A 49‐year‐old largely healthy woman was admitted to the hospital for hypercalcemia. She complained of fatigue, weight loss and anorexia for several months. She was not on any medications or supplements. She was afebrile, not dyspneic, with a heart rate of 57/minute, blood pressure of 118/60 mm HG. The remainder of her physical was unremarkable. Her initial labs showed a calcium of 13.8 mg/dL, albumin of 3.4 g/dL and phosphorous of 3.0 mg/dL She had a creatinine of 1.93 mg/dL and hemoglobin of 10.4 g/dL Additional lab data revealed a low PTH level of 13 pg/mL (normal range, 14–72 pg/mL). Vitamin D levels revealed a total vitamin D 1,25 of 162 pg/mL (normal range, 18–72 pg/mL). Her hypercalcemia was managed with IVF and calcitonin. Because she had a PTH‐independent mechanism of hypercalcemia, there was a high concern for occult malignancy. CT scans of the chest, abdomen, and pelvis did not reveal any findings suggestive of cancer. Multiple myeloma was considered due to the associated anemia and renal failure. Studies for myeloma including serum and urine protein electrophoresis were not suggestive of myeloma. After discussion with hematology, we proceeded with a bone marrow biopsy. Her evaluation showed no evidence of myeloma, but the bone marrow biopsy revealed: multiple, small granulomata highly suggestive of sarcoidosis. Fungal and acid‐fast bacillus stains were negative. An angiotensin‐converting enzyme (ACE) level was found to be almost twice the upper limit of normal at 114 μ/L (normal, 9–67 μ/L). The patient started on ketoconazole to reduce 1 alpha‐hydroxylation of 25‐hydroxy vitamin D, resulting in a decrease in circulating levels of 1,25‐dihydroxylation vitamin D. Her ketoconazole was transitioned to prednisone, and her calcium level is now within normal limits after 4 weeks of her discharge from the hospital.
Sarcoidosis is a disease defined by the presence of idiopathic noncaseating granulomas. It is a multisystem disease with more than 90% of cases occur in the thorax. The majority of cases present as abnormalities detected on chest imaging or with pulmonary symptoms. It is unusual for sarcoidosis to involve the bone marrow, especially when there is no other organ system involvement as was seen in our patient. Hypercalcemia, which occurs because of increased vitamin D production, is an uncommon phenomenon in sarcoidosis. Hypercalcemia is estimated to occur in 10%–20% of patients with sarcoidosis. Symptomatic hypercalcemia as our patient experienced occurs in less than 5% of cases. Our case of extrapulmonary sarcoidosis limited to the bone marrow and presenting as hypercalcemia therefore represents the intersection of 2 rare findings.
A review of the literature revealed only a handful of reported cases of hypercalcemia from sarcoidosis without lung involvement. This case is the second case reported in the English literature. Hospitalists need to be aware of this condition even as we evaluate patients with hypercalcemia.
To cite this abstract:Dapaah‐Afriyie K, Finn A. Hypercalcemia Due to Sarcoidosis of the Bone Marrow. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 315. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/hypercalcemia-due-to-sarcoidosis-of-the-bone-marrow/. Accessed March 29, 2020.