The following laboratory investigations have been performed
|
Test |
Value |
|
S. TSH |
1.3 mU/L (0.5-5) |
|
S. free T4Â |
19 pmol/dL (11.0-21.0) |
|
S. free T3 |
5.1 mg/dL (3.1-6.0) |
|
S. Total protein |
7.4 g/dL (6.4-8.3) |
|
Gamma globulin |
0.78 g/dL (0.7-1.6) |
|
25(OH) D |
29 ng/ml (20-40) |
|
1,25 (OH) D |
123 ng/ml |
Â
Chest X-ray revealed symmetric hilar and mediastinal adenopathy and bilateral pulmonary micronodules.
E. What is the most likely cause of the patient’s hypercalcemia?
F. How would you manage this patient in view of his current work-up?Â
G. Discuss the prognosis of this patient.
You must be logged in to post a comment.
You cannot copy content of this page
This lab investigations are consistent with sarcoidosis (high 1,25 vit D) beside normal total Ig
F- steroid oral for sarcoidosis for suppression of PMN and lymphocytes, NSAIDs for arthralgias
methotrexate and hydroxychloroquine could be used
restriction of vit D and calcium intake
avoidance of sunexposure
G- according to the number and severity of organ involvement.
E. What is the most likely cause of the patient’s hypercalcemia?
Sarcoidosis
F. How would you manage this patient in view of his current work-up?
G. Discuss the prognosis of this patient.
*Non-pharmacological approach: avoid sun exposure and decrease dietary Ca.
*Pharmacological approach: immune suppression, first option steroid and should guard against steroid adverse effect.
A-sarcoidosis
B- steroids and immune suppression
c- good prognosis
What is the most likely cause of the patient’s hypercalcemia?
Sarcoidosis
How would you manage this patient in view of his current work-up?
Discuss the prognosis of this patient
good but depend on clinical condition assossiated with like pulmonary state , cardiovascular or neurological
Sarcoidosis
start CS
good prognosis, infrequent recurrence
The most likely diagnosis is Sarcoidosis.
Management:
start steroid
..methotrexate
prognosis generally is good
Sarcoidosis
Oral prednisone at a dose of 20 to
40 mg per day for 3 months is usually the initial recommended therapy
If a response is noted at 3 months, the prednisone dose should be tapered to 10 to 15 mg per day for an additional 6 to 9 months and then tapered off.
recurrence is possible, patients should be followed closely for 1 to 2 years after discontinuing treatment
Overall, spontaneous remission with few or no consequences occurs in more than 50% of patients within 3 years of diagnosis and in two thirds of patients within a decade. After one or more years of remission without treatment, recurrence occurs in fewer than 5% of patients. Up to one third of patients have unrelenting disease that leads to significant organ impairment, but less than 5% of patients die from sarcoidosis. Black Americans tend to have a worse prognosis with more chronic disease and more extrathoracic involvement of the eyes, liver, bone marrow, extrathoracic lymph nodes, and skin. In the absence of extrathoracic disease, patients with stage I radiographs generally have the best prognosis. Pulmonary function testing is more reliable in determining prognosis than is radiograph staging. Patients with neurologic and cardiac involvement have a poorer prognosis.
The most likely diagnosis is sarcoidosis
treatment mainly supportive
steroid
IS like MTX
physiotherapy
the prognosis generally is good but depends on the stages of lung involvement and cardiac involvement.
E- sarcoidosis
F-
Treatment in patients with pulmonary involvement is as follows:
Noncorticosteroid agents include the following:
G- As this is stage 2 so remission 60-7-%
chest radiographic clearing 31%
Mortality 11%
E. What is the most likely cause of the patient’s hypercalcemia?
Sarcoidosis
F. How would you manage this patient in view of his current work-up?
Symptomatic treatment
Avoid calcium and Vit D supplementations and decrease dietary intake .
Avoid Sun exposure .
Steroid .
