Hindawi Publishing Corporation Case Reports in Nephrology Volume 2016, Article ID 4186086, 6 pages http://dx.doi.org/10.1155/2016/4186086
Case Report Granulomatous Interstitial Nephritis Presenting as Hypercalcemia and Nephrolithiasis Saika Sharmeen,1 Esra Kalkan,1 Chunhui Yi,2 and Steven D. Smith3 1
Department of Medicine, Mount Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA Department of Pathology, Mount Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA 3 Department of Medicine, Division of Nephrology, Mount Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA 2
Correspondence should be addressed to Saika Sharmeen; [email protected] Received 30 November 2015; Accepted 29 December 2015 Academic Editor: Ze’ev Korzets Copyright © 2016 Saika Sharmeen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We report a case of acute kidney injury as the initial manifestation of sarcoidosis. A 55-year-old male was sent from his primary care physician’s office with incidental lab findings significant for hypercalcemia and acute kidney injury with past medical history significant for nephrolithiasis. Initial treatment with intravenous hydration did not improve his condition. The renal biopsy subsequently revealed granulomatous interstitial nephritis (GIN). Treatment with the appropriate dose of glucocorticoids improved both the hypercalcemia and renal function. Our case demonstrates that renal limited GIN due to sarcoidosis, although a rare entity, can cause severe acute kidney injury and progressive renal failure unless promptly diagnosed and treated.
1. Background Granulomatous interstitial nephritis (GIN) is a rare cause of acute kidney injury (AKI). Causes of GIN include sarcoidosis, drugs (NSAIDs, antibiotics), and infections (mycobacterial, fungal, bacterial, and viral). Renal involvement as an initial manifestation of sarcoidosis is another rare entity. Renal failure commonly ranges from 0.7% to 4.3% in cases series of patients with previously identified sarcoidosis [1]. The majority of sarcoid related renal failure in these cases is due to two pathologic processes: (1) nephrocalcinosis with or without nephrolithiasis and (2) interstitial nephritis with or without granulomas. We report a case of GIN causing acute kidney injury as the initial presentation of sarcoidosis.
2. Clinical Case A 55-year-old man was sent from his primary care physician’s office with incidental findings of severe hypercalcemia and acute kidney injury (AKI). His medical history was significant for nephrolithiasis and ureteral stone removal one year prior to presentation at which time the serum creatinine was 2.05 mg/dL with a calcium of 10.5 mg/dL. No further
work-up was performed at that time. On presentation he was not taking any medications or using alcohol, tobacco, or illicit drugs. He had no prior surgeries. He denied cough, shortness of breath, polyuria, polydipsia, bone pain, and abdominal pain but complained of chronic low back pain and a 20 lb weight loss over the previous several months. The blood pressure was 165/102 mmHg, heart rate was 80, and he was afebrile. Physical exam was otherwise unremarkable with a clear chest, no peripheral lymphadenopathy, no rash, and no edema. Laboratories (Table 1) were remarkable for Ca 13.5 mg/dL, creatinine 7.6 mg/dL, and phosphorus 7.4 mg/dL. Urinalysis showed calcium-oxalate crystals with 4–10 RBCs/HPF with normal morphology and the urine albumin/creatinine ratio was normal at 24 mg/g. Evaluation of the hypercalcemia revealed the following: PTH < 3 (11–67 pg/mL), 25-hydroxyvitamin D 23.8 (30–95 ng/mL), 1,25-dihydroxyvitamin D 79 (18–72 pg/mL), and angiotensin converting enzyme (ACE) level 82 (9–67 U/L) (Table 2). Serum and urine immunofixations did not detect a monoclonal protein. A skeletal survey showed no lytic or blastic osseous lesions. Thyroid function tests were normal. His chest X-ray was negative and PFTs (pulmonary function tests) were normal but a computed tomography (CT) scan
Hospital day 1 135 5.3 101 21 57 7.59 167 8 13.5 Unable to calculate Not checked 7.4 Not checked Not checked Not checked Not checked Not checked Not checked Not checked 12.8 13 39.2 386 83.3 5.2 77.6 9 7.7 0.5
139 4.4 104 25 23 1.79 137 40 10.5
10.4
Not checked Not checked 7.3 4.1 0.6 0.1 68 26 24 12.8 13 39.2 386 83.2 5.2 77.6 9 7.7 0.3
Sodium Potassium Chloride Carbon dioxide Blood urea nitrogen Creatinine Glucose eGFR Calcium
Corrected calcium∗
∗
The normal albumin level is defaulted to 4.
