Case Report: Pulmonary Alveolar Calcification as a Result of Severe Hypercalcemia due to Acute Lymphoblatic Leukemia.

Abstract

Severe hypercalcemia is a rare metabolic disorder in pediatric medicine. This report describes a rare case of severe hypercalcemia and its clinical manifestations in a 2-year-old toddler. The radiological findings caused by hypercalcemia and osteolysis were emblematic of the osteolytic lesions. Hypercalcemia led to massive pulmonary alveolar calcification. The hypercalcemia was successfully treated with pamidronate, a bisphosphonate drug class. Further investigation resulted in a diagnosis of acute lymphoblastic leukemia (ALL). The patient is currently on chemotherapy and has a favorable prognosis. Although severe hypercalcemia alone is an unusual finding as the first sign for ALL, this should be considered, not to mention the radiological images resulted from calcium deposits.

Reply to: Severe hypercalcemia as a form of acute lymphoblastic leukemia presentation in children

“…( 6 ) In addition, the medium- and long-term adverse effects of bisphosphonates have been associated with osteonecrosis of the jaw and ectopic deposition of calcium. ( 7 ) However, to date, no adverse effects related to bisphosphonates have been observed in the described case. Nevertheless, hypocalcemia occurred for 10 days after the initiation of treatment with zoledronate, highlighting the need to monitor serum calcium levels two to four weeks after the initiation of treatment, which is the period of activity of bisphosphonates.…”

To: Severe hypercalcemia as a form of acute lymphoblastic leukemia presentation in children

“…Severe hypercalcemia of malignancy in children has been extensively described in the medical literature. ( 1 ) However, this complication usually presents as a late symptom of acute lymphoblastic disease and not as an early manifestation, as described in a case report by Martins et al ( 2 ) Colleti Junior et al ( 3 ) also observed that hypercalcemia was present as an early symptom of malignancy, and the serum calcium levels were higher than usual (ionic calcium: 2.95mmol/L; normal value: 1.11-1.40mmol/L). In this case, immediately after diagnosis, in addition to hydration and low doses of loop diuretic, treatment was initiated with pamidronate, a bisphosphonate, and resulted in a rapid decrease in the serum calcium levels.…”

“…Is there a report of calcium deposition in other tissues? In Colleti Junior et al, ( 3 ) a rare alveolar lung deposition was shown on chest computed tomography ( Figure 2 ), and the diagnosis of this symptom was essential during patient follow-up. Therefore, the side effects of treatment with bisphosphonates should be considered.…”

“…In the first case, early treatment with bisphosphonates might have avoided an invasive procedure, such as hemofiltration. ( 3 , 4 ) It is important to describe the protein levels of parathyroid hormone (PTHrP) - often reported as normal - because, in most cases, hypercalcemia caused by malignant disease is associated with the production of PTHrP, ( 5 ) and the measurement of this protein is essential for the differential etiological diagnosis. In addition, the absence of signs of osteopenia is noteworthy in this case because the high calcium levels are due in part to osteolytic activity, which is blocked by bisphosphonate (otherwise, the calcium levels would not have decreased with the use of zoledronate).…”

“…In addition, the absence of signs of osteopenia is noteworthy in this case because the high calcium levels are due in part to osteolytic activity, which is blocked by bisphosphonate (otherwise, the calcium levels would not have decreased with the use of zoledronate). Colleti Junior et al ( 3 ) reported that the osteolytic activity is so extensive that classic lesions are observed in a punch biopsy ( Figure 1 ). Another relevant aspect is the evaluation of tissue calcium deposition after treatment with bisphosphonates.…”