Endocrine Abstracts

Background: Hypercalcemia is not uncommon in granulomatous disorders, especially sarcoidosis and tuberculosis. Prevalence in sarcoidosis may be 2-63%, depending on the population studied. Uncontrolled synthesis of 1,25-dihydroxyvitamin-D by the macrophages is the underlying mechanism. Here we present a case of hypercalcemia, initially thought to be due to hypervitaminosis-D but later diagnosed to have sarcoidosis.

Case Presentation: This 49-year-old gentleman presented to the casualty in Nov 2019 with symptoms of 3 days duration suggestive of hypercalcemia. There was recent history of consumption of 60,000 units/day of cholecalciferol for 1 week. He did not have history of fever, unintentional weight loss, cough or kidney stones. The corrected serum calcium was 15 mg/dl, creatinine 3.1 mg/dl, parathyroid hormone 4.5 pg/ml and 25-hydroxyvitamin-D 69.5 ng/ml.A probable diagnosis of vitamin-D toxicity was made. He was treated for hypercalcemia as per standard of care and intravenous hydrocortisone was given. His serum calcium normalised and was discharged on oral prednisolone of 20 mg/day tapered over 1 month. In Nov 2020, patient presented with high normal calcium with normal vitamin-D levels. Serum ACE was found to be 154.38 U/l. CT Chest and USG abdomen revealed multiple nodules in lungs, spleen and liver with mediastinal lymphadenopathy and bilateral nephropathic changes. PET-CT revealed multiple enlarged metabolically active lymph nodes in chest and abdomen. Lung parenchymal biopsy and immunohistochemistry confirmed sarcoidosis. He was started on 60 mg of oral prednisolone gradually tapered to 10 mg/day. Serum calcium has become normal with improvement of renal function.

Conclusions: In this case, occult sarcoidosis with high normal serum calcium deteriorated to severe, symptomatic hypercalcemia because of cholecalciferol overdose. Follow up with normalization of serum 25-hydroxyvitamin-D and regular monitoring of serum calcium led to the detection of subclinical sarcoidosis.