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'Surgical cure' for non-parathyroid hypercalcemia.

Joglekar SP, Hudson RL, Logasundaram R, Pereira JH - World J Surg Oncol (2009)

Bottom Line: We propose that sarcoidosis should be kept in mind as a cause of unexplained hypercalcemia.Increased awareness of radiological features of splenic involvement in sarcoidosis, would help in diagnosis.We believe that we are reporting 9th case in the literature while writing this report.

View Article: PubMed Central - HTML - PubMed

Affiliation: James Paget University Hospital NHS Trust, Great Yarmouth, UK. sandeep.joglekar@jpaget.nhs.uk

ABSTRACT

Background: Sarcoidosis is a granulomatous disease of unknown aetiology. Over 90% patients of sarcoidosis present with pulmonary findings. Other organs such as lymph nodes, skin, and joints may be involved. Isolated granulomatous disease confined to the spleen is rare.

Case presentation: This report documents a rare case of isolated granulomatous disease of spleen presenting as hypercalcemia. After all possible causes for hypercalcemia were ruled out, splenectomy was done which proved diagnostic and therapeutic, as calcium levels returned to normal.

Conclusion: We propose that sarcoidosis should be kept in mind as a cause of unexplained hypercalcemia. Increased awareness of radiological features of splenic involvement in sarcoidosis, would help in diagnosis. We believe that we are reporting 9th case in the literature while writing this report.

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CT Image – (CT scan image showing multiple splenic nodules).
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Figure 1: CT Image – (CT scan image showing multiple splenic nodules).

Mentions: A 46 year old lady presented with back and leg pain. She had a history of sciatica for 17 years. She also complained of poor appetite, loss of 3 stones of weight in 6 months. Patient also complained of intermittent nausea, vomiting, constipation. Past medical history included previous discectomy and laminectomy, Raynaud's syndrome, essential hypertension, and hysterectomy for endometriosis. Drug allergies included penicillin, erythromycin, septrin, acupan, doxycycline. On examination, pulse and blood pressure were stable. Chest and abdominal examination were normal. Serum investigations revealed a raised corrected calcium of 3.72 mmol/L, urea of 9.4 mmol/L and creatinine of 135 umol/L. ESR was 52 mm/hr, liver function tests were normal. Coagulation studies, protein electrophoresis were within normal limits. Patient subsequently underwent investigations for causes of hypercalcemia. Urine analysis was negative for Bence-Jones proteins. Thyroid function tests were within normal limits. Serum parathormone levels were 1.1 pmol/L. Serum angiotensin convertase enzyme levels were normal (26 U/L). Ultrasound abdomen revealed slightly enlarged spleen. Skeletal survey did not reveal bony secondary deposits or other abnormalities. MRI scan of lumbosacral spine showed posterocentral and right posterolateral disc protrusion at L5/S1 with compression of thecal sac, which explained the back and leg pain. Ultrasound of neck did not reveal thyroid or parathyroid abnormalities. Bone marrow studies were reported normal. CT scan of chest and abdomen was done to rule out occult malignancy as a cause of hypercalcemia. This revealed borderline enlarged spleen (cranio-caudal diameter of 12.7 cms) studded with multiple low density coalescent nodular lesions (figure 1). Patient was started on oral steroids and was given an infusion of alendronate for hypercalcemia. All investigations were discussed in upper GI multidisciplinary meeting and a decision to perform splenectomy was made. Patient underwent laparotomy and splenectomy. Intra-operative findings included enlarged spleen studded with white nodules (figure 2). Postoperative recovery was uneventful. Patient was given chemo-prophylaxis with oral penicillin V and prophylactic pneumococcal and meningococcal vaccines. Histology of spleen showed epitheloid and giant cell granulomas dispersed throughout splenic parenchyma. Granulomas were non-caseating (figure 3). Some of the giant cells within the granulomas contained calcific spherules. Sections from hilar lymph nodes showed a similar granulomatous process. Special stains did not identify fungi or mycobacteria. Final diagnosis of splenic sarcoidosis was made. Postoperatively, calcium levels returned back to normal. Follow-up after one month revealed no further clinical problems and normal serum calcium levels. At 6 months follow up, patient remained asymptomatic. Opthalmic opinion was saught in view of diagnosis of sarcoidosis,. This was found to be entirely normal.


