Case Presentation: : A 70-year-old woman presented to the emergency department with general malaise and fatigue. She has a history of diabetes mellitus type 2, hypertension and dyslipidemia for which she takes Metformin, Nifedipine and Simvastatin. She had normal vital signs, no mental status changes, and physical exam was unremarkable. She was found to have severe hypercalcemia to 15.9 mg/dL and acute kidney injury with Cr 2.15 mg/dL. Further investigation revealed PTH 13 pg/mL (normal 15-65 pg/mL), PTHrP <0.74 pmol/L (normal <2.0 pmol/L), ACE level 134 U/L (normal 14-82 U/L), 25OH-Vitamin D 27.8 ng/mL, and 1,25-Vitamin D 166.6 pg/mL. Mammography and colonoscopy were normal in the past year. Chest radiography and CT of the chest revealed several small right upper lobe pulmonary nodules and mediastinal and hilar lymphadenopathy suggestive of sarcoidosis. Skeletal survey revealed lucency in the right humerus without any cortical bone thickening or other signs of Paget’s disease. SPEP analysis was negative and bone marrow aspirate and core biopsy revealed multiple small non-caseating granulomas. She was diagnosed with hypercalcemia secondary to bony involvement of sarcoidosis. She was treated with high dose prednisone, aggressive fluid hydration, and intramuscular calcitonin. The patient’s calcium decreased to 11 mg/dL and her acute kidney injury resolved within 48 hours.
Sarcoidosis of the bone is usually found in patients with known pulmonary sarcoid and is rarely a presenting feature of the disease. Radiological findings show lace-like honeycomb cystic and lytic lesions of cortical bone, with cavities of varying sizes and surrounding sclerosis. Skeletal sarcoidosis usually affects the phalanges in the hands and feet, but has also been described in the nasal bones and vertebrae. Involvement of the humerus and long bones is extremely rare. The differential diagnosis includes metastasis, hyperparathyroidism with secondary brown tumors, Paget’s disease, multiple myeloma and lymphoma. Skeletal sarcoidosis is rarely seen in the absence of skin lesions and 80-90% of cases have evidence of pulmonary involvement. To our knowledge, this report describes the first case of lytic humerus lesions and secondary hypercalcemia as the presenting sign of sarcoidosis.
Hypercalcemia can be a life-threatening emergency. Although skeletal sarcoidosis is a rare condition, physicians, especially, in the hospital setting should have a high index of suspicion for sarcoid-induced hypercalcemia. Treatment of hypercalcemia secondary to sarcoidosis consists of a low calcium diet, adequate hydration, and minimizing sunlight exposure and steroids to reduce overproduction of calcitriol in activated macrophages.
To cite this abstract:Nehme M, DuBuske I, Teufel K. Skeletal Sarcoidosis and Hypercalcemia. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 637. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/skeletal-sarcoidosis-and-hypercalcemia/. Accessed January 24, 2020.