Hypercalcemia

Dr. Brook Pittenger presented a case of a 66-year-old veteran with history of hypothyroidism and episodic conjunctivitis who presented with symptomatic hypercalcemia (myalgias, constipation, AKI), and bilateral hilar LAD concerning for sarcoidosis.

We reviewed a hypercalcemia framework (taken from Frameworks for IM by Dr. Andre Mansoor) and targeted workup/management based on this framework.

Hypercalcemia Framework.JPG

Patient was treated with IVF. Calcitonin, bisphosphonates and steroids deferred on admission. Per Dr. Pittenger’s review of the literature, bisphosphonates may be beneficial for long term remission (cases series 3 patients, Arch Osteoporos 2017). Patient was subsequently started on prednisone and is symptomatically improving with down trending serum Ca++. Bronchoscopy and biopsy obtained today for confirmation. 

A definitive diagnostic test for sarcoidosis does not exist. Diagnosis requires: compatible clinical and radiographic manifestations, exclusion of other diseases that may present similarly, histology showing noncaseating granulomas. The main exceptions to the need for biopsy are the presence of bilateral hilar adenopathy in an asymptomatic patient who can be monitored and the presentation of Lofgren’s syndrome (fever, erythema nodosum, arthralgias and bilateral LAD).