'Surgical cure' for non-parathyroid hypercalcemia.

Joglekar SP, Hudson RL, Logasundaram R, Pereira JH - World J Surg Oncol (2009)

CT Image – (CT scan image showing multiple splenic nodules).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2662839&req=5

Figure 1: CT Image – (CT scan image showing multiple splenic nodules).
Mentions: A 46 year old lady presented with back and leg pain. She had a history of sciatica for 17 years. She also complained of poor appetite, loss of 3 stones of weight in 6 months. Patient also complained of intermittent nausea, vomiting, constipation. Past medical history included previous discectomy and laminectomy, Raynaud's syndrome, essential hypertension, and hysterectomy for endometriosis. Drug allergies included penicillin, erythromycin, septrin, acupan, doxycycline. On examination, pulse and blood pressure were stable. Chest and abdominal examination were normal. Serum investigations revealed a raised corrected calcium of 3.72 mmol/L, urea of 9.4 mmol/L and creatinine of 135 umol/L. ESR was 52 mm/hr, liver function tests were normal. Coagulation studies, protein electrophoresis were within normal limits. Patient subsequently underwent investigations for causes of hypercalcemia. Urine analysis was negative for Bence-Jones proteins. Thyroid function tests were within normal limits. Serum parathormone levels were 1.1 pmol/L. Serum angiotensin convertase enzyme levels were normal (26 U/L). Ultrasound abdomen revealed slightly enlarged spleen. Skeletal survey did not reveal bony secondary deposits or other abnormalities. MRI scan of lumbosacral spine showed posterocentral and right posterolateral disc protrusion at L5/S1 with compression of thecal sac, which explained the back and leg pain. Ultrasound of neck did not reveal thyroid or parathyroid abnormalities. Bone marrow studies were reported normal. CT scan of chest and abdomen was done to rule out occult malignancy as a cause of hypercalcemia. This revealed borderline enlarged spleen (cranio-caudal diameter of 12.7 cms) studded with multiple low density coalescent nodular lesions (figure 1). Patient was started on oral steroids and was given an infusion of alendronate for hypercalcemia. All investigations were discussed in upper GI multidisciplinary meeting and a decision to perform splenectomy was made. Patient underwent laparotomy and splenectomy. Intra-operative findings included enlarged spleen studded with white nodules (figure 2). Postoperative recovery was uneventful. Patient was given chemo-prophylaxis with oral penicillin V and prophylactic pneumococcal and meningococcal vaccines. Histology of spleen showed epitheloid and giant cell granulomas dispersed throughout splenic parenchyma. Granulomas were non-caseating (figure 3). Some of the giant cells within the granulomas contained calcific spherules. Sections from hilar lymph nodes showed a similar granulomatous process. Special stains did not identify fungi or mycobacteria. Final diagnosis of splenic sarcoidosis was made. Postoperatively, calcium levels returned back to normal. Follow-up after one month revealed no further clinical problems and normal serum calcium levels. At 6 months follow up, patient remained asymptomatic. Opthalmic opinion was saught in view of diagnosis of sarcoidosis,. This was found to be entirely normal.

Bottom Line: We propose that sarcoidosis should be kept in mind as a cause of unexplained hypercalcemia.Increased awareness of radiological features of splenic involvement in sarcoidosis, would help in diagnosis.We believe that we are reporting 9th case in the literature while writing this report.

View Article: PubMed Central - HTML - PubMed

Affiliation: James Paget University Hospital NHS Trust, Great Yarmouth, UK. sandeep.joglekar@jpaget.nhs.uk

ABSTRACT

Background: Sarcoidosis is a granulomatous disease of unknown aetiology. Over 90% patients of sarcoidosis present with pulmonary findings. Other organs such as lymph nodes, skin, and joints may be involved. Isolated granulomatous disease confined to the spleen is rare.

Case presentation: This report documents a rare case of isolated granulomatous disease of spleen presenting as hypercalcemia. After all possible causes for hypercalcemia were ruled out, splenectomy was done which proved diagnostic and therapeutic, as calcium levels returned to normal.

Conclusion: We propose that sarcoidosis should be kept in mind as a cause of unexplained hypercalcemia. Increased awareness of radiological features of splenic involvement in sarcoidosis, would help in diagnosis. We believe that we are reporting 9th case in the literature while writing this report.

Show MeSH
Related in: MedlinePlus