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Scurt FG, Gross CR, Chatzikyrkou C. Hypercalcemia and Fever in a Kidney Transplant Recipient. KIDNEY360 2024; 5:1062-1064. [PMID: 39052474 DOI: 10.34067/kid.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christian R Gross
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christos Chatzikyrkou
- PHV Dialysis Center Halberstadt, Halberstadt, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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2
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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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3
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Motlaghzadeh Y, Bilezikian JP, Sellmeyer DE. Rare Causes of Hypercalcemia: 2021 Update. J Clin Endocrinol Metab 2021; 106:3113-3128. [PMID: 34240162 DOI: 10.1210/clinem/dgab504] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary hyperparathyroidism and malignancy are the etiologies in 90% of cases of hypercalcemia. When these entities are not the etiology of hypercalcemia, uncommon conditions need to be considered. In 2005, Jacobs and Bilezikian published a clinical review of rare causes of hypercalcemia, focusing on mechanisms and pathophysiology. This review is an updated synopsis of rare causes of hypercalcemia, extending the observations of the original article. EVIDENCE ACQUISITION Articles reporting rare associations between hypercalcemia and unusual conditions were identified through a comprehensive extensive PubMed-based search using the search terms "hypercalcemia" and "etiology," as well as examining the references in the identified case reports. We categorized the reports by adults vs pediatric and further categorized the adult reports based on etiology. Some included reports lacked definitive assessment of etiology and are reported as unknown mechanism with discussion of likely etiology. EVIDENCE SYNTHESIS There is a growing understanding of the breadth of unusual causes of hypercalcemia. When the cause of hypercalcemia is elusive, a focus on mechanism and review of prior reported cases is key to successful determination of the etiology. CONCLUSIONS The ever-expanding reports of patients with rare and even unknown mechanisms of hypercalcemia illustrate the need for continued investigation into the complexities of human calcium metabolism.
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Affiliation(s)
- Yasaman Motlaghzadeh
- Stanford University School of Medicine, Division of Endocrinology, Gerontology and Metabolism, Palo Alto, CA 94305, USA
| | - John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Deborah E Sellmeyer
- Stanford University School of Medicine, Division of Endocrinology, Gerontology and Metabolism, Palo Alto, CA 94305, USA
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4
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Moyses-Neto M, Garcia TMP, Nardin MEP, Muglia VA, Molina CAF, Romao EA. Causes of hypercalcemia in renal transplant recipients: persistent hyperparathyroidism and others. ACTA ACUST UNITED AC 2021; 54:e10558. [PMID: 33909856 PMCID: PMC8075129 DOI: 10.1590/1414-431x202010558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 02/02/2021] [Indexed: 11/22/2022]
Abstract
Hypercalcemia is common in patients after kidney transplantation (KTx) and is associated with persistent hyperparathyroidism in the majority of cases. This retrospective, single-center study evaluated the prevalence of hypercalcemia after KTx. KTx recipients were evaluated for 7 years after receiving kidneys from living or deceased donors. A total of 301 patients were evaluated; 67 patients had hypercalcemia at some point during the follow-up period. The median follow-up time for all 67 patients was 62 months (44; 80). Overall, 45 cases of hypercalcemia were classified as related to persistent post-transplant hyperparathyroidism (group A), 16 were classified as "transient post-transplant hypercalcemia" (group B), and 3 had causes secondary to other diseases (1 related to tuberculosis, 1 related to histoplasmosis, and 1 related to lymphoma). The other 3 patients had hypercalcemia of unknown etiology, which is still under investigation. In group A, the onset of hypercalcemia after KTx was not significantly different from that of the other groups, but the median duration of hypercalcemia in group A was 25 months (12.5; 53), longer than in group B, where the median duration of hypercalcemia was only 12 months (10; 15) (P<0.002). The median parathyroid hormone blood levels around 12 months after KTx were 210 pg/mL (141; 352) in group A and 72.5 pg/mL (54; 95) in group B (P<0.0001). Hypercalcemia post-KTx is not infrequent and its prevalence in this center was 22.2%. Persistent hyperparathyroidism was the most frequent cause, but other important etiologies must not be forgotten, especially granulomatous diseases and malignancies.
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Affiliation(s)
- M Moyses-Neto
- Divisão de Nefrologia, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - T M P Garcia
- Divisão de Nefrologia, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - M E P Nardin
- Divisão de Nefrologia, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - V A Muglia
- Divisão de Nefrologia, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - C A F Molina
- Divisão de Urologia, Departamento de Cirurgia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - E A Romao
- Divisão de Nefrologia, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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5
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Xie D, Xu W, You J, Yuan X, Li M, Bi X, Zhang K, Li H, Xian Y. Clinical descriptive analysis of severe Pneumocystis jirovecii pneumonia in renal transplantation recipients. Bioengineered 2021; 12:1264-1272. [PMID: 33896387 PMCID: PMC8806328 DOI: 10.1080/21655979.2021.1911203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pneumocystis jirovecii (P. jirovecii) pneumonia (PJP) is an opportunistic fungal infection after renal transplantation, which is always severe, difficult to diagnose, combined with multiple complications and have poor prognosis. We retrospectively analyzed clinical data, including risk factors, diagnosis, treatment and complications of seven clinical cases suffered with severe PJP after renal transplantation in our department in 2019. All the seven recipients were routinely prescribed with PJP prophylaxis after renal transplantation, and six of them suffered acute graft rejection before the infection. P. jirovecii sequence was identified in blood or broncho-alveolar lavage fluid (BALF) by the metagenomic next-generation sequencing (mNGS) in all patients. All the patients were improved with the therapy trimethoprim-sulfamethoxazole (TMP-SMX) combined with caspofungin for the PJP treatment, but suffered with complications including renal insufficiency, leukopenia, thrombocytopenia, gastrointestinal bleeding, mediastinalemphysema, pulmonary hemorrhage, and hemophagocytic syndrome and other severe infections. Taken together, mNGS is a powerful tool that could be used to diagnose PJP in renal transplantation recipients. And PJP prophylaxis should be prescribed during and after treatment for acute rejection. TMP-SMX is the first-line and effective drug for PJP treatment, but the complications are always life-threatening and lead to poor prognosis. We should pay attention to these life-threatening complications.
