Poster Presentation ESA-SRB-APEG-NZSE 2022

A 31 year old unemployed female was asked to present by her gastroenterologist after routine pathology revealed a corrected calcium (CCa) of 3.16 mmol/L and an acute kidney injury with an eGFR of 21 ml/min/1.73m² with previously normal pathology. She was initially referred to gastroenterology for vomiting and a seven month unintentional weight loss of 60kg. Investigations included abdominal ultrasound revealing non-alcoholic steatohepatitis (NASH) with a fibroscan suggestive of cirrhosis. Following endoscopy, there was a finding of terminal ileum biopsy showing non-necrotising granulomas.

Other background included absence seizures, idiopathic intracranial hypertension and Darier disease. Her medications included lamotrigine and topiramate. She did not drink alcohol or smoke. She had typical symptoms of hypercalcaemia and no history of nephrolithiasis or fractures. On examination, her blood pressure was 118/78 mmHg with a pulse rate of 65 beats per minute. She had a normal cardiovascular examination and no lymphadenopathy.

Her CCa improved from 3.16 to 2.9 mmol/L with intravenous rehydration as did her renal function from an eGFR of 21 to 35 ml/min/1.73m². Parathyroid hormone (PTH) level was reduced (1.4 pmol/L) and subsequent investigations were unremarkable except for elevated angiotensin converting enzyme (ACE). A PTH related protein level is pending. She required intravenous pamidronate on two occasions for rebound hypercalcaemia.  A FDG PET scan demonstrated increased uptake in right cervical chain lymph nodes and subsequent excisional biopsy showed progressive transformation of germinal centres.

This case presents a diagnostic and management dilemma of PTH-independent hypercalcaemia with acute kidney injury, with differentials of lymphoma and sarcoidosis. This is in the setting of NASH with uncertain aetiology, in a previously well 31 year old female. ACE has poor sensitivity and specificity (1) and cautious interpretation is required in liver disease(2). Haematological review is pending, with consideration of chemotherapy and corticosteroids.