevated with appropriately low PTH but 1,25(OH)2 vitamin D level was also low. There are few reported cases of hypercalcemia in granulomatous disease with normal levels of 1,25(OH)2 vitamin D levels, and our case is the first one to have MAC associated hypercalcemia with low 1,25(OH)2 vitamin D levels, suggesting an alternative mechanism for hypercalcemia in these patients.

Sarcoidosis and calcium homeostasis disturbances-Do we know where we stand?

The majority of cases involving hypercalcemia in the setting of sarcoidosis are explained by the overproduction of calcitriol by activated macrophages. Vitamin D takes part in the regulation of granuloma formation. However, using vitamin D metabolites to assess the activity of the disease is still problematic, and its usefulness is disputable. In some cases, though, a calcium metabolism disorder could be a valuable tool (i.e. as a marker of extrathoracic sarcoidosis). Although sarcoidosis does not cause a decrease in bone mineral density, increased incidence of vertebral deformities is noted. Despite increasing knowledge about calcium homeostasis disorders in patients with sarcoidosis, there is still a need for clear guidelines regarding calcium and vitamin D supplementation in these patients.

Hypercalcaemia secondary to disseminated Mycobacterium abscessus and Mycobacterium fortuitum

The incidence and prevalence of nontuberculous mycobacteria (NTM) infection is on the rise with many cases still going unreported. Given the vague and nonspecific clinical features of NTM infections, it is often missed or mistaken for Mycobacterium tuberculosis. The presumption that NTM infections are benign and do not contribute to morbidity no longer holds true. NTM infections need to be considered in patients with disseminated multisystem disease and in those not responding to standard M. tuberculosis treatment. As NTM infection is associated with granuloma formation, it can result in hypercalcaemia. Interestingly, there is evidence that there may be other mechanisms in play contributing to hypercalcaemia besides the increased calcitriol levels.

Dose-response relationship between higher serum calcium level and higher prevalence of hyperuricemia: A cross-sectional study

The aim of the study was to examine the relationship between serum calcium (Ca) levels and the prevalence of hyperuricemia (HU).The data included in this analysis were extracted from a population-based study conducted at the Xiangya Hospital Health Management Centre. Serum Ca levels were measured using the Arsenazo III method. HU was defined as the uric acid ≥416 μmol/L for male subjects, and ≥360 μmol/L for female subjects. The association between serum Ca levels and the prevalence of HU was evaluated using logistic and spline regression.The present study included a total of 6337 subjects. The overall prevalence of HU for the target population was 17.5%. Compared with the lowest quintile, the odds ratios adjusted by age, sex, body mass index, smoking, and drinking for HU were 1.51 [95% confidence interval (CI): 1.20-1.91], 1.43 (95% CI: 1.13-1.82), 2.02 (95% CI: 1.61-2.54), and 2.54 (95% CI: 2.02-3.18) for the second, third, fourth, and fifth quintiles of serum Ca levels, respectively (P for trend <.001), and a positive dose-response relationship was observed. Similar results were observed for men and women, respectively. The findings were not materially altered by the adjustment for further potential confounders.Subjects with higher serum Ca levels are subject to a higher prevalence of HU in a dose-response relationship manner.

Severe hypercalcemia in a patient with extrapulmonary Mycobacterium abscessus: granuloma or immune reconstitution inflammatory syndrome? First case of Mycobacterium abscessus presenting as retroperitoneal lymphadenopathy with severe hypercalcemia: a case report and literature review

Background: Nontuberculous mycobacterium is a recognized cause of hypercalcemia, particularly in patients with acquired immunodeficiency syndrome (AIDS). Here we describe a case of severe hypercalcemia secondary to Mycobacterium abscessus (M. abscessus) in a patient with AIDS. To the best of our knowledge this is the first case report describing a case of M. abscessus presenting as retroperitoneal lymphadenopathy and severe hypercalcemia. Case description: A 56-year-old man with AIDS presented with altered mental status and somnolence for four days. Laboratory investigations were significant for calcium 16.49 mg/dL (RI 8.9-10.3 mg/dL), 1,25 dihydroxyvitamin D level 44.1 pg/ml (RI 19.9-79.3 pg/ml) and parathyroid hormone (PTH) 4 pg/mL (RI 15-65 pg/mL). CT scan of Abdomen and Pelvis showed hepatosplenomegaly with large retroperitoneal, retrocrural, and mesenteric lymphadenopathy which had an intense focal uptake on Gallium scan. Bone marrow biopsy revealed mild plasmacytosis (5%) with no evidence of myelodysplasia, acute leukemia or lymphoma. A subsequent lymph node biopsy showed fragments of fibrous tissue with lymphohistiocytic infiltrate and many acid-fast bacilli. Pre-antibiotic blood cultures grew Mycobacterium which was identified later as M. abscessus at four weeks. Conclusion: hypercalcemia in HIV-infected patients may suggest malignancy or infectious etiology, among other causes. Clinicians should be aware of the risk of hypercalcemia with nontuberculous mycobacterium (NTM) infection, whether as first manifestation or a late presenter in the disease course after initiating antiretroviral therapy (ART). We suggest careful monitoring of serum calcium level upon diagnosis of NTM infection and after initiation of ART, NTM therapy or vitamin D supplementation.

