Endocrine Abstracts

Background: Sarcoidosis is an inflammatory granulomatous multisystem disorder commonly presenting with noncaseating granulomas in lung and lymphoid tissue. Other organs like skin, eye and joints also involved.

Case report: We present a 62-year-old diabetic woman presented to the emergency with progressive alteration in sensorium and left hemiparesis for two days. Patient had lower respiratory tract associated with recurrent hypoglycaemic attacks two weeks back and resolved after a course of antibiotics. She had neck stiffness and left gaze deviation. Biochemistry revealed blood urea – 72 mg/dl, serum creatinine – 1.8 mg/dl, HbA1C – 6.7. Corrected calcium – 15.5 mg/d and phosphorous – 4.4 mg/dl. It suggested hypercalcaemia crisis with normal phosphorous levels. Further evaluation revealed Parathyroid hormone - 19.2 pg/ml and 25hydroxy vitamin D – 45.6 ng/ml levels which were normal. CSF analysis MRI brain serum immunoelectrophoresis which were normal ruled out meningitis, stroke and myeloma respectively. PET MRI whole body was done to rule out malignancy which revealed enhanced uptake in mediastinal lymph nodes. Sr ACE levels were elevated with 87 unit/l. Fibre optic Bronchoscopy was done and biopsy of lymph nodes revealed noncaseating granulomas. Biopsy was negative for acid fast bacilli and gene expert which ruled out tuberculosis. All the above investigations suggested sarcoidosis presenting as hypercalcaemia encephalopathy. Intravenous fluids to relieve dehydration and pamidronate 90 mg infusion was given to patient. Serum calcium levels settled down to normal gradually over two days to 10.2 mg/dl and sensorium improved. Patient was started on prednisolone 60 mg with tapering doses and monitored for next three months till steroids were stopped.

Discussion: Sarcoidosis usually presents with Hypercalcaemia as either renal failure or pancreatitis however encephalopathy is a rare manifestation. In our case encephalopathy with localising signs like left hemiparesis masqueraded as cerebrovascular stroke. Common causes of Hypercalcaemia include primary hyperparathyroidism, malignancy, milk alkali syndrome etc. Increased activity of 1 alpha hydroxylase enzyme in alveolar macrophages which converts 25 hydroxycholecalciferol into active form of 1,25 dihydroxycholecalciferol is the common cause of Hypercalcaemia in sarcoidosis. Other causes include increased production of parathyroid hormone related protein which, causes upregulation of 1 alpha hydroxylase.

Conclusion: Hypercalcemia can masquerade as stroke and should be evaluated when presented as metabolic encephalopathy with normal brain imaging. Sarcoidosis is a rare cause of hypercalcemic encephalopathy and is easily treatable when compared with primary hyperparathyroidism and malignancy related Hypercalcemia.