Ionized Ca Phosphorus, inorganic Protein, total Albumin Bilirubin, total Bilirubin, direct ALP AST ALT WBC Hemoglobin Hct Platelet MCV Eosinophils (%) Neutrophil (%) Lymphocytes (%) Monocytes (%) Basophil (%)
Variable
Baseline labs, 6 months before admission
1.7 6.1 6 3.4 0.6 Not checked 43 22 23 13.2 11.2 33.6 302 84.1 3.9 77.8 10 7.9 0.4
13.4 Not checked 4.7 5.5 2.9 0.3 Not checked 42 21 28 8.6 10.6 33.1 298 85.9 6.7 70 12.7 10.1 0.5
11.8 Not checked 7.5 7.2 3.9 0.5 Not checked 113 23 39 10.8 12.1 37.2 295 85.3 7.1 69 13.6 10.1 0.2
13.2 Not checked Not checked 5.3 2.8 0.3 0.2 66 28 52 18.7 10.3 32.1 306 85.9 0.4 91.1 4.8 3.7 0
10.3
Hospital day 12,1 Hospital Day 16 time (prednisone Hospital day 2 Hospital day 6 dexamethasone 60 mg Qd was given started) 138 138 134 136 5.2 5.1 5.3 4.9 104 110 106 112 16 17 17 18 57 65 57 40 6.79 4.98 7.6 6.49 106 216 148 99 9 12 7 9 13.1 9.3 12.9 10.9
Table 1: Lab values during hospitalization and after discharge.
135 4.3 111 17 67 4.52 145 14 8.1 Unable to calculate 1.12 Not checked Not checked Not checked Not checked Not checked Not checked Not checked Not checked 13.1 9.9 31.8 105 85.5 Not checked Not checked Not checked Not checked Not checked
Day 18 (discharge day)
Not checked 3.4 6.2 3.7 0.4 0.3 67 20 25 14.8 12.4 37 300 87.6 2.1 91 4.3 2.4 0.2
9.8
139 4.9 104 19 68 2.89 94 23 9.6
15 days after discharge
1.16–1.32 mmol/L 2.5–4.5 mg/dL 6.3–8.2 g/dL 3.5–5 g/dL 0.2–1.3 mg/dL 0.0–0.4 mg/dL 38–126 U/L 15–46 U/L 13–69 U/L 3.4–11 k/𝜇L 13.0–17 g/dL 38–51% 150–450 k/𝜇L 80–100 fL 0.0–0.6% 40–74% 18–44 4.7–12.0% 0.1–1.4%
8.5–10.5 mg/dL
136–146 mmol/L 3.5–5.1 mmol/L 96–107 mmol/L 22–30 mmol/L 8–24 mmol/dl 0.66–1.25 mg/dL 74–106 mg/dL >90 8.4–10.3 mg/dL
Reference range
2 Case Reports in Nephrology
Case Reports in Nephrology
3 Table 2: Lab values.
Variable LDH Creatinine kinase Cholesterol, total HDL LDL Cholesterol/HDL ratio Triglycerides ESR CRP ACE, before steroid treatment ACE, after steroid treatment Vit D, 25 hydroxy Vit D, 1,25 hydroxy, before steroid treatment Vit D, 1,25 hydroxy, after steroid treatment PTH, intact ANA Immunofixation, serum IgG, serum IgA, serum IgM, serum Immunofixatin elec., urine Protein, random urine C3 C4 Quantiferon-Tb gold Mitogen-nil NIL TB Ag-nil ASO Ab ANCA vasculitides Proteinase 3 Ab Myeloperoxidase Ab Hep A Ab, IgM Hep A Ab, total Hep B sAg Hep B Core Ab, total Hep BS ab HepC Ab HIV 1/2 Ab screen, rapid HgbA1c Urine culture Urine chemistry Protein, random urine Microalbumin, random, urine Sodium, random, urine Potassium, random, urine Calcium, random, urine Thyroxine, free TSH PSA free PSA percent free Total PSA
Measurement 478 40 187 28 87 6.7 362 26 Not checked 82 24 27.8 79 19 3.72 Negative Polyclonal pattern 1330 187 44 Polyclonal IGG and polyclonal light chains 10 119 22 Indeterminate 0.16 0.03 0 46
Reference range 313–618 U/L 55–170 40 mg/dL
Case Report Granulomatous Interstitial Nephritis Presenting as Hypercalcemia and Nephrolithiasis Saika Sharmeen,1 Esra Kalkan,1 Chunhui Yi,2 and Steven D. Smith3 1
Department of Medicine, Mount Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA Department of Pathology, Mount Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA 3 Department of Medicine, Division of Nephrology, Mount Sinai St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA 2
Correspondence should be addressed to Saika Sharmeen; [email protected] Received 30 November 2015; Accepted 29 December 2015 Academic Editor: Ze’ev Korzets Copyright © 2016 Saika Sharmeen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We report a case of acute kidney injury as the initial manifestation of sarcoidosis. A 55-year-old male was sent from his primary care physician’s office with incidental lab findings significant for hypercalcemia and acute kidney injury with past medical history significant for nephrolithiasis. Initial treatment with intravenous hydration did not improve his condition. The renal biopsy subsequently revealed granulomatous interstitial nephritis (GIN). Treatment with the appropriate dose of glucocorticoids improved both the hypercalcemia and renal function. Our case demonstrates that renal limited GIN due to sarcoidosis, although a rare entity, can cause severe acute kidney injury and progressive renal failure unless promptly diagnosed and treated.
