W3S1:
The patient was treated with dextromethorphan (anti-tussive), and sevelamer 1600 mg. Calcium carbonate and alfacalcidol had been stopped.
Two months later, the patient presented to the clinic with severe abdominal pain and vomiting. She was constantly complaining of a dry cough. Examination revealed multiple purple tender plaques over the back of the neck.
Pariser, Robert J., MD; Paul, Joan, MD, MPH; …Show all. Published April 30, 2013. Volume 68, Issue 5. © 2012.
Follow-up of her laboratory work-up is shown in Table-2
|
Test |
Value |
|---|---|
|
S. Creatinine |
3.6 mg/dL |
|
S. corrected Calcium |
13 mg/dl |
|
S, Phosphorus |
5.1 mg/dl |
|
iPTH |
80 pg/mL |
|
Hemoglobin (Hgb) |
10.4 g/dl |
C. Interpret the above laboratory investigations.
D. Would you order any further investigations?
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C. Interpret the above laboratory investigations.
Worsening lab results hypercalcemia, decreasing PTH, multiple purple tender plaques over the back of the neck
skin lesion looks like sarcoidosis
D. Would you order any further investigations?
chest x ray, HRCT , ACE level , skin biopsy to check for granulomas, HRCT chest, chest CT, LFT , tuberclin test to exclude TB , 1,25 VitD, TB screen, full pulmonology assessment
Persistent dry cough and worsening hypercalcaemia.
PTH below the target (inappropriately suppressed to the degree of hypercalcemia).
Skin lesion looks like sarcoidosis Plaque.
Pulmonology consultation
CXR
1,25 VitD
ACE level
tissue biopsy
C – worse Calcium level ⬆️
PTH ⬇️
D same pervious add skin biopsy
Interpret the above laboratory investigations.
Worsening lab results hypercalcemia, decreasing PTH looks like sarcoid disease
Would you order any further investigations?
review all taken medication we need chest x ray, HRCT , ACE level
biopsy from affected organ LN, HRCT chest
Worsening hypercalcemia, worsening PTH suppression,
painful papules, persistent cough
exclude sarcoidosis, 25OH vitamin D, 1,25OH vitamin D, ACE level, HRCT chest, quantiferone test
Worsened hypercalcemia and hyperphosphatemia decrease PTH
chest ct skin biopsy
Worsening hypercalcaemia
Improvement of hyperphosphatemia
PTH level decreased more
25 OH vit D , 1,25 OH vit D , ACE level , CXR
There is worsening of her condition, hypercalcimia , hyperphosphatemia, decrease PTH , persistent dry cough.
I will think more in granuloumatous lung disease
So order another CXR if the previous not informative , HRCT , TB screen , ACE level and 1,25 vit D 3 level.
In edition to Skin lesion biopsy or LN biopsy.
C.ca level increased , phosphorus level improved while PTH getting lower
D)test for TB
and ACE level to check sarcoidosis.
C: worsening hypercalcemia, and improved PTH and Phosphate
D: 1,25(OH)D and 25(OH)D levels
Tests for TB
s-ACE if not already done
CXR + CT chest
C. Interpret the above laboratory investigations.
1-No difference in s.cr levels and Hgb level.
2-More elevation of s calcium .
3-Improved S phosphorus .
4-More suppression of iPTH .
5- Persistent dry cough .
D. Would you order any further investigations?
1- Chest X ray .
2-1,25 OH vitamin D level .
3- ACE level .
4- Tuberculin skin test .
Hypercalcemia has progressed (despite stopping CaCO3 and vitD3)
PTH is suppressed (by the high Ca)
Slight improvement in PO4
the skin lesions are typical of Papular Sarcoidosis
So I will direct my investigations towards this line (CXR/HRCT/ACE/Biopsy of skin lesions)
Interpret the above laboratory investigations.
progressive hypercalcemia,serum phosphorus decreased (become within target),PTH level decreased from the previous lab(low bone turn over) and anaemia.
