Human Immunodeficiency Virus–Positive Patient Presenting With Acute Renal Failure and Hypercalcemia Diagnosed With Sarcoidosis

Abstract

Abstract Objectives A 42-year-old African American man with a history of HIV infection on highly active antiretroviral therapy (HARRT) presented with excessive thirst, polydipsia, polyuria, weight loss, and abnormal kidney function tests. Physical examination was normal. Methods The patient workup results were as follows: calcium 13.8 mg/dL (8.4-10.3 mg/dL), ACE 88 U/L (8-52 U/L), PTH 7.34 pg/mL (14-72 pg/mL), 1,25 (OH)2 vitamin D 125 pg/mL (19.9-79.3 pg/mL), BUN 38 mg/dL (6-20 mg/dL), Cr 2.42 mg/dL (0.4-1.2 mg/dL), glucose 87 mg/dL (70-99 mg/dL), CD4 count 303/μL (544-1,894/μL). Chest CT scan showed diffuse pulmonary nodules with mediastinal and bilateral hilar lymphadenopathy. A transbronchial biopsy was performed. Results Biopsy revealed noncaseating granuloma and Schaumann bodies. AFB and GMS stains were negative for micro-organisms. These findings were compatible with sarcoidosis. The patient received prednisone and showed significant improvement in his renal function (creatinine: 1.23 mg/dL) and calcium level (9.12 mg/dL). Conclusion CD4+ T lymphocytes have a crucial role in the formation of sarcoid granulomas. However, HIV infection is characterized by a profound loss of the CD4+ T-lymphocytes. Therefore, sarcoidosis in HIV-positive patients is rare. The development of sarcoidosis usually occurs when a significant increase in CD4+ T-cell count induced by HAART has taken place. Pulmonary involvement and symptoms are responsible for the majority of the morbidity and mortality in sarcoidosis. Renal involvement is significantly less common than respiratory symptoms. This patient was one out of two HI- positive cases of sarcoidosis among 200 patients who were diagnosed with sarcoidosis in our three major affiliated hospitals from 2000 to 2019. This case is unique and rare both in terms of unusual presentation of renal failure and hypercalcemia and also the co-occurrence of sarcoidosis in an HIV-positive patient while the CD4 count is lower than the normal limit.