1. Background Granulomatous interstitial nephritis (GIN) is a rare cause of acute kidney injury (AKI). Causes of GIN include sarcoidosis, drugs (NSAIDs, antibiotics), and infections (mycobacterial, fungal, bacterial, and viral). Renal involvement as an initial manifestation of sarcoidosis is another rare entity. Renal failure commonly ranges from 0.7% to 4.3% in cases series of patients with previously identified sarcoidosis [1]. The majority of sarcoid related renal failure in these cases is due to two pathologic processes: (1) nephrocalcinosis with or without nephrolithiasis and (2) interstitial nephritis with or without granulomas. We report a case of GIN causing acute kidney injury as the initial presentation of sarcoidosis.
2. Clinical Case A 55-year-old man was sent from his primary care physician’s office with incidental findings of severe hypercalcemia and acute kidney injury (AKI). His medical history was significant for nephrolithiasis and ureteral stone removal one year prior to presentation at which time the serum creatinine was 2.05 mg/dL with a calcium of 10.5 mg/dL. No further
work-up was performed at that time. On presentation he was not taking any medications or using alcohol, tobacco, or illicit drugs. He had no prior surgeries. He denied cough, shortness of breath, polyuria, polydipsia, bone pain, and abdominal pain but complained of chronic low back pain and a 20 lb weight loss over the previous several months. The blood pressure was 165/102 mmHg, heart rate was 80, and he was afebrile. Physical exam was otherwise unremarkable with a clear chest, no peripheral lymphadenopathy, no rash, and no edema. Laboratories (Table 1) were remarkable for Ca 13.5 mg/dL, creatinine 7.6 mg/dL, and phosphorus 7.4 mg/dL. Urinalysis showed calcium-oxalate crystals with 4–10 RBCs/HPF with normal morphology and the urine albumin/creatinine ratio was normal at 24 mg/g. Evaluation of the hypercalcemia revealed the following: PTH < 3 (11–67 pg/mL), 25-hydroxyvitamin D 23.8 (30–95 ng/mL), 1,25-dihydroxyvitamin D 79 (18–72 pg/mL), and angiotensin converting enzyme (ACE) level 82 (9–67 U/L) (Table 2). Serum and urine immunofixations did not detect a monoclonal protein. A skeletal survey showed no lytic or blastic osseous lesions. Thyroid function tests were normal. His chest X-ray was negative and PFTs (pulmonary function tests) were normal but a computed tomography (CT) scan
Hospital day 1 135 5.3 101 21 57 7.59 167 8 13.5 Unable to calculate Not checked 7.4 Not checked Not checked Not checked Not checked Not checked Not checked Not checked 12.8 13 39.2 386 83.3 5.2 77.6 9 7.7 0.5
139 4.4 104 25 23 1.79 137 40 10.5
10.4
Not checked Not checked 7.3 4.1 0.6 0.1 68 26 24 12.8 13 39.2 386 83.2 5.2 77.6 9 7.7 0.3
Sodium Potassium Chloride Carbon dioxide Blood urea nitrogen Creatinine Glucose eGFR Calcium
Corrected calcium∗
∗
The normal albumin level is defaulted to 4.
