SAT242 Unusual Case Of Sarcoidosis Presenting With Severe Hypercalcemia: Case Report

Disclosure: G. Bhullar: None. M. Vora: None. Background: This case study discusses an unusual case of hypercalcemia found on routine labs. Clinical Case: A middle-aged Caucasian female with history of MVP, HTN, and anxiety was found to have normal-high calcium of 10.4 mg/dL (nml 8.7-10.4mg/dL) during routine labs offered by her employer. She considered herself relatively asymptomatic and underwent repeat lab testing at her PCP’s office 2 months later which showed calcium of 13.9 mg/dL, ionized calcium of 1.70 mmol/L (nml 1.12-1.32 mmol/L), and intact PTH of 12.4 pg/mL (nml 14.0-72.0 pg/mL). 1 day later, patient presented for an urgent outpatient endocrinology visit. Further questioning revealed polydipsia, polyuria, fatigue, and history of nephrolithiasis more than 10 years ago. Medications included vitamin D, metoprolol, spironolactone, and sertraline. She denied bone pain, weight loss, or GI issues. Physical exam, including heart, chest, and abdomen, was unremarkable. The patient was admitted to a local hospital for hydration and further workup. During her hospital stay, XRAY of chest revealed consolidation in right upper lobe with suspicion of bilateral hilar adenopathy. Contrast CT of chest, abdomen, and pelvis revealed extensive adenopathy, pulmonary nodules, and alveolar consolidation in right upper lobe. Calcified granulomas were found in the spleen. Lab studies showed elevated ACE levels at 87 U/L (nml 14-80 U/L), and elevated activated vitamin D at 108 ng/ml (nml 24.8-81.5 ng/ml). Biopsy results were positive for nonnecrotizing granuloma and negative for malignancy. No suspicious osseous lesions or thyroid gland abnormalities were found. PTHrP and serum protein electrophoresis were found to be in normal range. Hypercalcemia was corrected and patient was treated with glucocorticoids before discharge. Clinical Lesson: Patients with sarcoidosis usually endorse nonspecific symptoms and complaints of pulmonary manifestation may be absent at presentation. 6-13% of sarcoidosis cases involve hypercalcemia (1,2), furthermore, hypercalcemia is more frequently found in white patients (3), who more often present as asymptomatic (4). Thus, clinicians must maintain a high level of suspicion for granulomatous diseases in patients presenting with hypercalcemia regardless of the patient’s symptomology and physical exam findings. References: (1) Baughman RP, Janovcik J, Ray M, Sweiss N, Lower EE. Calcium and vitamin D metabolism in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2013;30(2):113-120.(2) Studdy PR, Bird R, Neville E, James DG. Biochemical findings in sarcoidosis. J Clin Pathol. 1980;33(6):528-533.(3) Burke RR, Rybicki BA, Rao DS. Calcium and vitamin D in sarcoidosis: how to assess and manage. Semin Respir Crit Care Med. 2010;31(4):474-484.(4) Newman LS, Rose CS, Maier LA. Sarcoidosis [published correction appears in N Engl J Med 1997 Jul 10;337(2):139]. N Engl J Med. 1997;336(17):1224-1234. Presentation: Saturday, June 17, 2023