Hypercalcemia and multiple osteolytic lesions in a child with disseminated paracoccidioidomycosis and pulmonary tuberculosis

Abstract

Objective: To describe the case of a child with paracoccidioidomycosis who presented hypercalcemia with multiple osteolytic lesions.Description: A 6-year-old boy was admitted with a one-month history of fever and hepatosplenomegaly. On admission, he looked sick, pale, and had disseminated lymphadenopathy and hepatosplenomegaly. The laboratory findings included anemia (hemoglobin = 6.8 g/dl), eosinophilia (1,222/mm 3 ), thrombocytopenia (102,000/mm 3 ), and hypoalbuminemia (serum albumin = 2.2 g/dl). Paracoccidioides brasiliensis was identified in bone marrow examination. In the second week after admission, the patient presented joint pain, poor activity and difficulty in walking. He presented hypercalcemia (maximum value = 14.9 mg%) and reduction in renal function, which lasted for two weeks. On the 42nd day after admission, his chest X-ray showed lytic lesions in clavicle, scapula, ribs, and humerus, with bilateral slipped capital humeral epiphysis. The patient presented nephrocalcinosis and nephrolithiasis, reduction in creatinine clearance and evidence of tubular lesions. At the end of the second month after admission, Mycobacterium tuberculosis was isolated in gastric lavage. The child received treatment for paracoccidioidomycosis and tuberculosis and has not had any sequelae for 3 years.Comments: The development of symptomatic hypercalcemia leading to renal lesion, associated with multiple osteolytic lesions, had never been described in paracoccidioidomycosis. Although pulmonary tuberculosis was diagnosed and could be related to hypercalcemia, the sudden onset of hypercalcemia and its normalization without specific treatment for tuberculosis suggests that bone lysis was the most important factor in the genesis of hypercalcemia. Descrição: Menino de 6 anos, internado com história de febre e hepatoesplenomegalia há 1 mês. À internação, apresentava-se em regular estado geral, descorado, com linfonodomegalia generalizada e hepatoesplenomegalia. Os exames laboratoriais identificaram anemia (hemoglobina = 6,8 g/dl), eosinofilia (1.222/mm 3 ), plaquetopenia (102.000/mm 3 ) e hipoalbuminemia (albumina = 2,2 g/dl). Paracoccidioides brasiliensis foi identificado no mielograma. A partir da segunda semana de internação, apresentou artralgia, hipoatividade e dificuldade à deambulação, sendo constatada hipercalcemia (dosagem máxima de 14,9 mg%) e redução da função renal, que duraram pouco mais de 2 semanas. No 42° dia de internação, foram vistas, na radiografia de tórax, múltiplas lesões líticas em clavículas, escápulas, costelas e úmeros, com escorregamento epifisário de úmero bilateral. Apresentou nefrocalcinose e nefrolitíase, com redução no clearance de creatinina e evidências de lesão tubular. No final do segundo mês de internação, na cultura do lavado gástrico, foi identificado Mycobacterium tuberculosis. Recebeu tratamento para paracoccidioidomicose e tuberculose e está há mais de 3 anos em acompanhamento, sem nenhuma seqüela.Comentários: O desenvolvimento da hipercalcemia sintomática, levando à lesão rena...

Acute‐subacute paracoccidioidomycosis: A paediatric cohort of 141 patients, exploring clinical characteristics, laboratorial analysis and developing a non‐survival predictor

“…The signs and symptoms presented by the majority of the patients from this cohort were related to the reticuloendothelial system, corresponding to the findings of other authors . Disseminated lethal cases affecting unusual organs and tissues with no clinical evidence were also observed in this study, confirming that the yeasts are capable to invade every tissue of the human body …”

“…Patients with acute‐subacute PCM present disseminated fungal infection, frequently involving the phagocytic‐mononuclear system and leading to generalised lymphadenopathy and hepatosplenomegaly . The laboratorial typical findings are anaemia, eosinophilia, hypoalbuminemia and hypergammaglobulinemia, with high antibody titres in serologic tests …”

Hypercalcemia in a patient with disseminated paracoccidioidomycosis: a case report

“…Hypercalcemia is well described in various granulomatous disorders; however, the association of P. brasiliensis and hypercalcemia is rare. To the best of the authors' knowledge, only two cases have been reported previously, neither of which offered a clear documentation of the etiology of the hypercalcemia [ 6 , 7 ].…”

Symptomatic hypercalcaemia in paediatric tuberculosis

“…There are only a few cases in the literature over the last 25 yrs which have reported children with hypercalcaemia associated with TB, often with severe disease (table 1) [4][5][6][7][8][9][10]. Our case describes a teenage female with extensive pulmonary TB associated with symptomatic hypercalcaemia that persisted despite cessation of vitamin D supplementation.…”