Ionized Ca Phosphorus, inorganic Protein, total Albumin Bilirubin, total Bilirubin, direct ALP AST ALT WBC Hemoglobin Hct Platelet MCV Eosinophils (%) Neutrophil (%) Lymphocytes (%) Monocytes (%) Basophil (%)
Variable
Baseline labs, 6 months before admission
1.7 6.1 6 3.4 0.6 Not checked 43 22 23 13.2 11.2 33.6 302 84.1 3.9 77.8 10 7.9 0.4
13.4 Not checked 4.7 5.5 2.9 0.3 Not checked 42 21 28 8.6 10.6 33.1 298 85.9 6.7 70 12.7 10.1 0.5
11.8 Not checked 7.5 7.2 3.9 0.5 Not checked 113 23 39 10.8 12.1 37.2 295 85.3 7.1 69 13.6 10.1 0.2
13.2 Not checked Not checked 5.3 2.8 0.3 0.2 66 28 52 18.7 10.3 32.1 306 85.9 0.4 91.1 4.8 3.7 0
10.3
Hospital day 12,1 Hospital Day 16 time (prednisone Hospital day 2 Hospital day 6 dexamethasone 60 mg Qd was given started) 138 138 134 136 5.2 5.1 5.3 4.9 104 110 106 112 16 17 17 18 57 65 57 40 6.79 4.98 7.6 6.49 106 216 148 99 9 12 7 9 13.1 9.3 12.9 10.9
Table 1: Lab values during hospitalization and after discharge.
135 4.3 111 17 67 4.52 145 14 8.1 Unable to calculate 1.12 Not checked Not checked Not checked Not checked Not checked Not checked Not checked Not checked 13.1 9.9 31.8 105 85.5 Not checked Not checked Not checked Not checked Not checked
Day 18 (discharge day)
Not checked 3.4 6.2 3.7 0.4 0.3 67 20 25 14.8 12.4 37 300 87.6 2.1 91 4.3 2.4 0.2
9.8
139 4.9 104 19 68 2.89 94 23 9.6
15 days after discharge
1.16–1.32 mmol/L 2.5–4.5 mg/dL 6.3–8.2 g/dL 3.5–5 g/dL 0.2–1.3 mg/dL 0.0–0.4 mg/dL 38–126 U/L 15–46 U/L 13–69 U/L 3.4–11 k/𝜇L 13.0–17 g/dL 38–51% 150–450 k/𝜇L 80–100 fL 0.0–0.6% 40–74% 18–44 4.7–12.0% 0.1–1.4%
8.5–10.5 mg/dL
136–146 mmol/L 3.5–5.1 mmol/L 96–107 mmol/L 22–30 mmol/L 8–24 mmol/dl 0.66–1.25 mg/dL 74–106 mg/dL >90 8.4–10.3 mg/dL
Reference range
2 Case Reports in Nephrology
Case Reports in Nephrology
3 Table 2: Lab values.
Variable LDH Creatinine kinase Cholesterol, total HDL LDL Cholesterol/HDL ratio Triglycerides ESR CRP ACE, before steroid treatment ACE, after steroid treatment Vit D, 25 hydroxy Vit D, 1,25 hydroxy, before steroid treatment Vit D, 1,25 hydroxy, after steroid treatment PTH, intact ANA Immunofixation, serum IgG, serum IgA, serum IgM, serum Immunofixatin elec., urine Protein, random urine C3 C4 Quantiferon-Tb gold Mitogen-nil NIL TB Ag-nil ASO Ab ANCA vasculitides Proteinase 3 Ab Myeloperoxidase Ab Hep A Ab, IgM Hep A Ab, total Hep B sAg Hep B Core Ab, total Hep BS ab HepC Ab HIV 1/2 Ab screen, rapid HgbA1c Urine culture Urine chemistry Protein, random urine Microalbumin, random, urine Sodium, random, urine Potassium, random, urine Calcium, random, urine Thyroxine, free TSH PSA free PSA percent free Total PSA
Measurement 478 40 187 28 87 6.7 362 26 Not checked 82 24 27.8 79 19 3.72 Negative Polyclonal pattern 1330 187 44 Polyclonal IGG and polyclonal light chains 10 119 22 Indeterminate 0.16 0.03 0 46
Reference range 313–618 U/L 55–170 40 mg/dL
