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1998 Presentations for the Poster and Vignette Sessions
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HYPERCALCEMIA ASSOCIATED WITH SARCOIDOSIS. M. Flejsierowicz, M.D., S.B. Magill, M.D., PhD Sinai Samaritan and St. Luke's Medical Centers, Milwaukee, WI.

A 34 year old white male presented to his primary care physician with a two week history of polyuria, polydypsia and generalized fatigue. Initial evaluation included comprehensive metabolic panel which revealed a serum calcium of 16.7 mg/dl, creatinine of 2.5 mg/dl and BUN of 38 mg/dl. The patient was admitted to the hospital for further evaluation and treatment. He denied any other complaints, including nausea, vomiting, constipation or weight loss. He admitted to having intermittent night sweats. The patient owns and operates construction company with his wife and works outdoors. At presentation the patient had a clear sensorium. He had a deeply tanned appearance. Physical exam including neurological exam was unremarkable. Admission chemistries: Na 142 mmol/l, K 3.8 mmol/l, Cl 102 mmol/l, bicarbonate 29 mmol/l, BUN 38mg/dl, creatinine 2.7 mg/dl, glucose 82mg/dl, calcium 13.5 mg/dl, ionized calcium 1.67 mmol/l (1.17­1.31) and phosphorous of 3.9 mg/dl. Chest X ray and CT imaging demonstrated mediastinal and bilateral hilar adenopathy. The patient underwent mediastrinoscopy. Biopsy of the paratracheal lymph nodes revealed non necrotizing granulomatous inflammation consistent with sarcoidosis. He was treated with IV hydration and IV pamidronate. Other laboratory data included: PTH­relate peptide of 0.6 pmol/L an ACE level of 85 U/L, 1.25 (OH) 2 Vit D of 87, 25(OH) 2 Vit D of 41 ng/ml. By the time of discharge ionized calcium was 1.47 mmol/l, creatinine had corrected to 1.8 mg/dl. BUN was 23 mg/dl.

Sarcoidosis is a multisystem disease of unknown etiology. Hypercalcemia occurs in 10% of cases, almost exclusively in patients with pulmonary involvement. Abnormalities of calcium metabolism are secondary to dysregulated production of 1,25(OH) 2 Vit D by activated macrophages within sarcoid granulomas. There have been previous reports of hypercalcemia induced by sun exposure in patient with sarcoidosis. We speculate that the significant sun exposure this patient received may have contributed to substrate availability for non renal production of 1,25 (OH)2 Vit D and exacerbated the degree of hypercalcemia.

Treatment: The drug of choice is prednisone 20­40mg/d. Chloroquine or hydrochloroquine are alternative agents if there is a contraindication to use of corticosteroids. We used pamidronate given the degree of hypercalcemia with initial presentation.

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