Hypercalcemic crisis as a prodromal feature of Pneumcystis jirovecii pneumonia

Abstract

We describe a patient who had developed hypercalcemic crisis, with altered mental status and renal failure, one year following aggressive corticosteroid-therapy for lupus nephritis. Her disease relapsed after successful live-related kidney transplantation 11 years ago. She had normal parathyroid hormone and 25-hydroxyvitamin D yet high 1,25 dihydroxyvitamin D. Four weeks later, she developed severe dyspnea and hypoxia with a reticulonodular pattern on chest computed tomography. Bacteriological and serological tests were negative for pathogens. However, bronchoalveolar lavage established the diagnosis of Pneumocystis jiroviceii pneumonia (PJP). Her pneumonia and hypercalcemia improved with Co-trimoxazole. The case indicates that severe hypercalcemia can herald PJP.

Severe hypercalcemia preceding a diagnosis of Pneumocystis jirovecii pneumonia in a liver transplant recipient

“…Peripheral monocytes and pulmonary alveolar macrophages assist with granuloma formation and produce excess calcitriol. Moreover inflammatory cytokines, specifically interferon gamma, increase synthesis and decrease degradation of calcitriol favoring progressive hypercalcemia [8, 9, 13]. Although our patient’s calcitriol remained within the normal range, it was towards the upper limit of normal and should be considered high in the presence of renal failure and low PTH levels.…”

“…Our patient had similar risk factors: age over 65 years, lymphopenia, and recent steroid use and initiation of MMF for allograft rejection. Other reported cases also share a history of recent treatment for rejection or primary disease with immunosuppression increase [3, 8, 9].…”

“…Most previously reported cases had moderate non-PTH mediated hypercalcemia, [3, 6, 8, 10] with higher levels seen in patients on calcium or vitamin D supplementation, and elevated calcitriol levels [3, 9, 11, 12]. The mechanism of hypercalcemia in PJP is thought to be similar to other granulomatous diseases.…”

A case of Pneumocystis pneumonia, with a granulomatous response and vitamin D‐mediated hypercalcemia, presenting 13 years after renal transplantation

“…For unclear reasons, Pneumocystis ‐related hypercalcemia has not been reported in solid organ transplant recipients other than renal recipients. Pneumocystis ‐induced hypercalcemia has been reported in an immunocompetent infant, in a patient in remission from leukemia, in a patient treated for lupus nephritis, and in the setting of AIDS …”

“…Reported cases of hypercalcemia in association with Pneumocystis jirovecii pneumonia infection in kidney transplant recipients Pneumocystis-related hypercalcemia has not been reported in solid organ transplant recipients other than renal recipients. Pneumocystis-induced hypercalcemia has been reported in an immunocompetent infant, in a patient in remission from leukemia, in a patient treated for lupus nephritis, and in the setting of AIDS 11,[16][17][18]. LNT reviewed the manuscript for accuracy.…”