Endocrine Abstracts

A 54-year-old man was admitted to hospital with a new diagnosis of Miliary Pulmonary Tuberculosis (TB). Early in admission he developed septic shock with multiorgan failure requiring organ support and anti-TB medications. Recovery was complicated by persistently low Glasgow coma score (GCS), noradrenaline dependency and limb threatening microvascular injury. At day-25 he was apyrexial but remained hypotensive and drowsy with no evidence of sepsis or hypoadrenalism. Over the next 48 hours, he showed signs of rapid recovery as alertness normalised and blood pressure improved; noradrenaline was withdrawn, allowing him to leave bed and engage in active rehabilitation. He was found to be mildly hypocalcaemic and severely vitamin D deficient. Vitamin D replacement was commenced with a weekly Colecaliferol (40,000 units) regime. Unexpectedly, recovery was severely setback during Vitamin D replacement which unmasked refractory symptomatic hypercalcaemia. This case raises three important points:

1) Current Vitamin D replacement guidance advocates the use of loading doses Vitamin D. This case highlights the risks of Vitamin D loading doses which should be avoided or used with caution in selected cases.

2) It seems prudent to stratify critically ill patients with granulomatous disease into a closely monitored group with cautious vitamin D replacement and close monitoring of calcium, phosphate, parathyroid hormone and Vitamin D levels.

3) While vitamin D-mediated hypercalcaemia in sarcoidosis is well described this case suggests that clinicians should be aware of the same phenomenon occurring in TB patients which has only been described in rare case reports.