Efficacy characteristics of different therapeutic modalities for locally advanced prostate cancer: a Bayesian network meta-analysis of randomized controlled trials

Background

Though previous studies have investigated the efficacy characteristics of several different therapeutic modalities for locally advanced prostate cancer (LAPCa) patients, the available results remained unestablished. Therefore, the aim of this meta-analysis was conducted to clarify such differences.

Methods

The online PubMed, EMBASE and Web of Science were comprehensively searched for relevant studies published before September 1st, 2017, and eventually eleven relevant studies met the inclusion criteria. The hazard odds ratios (HRs) with 95% credible interval (CI) were utilized to evaluate the efficacy characteristics of several different therapeutic modalities for LAPCa patients by Markov chain Monte Carlo methods.

Results

Five different therapeutic modalities were ultimately enrolled to shed light on the efficacy characteristics for LAPCa patients and seven different clinical outcomes were finally analyzed in this study. The cumulative rank probability of overall survival (OS) or cancer-specific survival (CSS) from best to worst was radiotherapy (RT) + orchiectomy, RT + long-term androgen deprivation therapy (LTADT), RT + short-term androgen deprivation therapy (STADT), LTADT and RT; RT + LTADT, RT + orchiectomy, RT + STADT, LTADT and RT, respectively. Meanwhile, in the terms of progression-free survival (PFS), biochemical failure rate (BFR), disease-free survival (DFS), local progression rate (LPR) and metastasis rate (MR), RT + LTADT as well as RT + STADT had a higher, whereas RT alone or LTADT had a relatively lower treatment effect.

Conclusions

All in all, our results indicated that RT + LTADT or RT + orchiectomy was among the best two therapeutic regimens in the prognostic aspects of the patients with LAPCa. Furthermore, in consideration of reducing invasive treatment of eligible patients, RT + LTADT could yield better survival benefit of LAPCa patients, compared with others. In addition, the results of our analysis might provide a reference in the clinical selection. Larger sample sizes of strictly designed randomised controlled trials (RCTs) were wanted to validate our findings.

A case of hypercalcaemia in an immunocompetent patient with Mycobacterium avium intracellulare

Mycobacterium avium intracellulare infection or colonization should be considered in the differential diagnosis of hypercalcemia, especially in immunocompromised individuals, in the appropriate clinical context.

Vitamin D-Mediated Hypercalcemia: Mechanisms, Diagnosis, and Treatment

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.

Mycobacterium avium-intracellulare and the unpredictable course of hypercalcemia in an AIDS patient

A 37-year-old man with AIDS presented with altered mental status four weeks after stopping his medications for Mycobacterium avium-intracellulare (MAI). He had low CD4 cell count and severe hypercalcemia. Bone marrow biopsy revealed bone marrow infiltration by granulomas positive for acid-fast bacilli and cultures grew MAI. His hypercalcemia continued to worsen with the initiation of MAI therapy but we were able to treat it successfully with pamidronate and calcitonin.

An unexpected cause of severe and refractory PTH-independent hypercalcemia: case report and literature review

Hypercalcemia is a common condition in the internal medicine practice. Sometimes its cause is not readily apparent, so extensive investigation is appropriate. Here we report an unexpected cause for hypercalcemia in an elderly woman. The case of an 82-years old woman with PTH-independent hypercalcemia, lymphocytosis, normal serum 1,25 (OH)vitamin D levels, and low serum PTHrp levels, is described. Medical history and complementary investigation were unremarkable, except for increased metabolic activity in the glutei regions, as measured by whole body 18F-FDG PET-CT. Reviewing her medical history, her sister recalled that she had been submitted to intramuscular methylmethacrylate injections, for cosmetic purposes, five years before presentation, which was confirmed by muscle biopsy. Low calcium intake, parenteral bisphosphonates, calcitonin, and glucocorticoids were used to control serum calcium levels. Methylmethacrylate injections, used cosmetically, are a new cause for hypercalcemia, even after many years. Hypercalcemia was probably due to calcitriol overproduction in foreign body granulomas. Persistent reactive lymphocytosis could be a clue for this inflammatory cause of hypercalcemia.