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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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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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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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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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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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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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Aguirre AR, Balbo BEP, Ianhez LE, da Costa MC, Andrade L. Hypercalcemia and Suppressed PTH Levels in a Renal Transplant Patient Infected withPneumocystis Carinii. Ren Fail 2009; 29:513-6. [PMID: 17497478 DOI: 10.1080/08860220701275014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Pneumocystis carinii pneumonia is a serious and relatively common complication of immunosuppressive therapy. In immunocompromised patients, P. carinii pneumonia can cause significant morbidity and mortality. Another common complication, typically seen in the subpopulation of renal transplant recipients, is hypercalcemia. The prevalence of hypercalcemia varies, reaching as high as 71%. We report the case of a renal transplant recipient who developed P. carinii pneumonia and hypercalcemia, the latter being resolved after the successful treatment of the former. We argue that there is a causal relationship between P. carinii pneumonia and hypercalcemia in renal transplant recipients. In immunocompromised patients, pulmonary infection accompanied by hypercalcemia should raise the suspicion of P. carinii pneumonia.
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Affiliation(s)
- Anna Rita Aguirre
- Intensive Care Unit, Nephrology Department, University of São Paulo School of Medicine, São Paulo, Brazil.
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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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Chen WC, Chang SC, Wu TH, Yang WC, Tarng DC. Hypercalcemia in a renal transplant recipient suffering with Pneumocystis carinii pneumonia. Am J Kidney Dis 2002; 39:E8. [PMID: 11840399 DOI: 10.1053/ajkd.2002.30578] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hypercalcemia occurs frequently after renal transplantation. Preexisting hyperparathyroidism is the most common cause of post-transplantation hypercalcemia. We describe a renal transplant recipient infected with Pneumocystis carinii pneumonia (PCP) who developed hypercalcemia, elevated 1,25-dihydroxyvitamin D, and suppressed parathyroid hormone levels. This phenomenon mimics the extrarenal production of 1,25-dihydroxyvitamin D by activated alveolar macrophages in granulomatous diseases with hypercalcemia. To the best of our knowledge, this is the first report of 1,25-dihydroxyvitamin D-mediated hypercalcemia caused by PCP in a renal transplant recipient. This entity should be included in the differential diagnosis for renal transplant recipients with hypercalcemia, especially in patients who develop lung infections.
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Affiliation(s)
- Wen-Chin Chen
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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