G. Discuss the prognosis of this patient
Spontaneous remission occurs in 60–80% of radiographic stage I patients,
50–60% of stage II patients, and fewer than 30% of stage III patients.
E: Sarcoidosis – Stage 2
F: Treatment for this patient would be Steroid therapy, if patient cannot tolerate steroids,
then consider MTX
If patient has any other systemic affliction, then we can can consider the use of NSAID
for arthropathies
G: Prognosis is determined by the degree of pulmonary involvement and extra-
pulmonary disease
E -> Sarcoid Disease
F ->
G ->
Good prognostic signs include
Poor prognostic signs include
What is the most likely cause of the patient’s hypercalcemia?
Sarcoidosis stage II
How would you manage this patient in view of his current work-up?
Nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for the treatment of arthralgias and other rheumatic complaints.
Corticosteroids can produce small improvements in the functional vital capacity and in the radiographic appearance in patients with more severe stage II
Methotrexate (MTX) has been a successful alternative to prednisone
Chloroquine and hydroxychloroquine have been used for cutaneous lesions, hypercalcemia and bone lesions
Discuss the prognosis of this patient.
Markers for a poor prognosis include advanced chest radiography stage, extrapulmonary disease (predominantly cardiac and neurologic), and evidence of pulmonary hypertension.
Multiple studies have demonstrated that the most important marker for prognosis is the initial chest radiography stage.
What is the most likely cause of the patient’s hypercalcemia?
Sarcoidosis is the most likely cause.
How would you manage this patient in view of his current work-up?
first of all, reduce Ca dietary intake and reduce sun exposure
we can start by conservative management if the patient is asymptomatic but if he has symptoms, we may start him on corticosteroid.
second-line treatment includes AZa and methotrexate
E. What is the most likely cause of the patient’s hypercalcemia?
Scaroidosis
F. How would you manage this patient in view of his current work-up?
Start the patient on high dose of prednisolone for a prolonged time, then might be tapered down gradually based on patient’s clinical status.
G. Discuss the prognosis of this patient.
Renal involvement in sarcoidosis is usually comes later in life after pulmonary involvement. This patient has a renal failure as a primary presentation of sarcoidosis. It is considered rare type of sarcoidosis and usually resistant to treatment of steroid or would required much prolonged years of steroid treatment.
sarcoisosis
…
options:
conserve
steroids
methotrexate
The most likely cause of hypercalcemia
Non-PTH, non-25(HO)vitD
Granulomatous disease Sarcoidosis
Management;
Prognosis
The prognosis is usually relatively positive, as it is generally not fatal
The overall death rate is less than 5% without treatment
Most patients do not require treatment, and their disease is resolved within 2-5 years.
E-the most likely cause for hypercalcimia in this patient sarcoidosis dueto hypercalcimia and picture of x-ray
F-the management we must start treating the patient dueto persistence and progression of hypercalcimia and symptoms start with steriod and if no response given immunosuppressant like methotrexate or azathioprine
G-the prognosis of this patient it’s a chronic disease may recurrant remission and relapse and unfortunately may reach to lung fibrosis
Ca level is not listed, but as it is high with near normal vitamin D, high (?; It seems 2 times upper limit) active vitamin D. with hilar lymphadenopathy most probable is sarcoidosis, we can check ACE level and take a biopsy.
Treating with steroids is key to maintaining normal Ca and treating sarcoidosis
the most likely diagnosis is
sarcoidosis
managment conservative treatment for symptomes

and added corticosteroid to reduce inflammaion
some times used immunosuprresion drugs as methotrexate for help to stop organ dammag
E. Sarcoidosis
F. Give her prednisolone and monitor the disease and may need to give her immunosuppressive drugs
G. Prognosis is variable might remite spontaneously but as she had ESKD might progress to lung fibrosis.
A principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis. These can be achieved by reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure. Immunosuppression have also been used successfully to treat hypercalcemia in granulomatous diseases.