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Affiliation(s)
- Dan Xie
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Wen Xu
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jingya You
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Xiaofeng Yuan
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Mingliang Li
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Xiaogang Bi
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Kouxing Zhang
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Heng Li
- Department of Kidney Transplantation, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Ying Xian
- Department of General Intensive Care Unit, Lingnan Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
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Nongnuch A, Petcharut J, Suksuwan W, Davenport A, Phuphuakrat A. Causes of hypercalcemia in people living with HIV in the HAART era. HIV Res Clin Pract 2020; 21:115-120. [PMID: 33076771 DOI: 10.1080/25787489.2020.1836900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hypercalcemia is an uncommon finding in people living with HIV (PLHIV). Causes of hypercalcemia in PLHIV have not been well documented. As such, we studied the causes of hypercalcemia in PLHIV. METHODS We conducted a retrospective review of PLHIV who had corrected serum calcium of ≥10.5 mg/dL between 2010 and 2019. Demographic data, associated diseases, and treatment details were collected. Corrected serum calcium levels were compared among the causes of hypercalcemia. RESULTS A total of 70 of 2168 (3.2%) PLHIV had hypercalcemia. Forty-nine (70.0%) were male with a mean age of 47.7 ± 4.7 years. Only two (2.9%) had symptoms of hypercalcemia. Fifty-four patients had identifiable causes of hypercalcemia; 21 infections (30.0%), 17 solid organ malignancies (24.3%), 14 hematologic malignancies (20.0%), and two other specific causes (2.9%). Mean corrected serum calcium concentrations of PLHIV who had solid organ malignancy, hematologic malignancy, infection, and unknown causes were 12.8 ± 2.1, 11.4 ± 1.0, 11.2 ± 0.6, and 10.8 ± 0.2 mg/dL, respectively. Corrected serum calcium levels were significantly greater in patients who had solid organ malignancy comparing to those with other causes of hypercalcemia (p < 0.05, all). Logistic regression identified solid organ malignancy as the only factor associated with moderate to severe hypercalcemia (odds ratio 12.72, 95% confidence interval 3.11-52.08; p < 0.001). CONCLUSIONS Hypercalcemia in PLHIV is associated with solid organ malignancy, hematologic malignancy, and infection. Most PLHIV with hypercalcemia are asymptomatic. Solid organ malignancy is associated with moderate to severe hypercalcemia, and as such PLHIV presenting with moderate to severe hypercalcemia should be investigated for solid organ malignancy.
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Affiliation(s)
- Arkom Nongnuch
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jutatip Petcharut
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Worramin Suksuwan
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - Angsana Phuphuakrat
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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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: 1] [Impact Index Per Article: 0.3] [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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8
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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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9
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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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10
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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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11
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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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12
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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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13
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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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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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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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Taweesedt PT, Disthabanchong S. Mineral and bone disorder after kidney transplantation. World J Transplant 2015; 5:231-242. [PMID: 26722650 PMCID: PMC4689933 DOI: 10.5500/wjt.v5.i4.231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/11/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
After successful kidney transplantation, accumulated waste products and electrolytes are excreted and regulatory hormones return to normal levels. Despite the improvement in mineral metabolites and mineral regulating hormones after kidney transplantation, abnormal bone and mineral metabolism continues to present in most patients. During the first 3 mo, fibroblast growth factor-23 (FGF-23) and parathyroid hormone levels decrease rapidly in association with an increase in 1,25-dihydroxyvitamin D production. Renal phosphate excretion resumes and serum calcium, if elevated before, returns toward normal levels. FGF-23 excess during the first 3-12 mo results in exaggerated renal phosphate loss and hypophosphatemia occurs in some patients. After 1 year, FGF-23 and serum phosphate return to normal levels but persistent hyperparathyroidism remains in some patients. The progression of vascular calcification also attenuates. High dose corticosteroid and persistent hyperparathyroidism are the most important factors influencing abnormal bone and mineral metabolism in long-term kidney transplant (KT) recipients. Bone loss occurs at a highest rate during the first 6-12 mo after transplantation. Measurement of bone mineral density is recommended in patients with estimated glomerular filtration rate > 30 mL/min. The use of active vitamin D with or without bisphosphonate is effective in preventing early post-transplant bone loss. Steroid withdrawal regimen is also beneficial in preservation of bone mass in long-term. Calcimimetic is an alternative therapy to parathyroidectomy in KT recipients with persistent hyperparathyroidism. If parathyroidectomy is required, subtotal to near total parathyroidectomy is recommended. Performing parathyroidectomy during the waiting period prior to transplantation is also preferred in patients with severe hyperparathyroidism associated with hypercalcemia.
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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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Pneumocystis Jirovecii Pneumonia in Renal Transplant Recipients: A National Center Experience. Transplant Proc 2013; 45:1614-7. [DOI: 10.1016/j.transproceed.2013.02.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 02/05/2013] [Accepted: 02/27/2013] [Indexed: 01/06/2023]
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