Would you order any further investigations?
persistent cough not responding to medical treatment,skin nodules and symptomatic hypercalcemia suggestive of gramnulomatus lung disease( TB or sarcoidosis)
1- chest radiology HRCT chest( hilar lymphadenopathy,pulmonary infiltrates and fibrosis)
2-1,25 OH vitamin D level
3- ACE level
4- Tuberculin skin test
This patient has hypercalcemia and hyperphosphatemia along with normal PTH.addin to that, he has skin rash and chest symptoms all these findings in favour of sarcoidosis.
so this patient has skin rash which is Erythema Nodosum and all this can be found in sarcoidosis.
this patient will need to do a chest x ray
1,25 vit D level
will need full pulmonology assessment
C. Interpret the above laboratory investigations.
CKD 5 HD-Hypercalcemia-Mild Hyperphosphatemia-Hyperphosphatemia
D.Would you order any further investigations
CXR
ACEI level
Vitamin D
Exclusion of TB by checking tuberculin skin test
C. Interpret the above laboratory investigations.
ESRD with hypercalcemia, hyperphosphatemia, hyperparathyroidism and anemia
D. Would you order any further investigations?
Good, I can see that i am thinking in the right direction, Sarcoidosis is the most probable reason for this patient hypercalcemia and hyperphosphatemia due to increase conversion of 25 Vit D to 1-25 Vit D due to abundant macrophages and increase 1-alpha hydroxylase enzymes. High 1-25 Vit D increases the intestinal absorption of Ca, and ph.
I would order CXR to check if there is parahilar lymphadenopathy or pulmonary micronodular, ACE level, and skin biopsy.
tuberculin test
vit d level
CXR
ACE level
pan CT
LN biopsy ifpresent
C- As compared to the previous labs :
no difference in s.cr levels and Hgb level
persistantly elevated s.calcium
improving s po4
more suppressed iPTH
The above investigation revealed
Impression;
Non-PTH cause of hypercalcemia
With the above image patient most probably have Sarcoidosis
Further investigation
C- interpretation of investigation marked hypercalcimia and it’s emergency decrease level of pth and po4still anemia present.
D- further investigation needed must do CT chest to exclude sarcoidosis,TB dueto persistence of chest complain also sarcoidosis causing hypercalcimia
Progressive hypercalcemia, despite stopping calcitriol and ca containing P binder combined with cough, brings situations like sarcoidosis. Here we expect high levels of 1,25 vitamin d.
Chest x-ray and or chest CT is good to evaluate lymphadenopathy
pt. follow up and presented after 2 month later in clinic
complain of >>abdominal pain , still dry cough , skin lesion over back of the neck
and lab . revealed >>still hypercalcemia , hyperphosphatemia low iPTH
so re-evaluate the pt. and further investigation
DD sarcoidosis , TB lung
on examination ;- looking for lymph node and listen heart and lung
and check for organomegaly liver or spleen
investigation recommended
chest x-ray >>>> granuloma and enlarged lymph node
chest CT and lung function test
biopsy for skin lesion
C. Patient has worsening of her clinical features with the skin lesion mostly plaque of sarcoidosis and worsening of her s.Ca, s. Phosphate and PTH
D. Chest x-ray and CT scan of chest, 1,25 vitD and Ace level and biopsy for Lymph node if enlarged.
Agree, the patient has persistent hypercalcemia, dry cough and skin lesions likely erythema nodosum, so consideration of granulomatous lung disease like sarcoidosis and TB is appropriate.
WORSINING HYPERCALCEMIA DESPITE STOPING CALCIUM AND ALFACALCIDOL POINTED TO OTHER CAUSES MOSTLIKLY SARCOIDOSIS BUT MALIGNANCY NEEDS TO BE EXCLUDED , FURTHER INVESTIGATION INCLUDING SKIN BIOPSY , CT SCAN CHEST ABD , ACE LEVEL
1,25 OH vit D is considered. Exclusion of granulomatous lung disease like sarcoidosis and TB would be helpful.
C. Interpret the above laboratory investigations.
· CKD- 5 D.
