Sarcoidosis Presenting with Acute Renal Failure, Hypercalcemia and Hyperkalemia

Presentation Number: FRI 330
Date of Presentation: April 1st, 2016

Regina Belokovskaya*1, Francisco Perez Mata2 and Oksana Davydov1
1Mt. Sinai St. Luke's Roosevelt Hospital, New York, NY, 2Mount Sinai St. Luke's and Mount Sinai Roosevelt Hospitals, New York, NY

Abstract

Introduction: Sarcoidosis is a chronic multisystem granulomatous disease of unknown etiology, which is characterized by the presence of noncaseating granulomas in involved organs. Of the patients diagnosed with sarcoidosis, 35 to 50 percent develop renal complications. Patient described here, was found to have sarcoidosis when he presented with acute renal failure, hyperkalemia, and mild hypercalcemia.

Clinical Case: A 55-year-old male with past medical history of right obstructing kidney stone and herpes zoster with post-herpetic neuralgia was referred to the emergency room for elevated creatinine. Few weeks prior to this admission, the patient  received calamine lotion and Tylenol treatment during his trip to Dominican Republic. He complained of unintentional weight loss over the last four months and a burning pain on the left chest wall at the site of the herpes zoster infection. On exam, he was hemodynamically stable with well crusted vesicular lesions in left-sided T2-T3 distribution on chest, back, and axilla. His laboratory values were significant for Creatinine of 7.59 mg/dL (0.66-1.25), BUN of 57 mg/dL (8-24), Sodium of 135 mmol/L (136-146), Potassium of 5.3 mmol/L (3.5-5.1), Calcium of 13.5 mg/dL (8.4-10.3), Phosphorus of 7.4 mg/dL (2.5-4.5), intact PTH of 3.72 pg/mL (11-67), Vitamin D 25-OH of 23.8 ng/dL (30-95), Hemoglobin A1C of 6.9 % (4.2-5.9). Hemoglobin and hematocrit were within normal limits. The complements came back within normal limits with negative ANA. HIV and Hepatitis C were negative, with reactive Hepatitis A Ab, Hepatitis B core and surface Ab.  Urinalysis showed moderate blood, glucose of 500, protein of 100, and a presence of moderate Calcium Oxalate crystals. Chest X-ray was negative for any acute pulmonary process. Ultrasound of the bilateral kidneys did not reveal any stones or hydronephrosis. Skeletal survey did not identify any lytic or blastic osseous lesions. Despite Normal Saline infusion at 150 cc/hr, Calcium remained elevated. Angiotensin-converting enzyme came back elevated at 82 (9-67 U/L). CT chest without IV contrast demonstrated airspace opacities in the right middle and lower lobes along with interlobular septal thickening. IR guided kidney biopsy showed granulomatous interstitial nephritis with diffuse interstitial inflammation including eosinophils - compatible with sarcoidosis. Initially, patient was started on pulse steroids, Solumedrol 40 mg every 6 hours IV and then PO Prednisone 1mg/kg. At the completion of his hospital stay, patient’s Creatinine decreased to 2.89, Calcium normalized at 9.6, and Potassium at 4.9. He was discharged on Prednisone 60 mg PO daily with close renal, endocrine and pulmonary follow-up.

Conclusion: Non-PTH mediated hypercalcemia, hyperkalemia, and acute renal failure in an asymptomatic patient should prompt a work-up for sarcoidosis.

 

Nothing to Disclose: RB, FP, OD