Abstract
Non-PTH mediated hypercalcemia has multiple etiologies including medications. There are some case reports showing TNF-alpha inhibitors causing sarcoidosis or sarcoidosis type presentation involving lungs, skin, lymph nodes, and kidneys.
We report here a 69-year-old male with a past medical history of prostate cancer status post prostatectomy (in remission), CKD stage 3, and seronegative rheumatoid arthritis who was sent to the ED from clinic due to hypercalcemia. On admission, patient had a calcium level of 14.2 (8.7–10.4 mg/dL), albumin 4.1 (3.4–4.8 g/dL), magnesium 2.0 (1.3–2.7 mg/dL), creatinine 2.5 (0.7–1.3 mg/dL), iPTH <2 (14–88 pg/mL), PSA 0.13 (0–4 ng/mL), 25-OH vitamin D 45.3 (30–100 ng/mL), 1,25-OH vitamin D 144 (19.9–79.3 pg/mL), alkaline phosphatase 46 (46–116 U/L) along with generalized weakness, nausea, vomiting, poor appetite, decreased oral intake, dizziness, and slight epigastric pain. Patient was given IV fluids and a dose of Reclast 3.3 mg IV was given 2 days after admission. At home for at least the past year before admission, patient was on etanercept for seronegative rheumatoid arthritis which was held on admission. CT thorax was done which showed geographic ground glass worst in the bilateral upper lobes where there is interlobular septal thickening and interstitial consolidation highly suspicious for interstitial pneumonitis and reactive appearing mediastinal lymphadenopathy. During the admission PTH-rP was 2.5 (0–2.3 pmol/L) and angiotensin converting enzyme was 36 (9–67 U/L). Based on previous case reports, etanercept was held. Upon discharge 6 days later, calcium had improved to 10.0 mg/dL, albumin 3.3 g/dL, and creatinine to 1.5 mg/dL. Upon follow up, etanercept was continued to be held. One month later, calcium level improved to 9.2 mg/dL, albumin 4.0 g/dL, iPTH 187 pg/mL, PTH-rP 3.0 pmol/L, and 1,25 OH vitamin D 50.7 pg/mL. Patient’s calcium levels remained within normal range for over one year after admission and 1,25-OH vitamin D remained normal. Moreover, patient had nuclear medicine parathyroid scan which showed no evidence parathyroid adenoma. An ultrasound thyroid was done which was negative for any thyroid/parathyroid mass or nodule. Whole body bone scan was done which showed no evidence of osseous metastatic disease. Given up trending PTH-rP levels, patient was evaluated by oncology and was found to be up to date on age recommended cancer screening and no evidence of current malignancy. Repeat CT thorax done over one year later showed stable to mildly improved bilateral ill-defined centrilobular ground glass nodules in both lungs, greater on the left side, may represent improving infectious/inflammatory process. In conclusion, when in doubt, a good medication review is essential in the evaluation of hypercalcemia because TNF-alpha inhibitors like etanercept may cause a sarcoidosis like presentation.
A Severe Rash (Questions)