· within target range Hb %
· hypercalcemia, hyperphosphatemia and PTH ( adynamic bone disease.)
D. Would you order any further investigations
Common tests & procedures
· physical examination: lung sounds. Observation of the lymph nodes for any swelling.
· 1,25(HO)vit D——-
· chest : Xray
· High resolution CT scan .
· pulmonary function test
· Bronchoscopy with Endobronchial ultrasound (EBUS) bronchoscopy .
· PET
· Eye examination ; to check the vision problem.
· Skin biopsy may be taken to check for granulomas.
Thanks for the detailed answer!
D- vitiamin d, 1-25 oH , ACE, CXR
Thanks! Exclusion of TB as a granulomatous lung disease should be considered.
C- CKD 5 , Hypercalcaemia not PTH driven
skin lesion and dry cough likely sarcoidosis
C. Interpret the above laboratory investigations.
D. Would you order any further investigations?
Great! Exclusion of TB as a granulomatous lung disease should be considered.
Interpret the above laboratory investigations.
ESRD with persistent hypercalcemia, normal PO4, a dry cough, and low PTH
subcutaneous fat necrosis may be secondary to hypercalcemia
Epigastric pain may be a manifestation of hypercalcemia.
Hypercalcemia in dialysis patients is most commonly due to the excessive use of calcium-based binders or the use of vitamin D receptor agonists, followed by malignancy-associated hypercalcemia.
As the calcium and one alfa stopped and still hypercalcemic with the persistent symptoms of a dry cough. Malignancy and sarcoidosis should be excluded.
Our differential diagnoses included hypercalcemia caused by a solid malignancy (destructive bone metastases or production of parathyroid hormone-related peptide (PTHrp)), a lymphoproliferative disorder (destructive bone lesions or production of PTHrp/1,25-dihydroxy vitamin D), or granulomatous disorders like sarcoidosis or tuberculosis, which produce 1,25-dihydroxy vitamin D. Ultimately, multiple myeloma.
D. Would you order any further investigations?
Send 25-OH Vit D, 1,25-dihydroxy vitamin D, angiotensin-converting enzyme (ACE), PTHrp, protein electrophoresis, ESR
Do a CT full-body scan with contrast.
Serum 1,25-dihydroxyvitamin D3 concentrations are increased in granulomatous disease and suppressed in cancer.
Great! The skin lesions are rather erythema Nodosum which may denote a granulomatous disease such as sarcoidosis or TB.
C- As compared to the previous labs :
1-no difference in s.cr levels and Hgb level
2-persistantly elevated s.calcium
3-improving s po4
4-more suppressed iPTH
D- 1- CXR
2- ACE level
3- pan CT
4- LN biopsy if found in radiology
We may consider 1,25 OH vit D and tuberclin test
C.Persistent hypercalcemia and hyperphosphatemia.
Relatively low PTH
Hb in target for dialysis patients
D. HRCT, bronchoscopy and lymph nodes biopsy.
Skin lesions biopsy (granulomas?)
ECG changes ?
ACE level
We may consider 1,25 OH vit D and tuberclin test
C-CKD 5D (with sever hypercalcemia sx and sx suggestive of sarcoidosis in view of (erythema nodosum ,respiratory symptoms and hypercalcemia)
SEVERE HYPERCALCEMIA
HYPERPHOSPHATEMIA
LOW PTH
HB in target
============
D:
hypercalcemia sx and sx suggestive of sarcoidosis in view of (erythema nodosum ,respiratory symptoms and hypercalcemia)
order,
CXR HRCT ,ACE
BAL,LUNG BIOPSY
PFT(RESTRICTIVE PATTERN )
ECG (CONDUCTION DEFECT )
S AMYLASE (TO R/O PANCREATITIS )
Great! we need to check serum 1,25 OH vit D as well
C. Interpret the above laboratory investigations.
D. Would you order any further investigations?
The skin lesions are impressive of erythema nodosum possibly a part of granulomatous disease such as TB or sarcoidosis. We may consider 1,25 OH vit D and tuberclin test.