Hypercalcemia as a Rare Manifestation of Pneumocystis jirovecii Pneumonia

Document Type

Conference Proceeding

Publication Date

11-1-2023

Publication Title

J Am Soc Nephrol

Abstract

Introduction: Pneumocystis Jirovecii pneumonia (PJP) is a fungal infection which disproportionally affects immunocompromised individuals. We present two cases of PJP associated with hypercalcemia and acute kidney injury (AKI) in renal transplant recipients (RTR). Case Description: Case 1: A 40-year-old male RTR patient presented with oneweek of fever, cough, and shortness of breath. CT Chest showed peripheral groundglass opacities. Patient remained febrile, tachycardic, and hypoxic. Given the clinical presentation and Fungitell > 500 pg/mL, treatment for PJP was started with Atovaquone and steroids. Hypercalcemia (ionized calcium 1.62 mmol/L) was reported with routine workup insignificant for pharmacological or alternate underlying conditions. PTH was suppressed at 6 pg/mL and 1,25 DiHydroxyvitamin D was elevated above 200 pg/mL. 25-Hydroxy Vitamin D levels were within normal limits. Due to lack of improvement in hypercalcemia with IV hydration, Denosumab was prescribed with improvement in serum calcium levels. Bisphosphonates were contraindicated with renal dysfunction. Case 2: A 63-year-old male RTR patient presented with a three-week history of fatigue, cough, and chills. Workup similarly revealed PJP, hypercalcemia, and AKI with an elevated 1,25 DiHydroxyvitamin D. Due to failed treatment with IV Saline, Miacalcin, and Ketoconazole, Denosumab was used with improvement in Hypercalcemia. Clinical improvement of PJP reported with Primaquine and Clindamycin. Discussion: Two renal transplant patients, on immunosuppressive medications, presented with AKI, hypercalcemia, and PJP. This hypercalcemia is believed to be due to an alveolar macrophage mediated process, increasing 1-a-hydroxylase activity and elevating 1,25-DiHydroxyvitamin D. Both patients responded favorably to denosumab, a RANK-L inhibitor which prevents osteoclast activation. PJP was suspected based on bilateral ground-glass opacities on imaging, elevated fungitell, and presence of dry cough in an immunocompromised patient. LDH was not elevated in Case 1, as sensitivity of LDH elevation in non-HIV patients with PJP is as low as 63%. Clinical improvement noted with treatment of PJP. Hypercalcemia is a unique presentation of PJP in renal transplant recipients. Early intervention is recommended given the potential for continued alveolar macrophage mediated Hypercalcemia and AKI.

Volume

34

First Page

329

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