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A6481 - Pulmonologist Insight on Renal Sarcoidosis: Report of Two Cases
Author Block: M. I. Shafi1, S. D. Williams2, I. Waseem3; 1Pulmonary/ Critical Care and sleep Medicine, Pulmonary/ Critical Care and sleep medicine, Cleveland, OH, United States, 2MetroHealth Medical Ctr, Cleveland, OH, United States, 3Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan.
Sarcoidosis is a multisystem inflammatory disease that mostly involves lungs, lymph nodes, skin, eye, CNS and kidney. Renal involvement is rare approximately involving 5-15% of patients, whereas pulmonary involvement is around 95 percent. Usual manifestations of renal sarcoidosis are hypercalciuria, hypercalcemia, interstitial nephritis, glomerular disease and obstructive uropathy, that leads to renal failure.We are presenting reports of two patients with rare presentation of renal sarcoidosis. Case 1: A 46-year-old African American Male presented with thirst, polyuria and generalize fatigue for 3 weeks. Also noticed a rash on his scalp and the nape. Examination was remarkable for maculopapular soft nodular rash on neck and left ear. Initial labs were remarkable for hypercalcemia of 12.7 mg/dl, elevated ionized calcium 1.65 mmol/L, creatinine of 7.10 mg/dl and elevated protein/creatinine ratio of 1469. PTH and Vitamin D2 25-OH were low. Urine calcium, PTHrP and 1-25 dihydroxy Vitamin D3 were within normal limit. Chest imaging showed bilateral hilar lymphadenopathy. Intravenous fluids and diuretics did not improve calcium and serum creatinine. Skin biopsy showed granulomatous inflammation. He was started on steroids with complete normalization of kidney functions and calcium level in 4 weeks. Case 2: A 57-year-old African American female with history of renal cell cancer post left nephrectomy admitted after work up for fatigue with laboratory studies showing calcium 15.3 mg/dl and new renal failure with creatinine of 5.4 mg/dl. Other pertinent labs includes fractional excretion of sodium of 1.4 %, low PTH and normal Vitamin D2 25 OH. Her urinalysis was remarkable for presence of calcium oxalate crystals. CT chest showed bilateral infiltrates with hilar and mediastinal lymphadenopathy, her metastatic workup was negative. Pulmonary function testing showed obstructive ventilatory defect. Bronchoscopy and transbronchial biopsy showed non-caseating granuloma consistent with sarcoidosis. Patient was started on steroids with improvement of renal function and normalization of calcium. Less than 5% of patient with sarcoidosis have renal involvement in which hypercalciuria and hypercalcemia is the most common presentation. Autonomous increase in 1,25-dihydroxy Vitamin D3 from alpha-1-hydroxylase results in hypercalcemia and hypercalciuria. Only few cases have been described in literature of renal sarcoidosis with normal urinary calcium and 1-25 dihydroxy vitamin D3 as our case one. It would be interesting to investigate other possible mechanism sarcoidosis causing hypercalcemia. Our second case is the only known case described in the literature of renal sarcoidosis affecting kidney in a patient with renal cancer post nephrectomy.