Altered Sensorium and ST Segment Elevation: Atypical Manifestations of Hypercalcemia in a Renal Transplant Patient With Mycobacterium Avium Intracellulare (MAI)

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Critical Care I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Hypercalcemia secondary to granulomatous diseases is a known cause of hypercalcemia. This case describes hypercalcemia secondary to MAI in a renal transplant patient treated emergently with hemodialysis with resolution of symptoms and calcium. ST segment elevation in inferior leads was also noted on electrocardiogram(EKG). CASE PRESENTATION: A 75 year old woman presented to the ED with altered sensorium and slurred speech, which developed after a hemodialysis treatment. On examination, she was disoriented and noted to have matted cervical lymphadenopathy. Lab results showed a corrected calcium of 13.74 mg/dl. Cardiac enzymes were negative and 12 lead EKG(Fig-1) revealed ST segment elevation in leads II, III and aVF. The patient underwent emergent dialysis, calcitonin was administered with correction of hypercalcemia. PTH was 38.5pg/ml, TSH was 2.27 U/ml, Vitamin D2 was <8ng/ml, vitamin D3 was 91 ng/ml and Alkaline Phosphatase 159 IU/L. CT Neck w/ IV contrast (Fig-2) demonstrated large cystic/necrotic enhancing lymph nodes. Cultures from a draining lymph node grew multiple acid fast bacilli, which on further microbiological analysis (Fig-3) revealed MAI. The patient was treated with Azithromycin and Rifabutin. Pamidronate was continued once weekly. The patient’s EKG also normalized. DISCUSSION: Hypercalcemia is a metabolic emergency noted in approximately 0.5% hospitalized patients1. The principal mechanism of hypercalcemia in granulomatous disease has been attributed to uninhibited production of 1,25 (OH)2 Vitamin D from extra-renal sources. Alveolar macrophages independently produce 1 a hydroxylase, leading to increased 1,25 (OH)2 Vitamin D and low vitamin D1. Glucocorticoids, chloroquine, ketoconazole and bisphosphonates have been used to treat hypercalcemia secondary to MAI, however some patients required hemodialysis. ST segment elevation is a rare finding of hypercalcemia found on electrocardiography. Disseminated MAI infection leading to hypercalcemia is rare. CONCLUSIONS: To our knowledge hypercalcemia is a rare complication resulting from disseminated MAI infection. Our patient also had atypical findings of ST segment elevation on EKG warranting the need for close cardiac monitoring in such patients. Reference #1: Roussos, A, Lagogianni, Gonis, A, Ilias I, Kazi, D, Patsopoulos, Philippou, N. Hypercalcemia in Greek patients with tuberculosis before the initiation of anti-tuberculosis treatment. Respiratory Medicine, 2001;95,187-190. Reference #2: Sharma, OP. Hypercalcemia in granulomatous disorders: a clinical review. Current Opinion in Pulmonary Medicine 2000, 6:442-447. Reference #3: L. Littmann, L. Taylor, and W. D. Brearley, ST-segment elevation: a common finding in severe hypercalcemia. Journal of Electrocardiology, vol. 40, no. 1, pp. 60-62, 2007. DISCLOSURE: The following authors have nothing to disclose: Shyam Shankar, Karan Wats, Hitesh Raheja, Ishan Malhotra, Nupur Uppal, Mangalore Amith Shenoy, Stephan Kamholz No Product/Research Disclosure Information