CASE HISTORY – July – August 2008

A patient with chronic renal failure and hypercalcemia: a case history


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A patient with chronic renal failure was referred to the endocrinologist due to hypercalcemia. The patient had visited the nephrologist and the urologist for regular follow-ups due to nephrolithiasis and chronic renal failure during the 2-year period 2003−2005 and had developed repeatedly hydronephrosis of the right kidney. Serum calcium was not determined until 2005. In order to clarify the cause of hypercalcemia, the patient underwent a systematic examination in the Department of Internal Diseases of Tartu University Hospital. The level of ionized calcium level had been between 1.59 and 1.7 mmol/l and the level of serum creatinine had reached 528 μmol/l during the episodes of hydronephrosis. The patient’s parathormon was suppressed, which excluded the primary hyperparathyroidism as the cause of hypercalcemia. Elevated levels of angiotensin converting enzyme (200 U/l, normal range 8-52 U/l) and enlarged mediastinal lymph nodes and peribronchovascular nodules on computered tomography were suggestive of sarcoidosis. Histological examination of the foci revealed a typical sarcoidosis. Treatment with prednisolone, 40 mg daily, led to a significant improvement of patient symptoms. The level of serum calcium  returned to normal in three weeks and serum creatinine dropped to 248 μmol/l. However, two months later the patient was admitted to the intensive care unit with a clinical picture of septic shock probably due to fulminant pneumonia as suggested by chest X-ray. After 10 hours the patient died. On autopsy, the lungs, the hilar and the mediastinal lymph nodes as well as the liver and the spleen were affected by fibrotic sarcoidosis whereas no patomorphologic features of pneumonia were found in the lungs. However, considering the clinical and X-ray findings, pneumonia as the primary cause of death can not be excluded in this particular case. The treatment with prednisolone may have facilitated the fulminant course of infectious disease. In the discussion the role of the active form of vitamin D − 1,25(OH2)D3 − in occurence of hypercalcemia in sarcoidosis is delineated and the natural history of the disease in the depicted case is analysed. It is important to emphasize that in patients with nephrolithiasis the measurement of the level of serum calcium is necessary and, if elevated, prompt elucidation of the etiology of hypercalcemia is desirable. In diseases like primary hyperparathyroidism and sarcoidosis hypercalcemia is potentially curable.