Severe hypercalcemia in a patient with extrapulmonaryMycobacterium abscessus: granuloma or immune reconstitution inflammatory syndrome? First case ofMycobacterium abscessuspresenting as retroperitoneal lymphadenopathy with severe hypercalcemia: a case report and literature review

Abstract

Background: Nontuberculous mycobacterium is a recognized cause of hypercalcemia, particularly in patients with acquired immunodeficiency syndrome (AIDS). Here we describe a case of severe hypercalcemia secondary to Mycobacterium abscessus (M. abscessus) in a patient with AIDS. To the best of our knowledge this is the first case report describing a case of M. abscessus presenting as retroperitoneal lymphadenopathy and severe hypercalcemia.Case description: A 56-year-old man with AIDS presented with altered mental status and somnolence for four days. Laboratory investigations were significant for calcium 16.49 mg/dL (RI 8.9–10.3 mg/dL), 1,25 dihydroxyvitamin D level 44.1 pg/ml (RI 19.9–79.3 pg/ml) and parathyroid hormone (PTH) 4 pg/mL (RI 15–65 pg/mL). CT scan of Abdomen and Pelvis showed hepatosplenomegaly with large retroperitoneal, retrocrural, and mesenteric lymphadenopathy which had an intense focal uptake on Gallium scan. Bone marrow biopsy revealed mild plasmacytosis (5%) with no evidence of myelodysplasia, acute leukemia or lymphoma. A subsequent lymph node biopsy showed fragments of fibrous tissue with lymphohistiocytic infiltrate and many acid-fast bacilli. Pre-antibiotic blood cultures grew Mycobacterium which was identified later as M. abscessus at four weeks.Conclusion: hypercalcemia in HIV-infected patients may suggest malignancy or infectious etiology, among other causes. Clinicians should be aware of the risk of hypercalcemia with nontuberculous mycobacterium (NTM) infection, whether as first manifestation or a late presenter in the disease course after initiating antiretroviral therapy (ART). We suggest careful monitoring of serum calcium level upon diagnosis of NTM infection and after initiation of ART, NTM therapy or vitamin D supplementation.

Hypercalcaemia inMycobacterium kansasiipulmonary infection

“…The mechanism of hypercalcaemia in granulomatous disease has been classically linked to increased production of calcitriol by activated macrophages with increased 1-alpha hydroxylase activity. This mechanism, driven by elevated calcitriol, has been best described in diseases like sarcoidosis,12 13 but also in TB,14 and other NTM 15. In our patient, calcitriol levels were within the normal range.…”

A Case of Hypercalcemia in an Immunocompetent Patient with Disseminated Mycobacterium marinum Infection with a Rain Barrel as the Most Likely Primary Source

“…Hypercalcemia is not unusual in several granulomatous diseases like mycobacterial infections. The supposed mechanism is through endogenous production of 1,25-(OH)2D3 in disease-activated macrophages in granulomas [ 4 , 5 ] . This process might be upregulated in the case of discontinuation of immunosuppressive therapy resulting in a rebound effect of interferon gamma on the granulomas.…”

Exploring the Risk Factors and Possible Role of Calcium in Infective Endocarditis

“…Therefore, the serum Ca 2+ level can serve as a crucial indicator of the risk of endocarditis, considering that untreated hyperparathyroidism can result in hypercalcemia, which may act as a contributing factor [78]. In immunocom-promised patients, Mycobacterium abscessus infection can cause severe hypercalcemia and native valve endocarditis due to a peripherally inserted central catheter line [79,80]. The increased risk of endocarditis associated with Mycobacterium abscessus infection may be linked to the development of hypercalcemia.…”