MOSTLIKLY DIAGNOSIS NOW IS SARCOIDSIS , NEXT PLAN TO REFERE FOR FOLLOW UP WITH PULMONOLOGIST FOR MANAGMENT , CORTICOSTEROIED AND EMOTIONAL SUPPORT THE PATIENT , PROGNOSIS GENERALY IS OK IF IT IS ISOLATED BUT WHEN IT IS SYSTEMIC WHICH OUR PATIENT HAVING PROGNOSIS IS NOT THAT GOOD
Besides Immunosuppression, a principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure.
E. What is the most likely cause of the patient’s hypercalcemia?
granulomatous disease,most probably sarcoidosis.
F. How would you manage this patient in view of his current work-up?
G. Discuss the prognosis of this patient.
It can remit spontaneously or with treatment within 2 years, but some patients can progress to a chronic form.
Mortality is usually around 1% to 5%.
Some features such as erythema nodosum, acute arthritis, and bilateral hilar lymph node enlargement, are related to a better prognosis.
However, cardiac and neurological sarcoidosis, lupus pernio, fibrosis, and pulmonary hypertension are related to the worst prognosis.
Thanks Dr Asharaf! A principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure. Immunosuppression as well is a main line of treatment.
E sarcoidosis
F HRCT , echo , respiratory referral , oral prednisolone
G sarcoid limited to lungs has good prognosis on its own not looking at other comorbidities.
Decreasing intestinal calcium absorption and calcitriol synthesis is a mainstay of treatment. These can be achieved by reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure. Second- and third-line therapies for pulmonary sarcoidosis, include methotrexate, azathioprine, leflunomide, biologic agents.
E. What is the most likely cause of the patient’s hypercalcemia?
F. How would you manage this patient in view of his current work-up?
G. Discuss the prognosis of this patient.
Agree that immunosuppression is a mainstay of treatment, however, a principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure.
E. What is the most likely cause of the patient’s hypercalcemia?
Graneumatus disease, most likely sarcoidosis
F. How would you manage this patient in view of his current work-up?
The first choice is glucocorticoids. For people who can’t take oral glucocorticoids, we recommend starting treatment with a nonbiologic immunosuppressant, like methotrexate, to control the disease. in addition to low calcium dialysate
G. Discuss the prognosis of this patient.
Spontaneous remission occurs in 60–80% of radiographic stage I patients, 50–60% of stage II patients, and fewer than 30% of stage III patients. Sarcoidosis kills fewer than 5% of people.
Agree that immunosuppression is a mainstay of treatment, however, a principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure.
E- Sarcoidosis
F- 1-steroids or methotrexate if intolerant to steroids
2-hydroxychloroquine for skin lesions
3-symptomatic ttt
G- good prognosis if limited and controlled disease
The prognosis depends mainly on clinical and radiological staging of the disease. Complete remission occurs in about 80 % in cases who are diagnosed early in the disease. A principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure.
E. Sarcoidisis
F. Corticosteroids
G.prognosis is good if limited
COrticosteriods is a main line of treatment, however, reduction of intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure should be the main aim of treatment.
E: mostly sarcoidosis on basis of
Clinical hx of skin lesion EN and respiratory sx and cxr and labs
F:
Corticosteroids
G:
Prognosis is good as young patient, erythema nodosum,cxr BHL
Thank you! The prognosis depends mainly on clinical and radiological staging of the disease. Complete remission occurs in about 80 % in cases who are diagnosed early in the disease. A principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure.
E. What is the most likely cause of the patient’s hypercalcemia?
F. How would you manage this patient in view of his current work-up?
G. Discuss the prognosis of this patient.
Spontaneous remission may occur in nearly two-thirds of patients with sarcoidosis. A principal aim of treatment is to reduce intestinal calcium absorption and calcitriol synthesis via reducing calcium intake (no more than 400 mg/day), reducing oxalate intake, elimination of dietary vitamin D supplements, and avoidance of sun exposure.