Disorders of Mineral Homeostasis

Abstract

A 55-year-old male presented with epigastric pain for the past 6 weeks. It was intermittent, moderate in severity, and associated with nausea and vomiting. He also had anorexia, constipation, and weight loss of 15 kg in the last 6 months. He underwent pyelolithotomy 2 months back for renal stone disease. There was no history of gallstone disease, bone pains, or fragility fracture. He was nonalcoholic and nonsmoker. On examination, he was dehydrated with a blood pressure 90/72 mmHg, pulse rate 126/min, and central venous pressure 2 cm H₂O. Abdominal examination revealed a 10 × 8 cm mass in the epigastrium extending to right hypochondrium. Ultrasonography of the abdomen showed a bulky pancreas with multiple collections in the peripancreatic region. On investigations, hemoglobin was 12.4 g/dl, total leukocyte count 12,300/cumm³, serum sodium 129 mEq/L, potassium 5 mEq/L, creatinine 2.6 mg/dl, corrected calcium 15.1 mg/dl, ionized calcium 1.75 mmol/L, phosphorus 3 mg/dl, and alkaline phosphatase 240 IU/L. His serum lipase was 77 U/L, amylase 24 U/L, and liver function tests were normal. Serum iPTH was 8.1 pg/ml (9–65), 25(OH)D 10 ng/ml, and 1,25(OH)₂D 62.2 pg/ml (19.6–54.3). Based on clinical and biochemical profile, a diagnosis of PTH-independent hypercalcemia and pancreatitis was considered. There was no history of intake of lithium, thiazides, vitamin A, or D. Angiotensin-converting enzyme levels were normal and workup for multiple myeloma was noncontributory. Contrast-enhanced CT of chest and abdomen revealed hilar lymphadenopathy and bulky pancreas with multiple collections in the lesser sac. ¹⁸F-FDG-PET showed avid uptake in the mediastinal lymph nodes. Transbronchial lymph node biopsy was suggestive of sarcoidosis. The patient was managed with intravenous saline, diuretics, zoledronic acid 5 mg, and prednisolone 1 mg/kg/day. There was a rapid normalization of serum calcium levels within 3–4 days, and prednisolone was gradually tapered over a period of 6 months with sustained normalization of serum calcium during follow-up. Later, he was subjected to cystogastrostomy for pancreatic pseudocyst.