A 46-year-woman was admitted with decreased appetite, weight loss, nausea, constipation, poor concentration, cough and shortness of breath on exertion. She had long standing history of low backache and had been taking paracetamol and codeine in combination, amitriptyline, tramadol, stemetil, diclofenac, and calcichew D3 one tablet/day On examination, blood pressure was elevated, erythematous nodules seen over right shin. Initial investigations showed normocytic anemia, elevated urea, creatinine (283 umol/l) and calcium. Paratharmone was still detectable even after stopping calcichew D3 and urea, creatinine(190 umol/l) and calcium continued to be elevated even after rehydration and intravenous bisphosphonate. Imaging studies showed normal chest X ray and ultrasound of thyroid and CT abdomen and chest revealed borderline spleenomegaly with multiple coalescent nodular lesions and patchy lower lobe fibrosis in lungs. Bone marrow study showed normal cellularity. Diagnostic splenectomy was done, histopathology of which confirmed sacroidosis. Renal function improved, (creatinine 145 umol/l) and calcium returned to normal in the next 3 days.
Granuloma is the site of calcitriol and sometimes paratharmone related protein production resulting in hypercalcemia. Steroids inhibit the calcitriol production in granulomas. Hypercalcemia per se with its consequences on kidneys or direct involvement of interstitium by granuloma result in renal failure.
In our patient, splenectomy resulted in removal of bulk granulomas and thus calcitriol and possibly paratharmone related protein. This helped in return of normal renal function and calcium.
03 - 07 May 2008
European Society of Endocrinology