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Hypercalcemia and Elevated Calcitriol in a Maintenance Dialysis Patient With Tuberculosis

Hypercalcemia and Elevated Calcitriol in a Maintenance Dialysis Patient With Tuberculosis Abstract • A patient on maintenance hemodialysis had widely disseminated tuberculosis, hypercalcemia, and elevated levels of calcitriol (1,25-dihydroxycholecalciferol). Hypercalcemia was not observed until the eighth month of hemodialysis, when persistent fevers began. At the end of a calcium-free dialysis, the plasma calcium concentration decreased to 6.6 mg/dL (1.65 mmol/L). The baseline calcitriol level was 56 pg/mL (normal, 19 to 50 pg/mL and increased to 147 pg/mL at the end of hemodialysis. Parathyroid hormone levels by three separate assays did not appreciably increase during the hypocalcemia Induced by the calcium-free hemodialysis. The serum phosphate concentration decreased from 7.3 to 4.5 mg/dL (2.36 to 1.45 mmol/L). Extrarenal production of calcitriol may occur in disseminated tuberculosis and may be stimulated by hypocalcemia and reduced serum phosphate. The expected parathyroid hormone response to hypocalcemia may have been inhibited by persistently elevated calcitriol levels or preexisting hypercalcemia. (Arch Intern Med 1986;146:1941-1945) References 1. Stern PH, De Olazabal J, Bell NH: Evidence of abnormal regulation of circulating 1,25-dihydroxy-vitamin D in patients with sarcoidosis and normal calcium metabolism. J Clin Invest 1980;66:852-855.Crossref 2. Sandler LM, Winearls CG, Fraher LJ, et al: Studies of the hypercalcemia of sarcoidosis: Effect of steroids and exogenous vitamin D3 on the circulating concentrations of 1,25-dihydroxy vitamin D3. Q J Med 1984;53: 165-180. 3. Zimmerman J, Holick MF, Silver J: Normocalcemia in a hypoparathyroid patient with sarcoidosis: Evidence for parathyroid hormone independent synthesis of 1,25 dihydroxyvitamin D. Ann Intern Med 1983;98:338.Crossref 4. Lee JC, Catanzaro A, Parthemore JG, et al: Hypercalcemia in disseminated coccidioidomycosis. N Engl J Med 1977;297:431-433.Crossref 5. Parker MS, Dokoh S, Woolfenden JM, et al: Hypercalcemia in coccidioidomycosis. Am J Med 1984;76:341-344.Crossref 6. Walker JV, Baran D, Yakum YN, et al: Histoplasmosis with hypercalcemia, renal failure, and papillary necrosis: Confusion with sarcoidosis. JAMA 1977;237:1350-1352.Crossref 7. Stoeckle JD, Hardy HL, Weber AL: Chronic beryllium disease: Long-term follow-up of 60 cases and selective review of the literature. Am J Med 1969;46:545-561.Crossref 8. Halverson JO, Mohler HK, Bergeim 0: Calcium in the blood in tuberculosis. JAMA 1917;68:1309-1311.Crossref 9. Shai F, Baker RK, Addrizzo JR, et al: Hypercalcemia in mycobacterial infection. J Clin Endocrinol Metab 1972;34:251-256.Crossref 10. Braman SS, Goldman AL, Schwarz MI: Steroid-responsive hypercalcemia in disseminated bone tuberculosis. Arch Intern Med 1973;132:269-271.Crossref 11. Abbasi AA, Chemplavil JK, Farah S, et al: Hypercalcemia in active pulmonary tuberculosis. Ann Intern Med 1979;90:324-328.Crossref 12. Gkonos PJ, London R, Hendler E: Hypercalcemia and elevated 1,25-dihydroxyvitamin D levels in a patient with end-stage renal disease and active tuberculosis. N Engl J Med 1984;311:1683-1685.Crossref 13. Kozeny GA, Barbato AL, Bansal VK, et al: Hypercalcemia associated with silicone-induced granulomas. N Engl J Med 1984;311:1103-1105.Crossref 14. Epstein S, Stern PH, Bell NH, et al: Evidence for abnormal regulation of circulating 1α,25-dihydroxyvitamin D in patients with pulmonary tuberculosis and normal calcium metabolism. Calcif Tissue Int 1984;36: 541-544.Crossref 15. Fraser DK, Kodicek E: Unique biosynthesis by kidney of biologically active vitamin D metabolite. Nature 1970;28:764-766.Crossref 16. Gray RW, Boyle I, DeLuca HF: Vitamin D metabolism: The role of kidney tissue. Science 1971;172:1232-1234.Crossref 17. Haussler MR, Baylink DJ, Hughes MR, et al: The assay of 1,25-dihydroxy vitamin D3: Physiologic and pathologic modulation of circulating hormone levels. Clin Endocrinol 1976;5( (suppl) ):151-165.Crossref 18. Lund B, Clausen E, Friedberg M, et al: Serum 1,25-dihydroxycholecalciferol in anephric haemodialyzed, and kidney-transplanted patients. Nephron 1980;25:30-33.Crossref 19. Reinhardt TA, Horst RL, Orf JW, et al: A microassay for 1,25-dihydroxyvitamin D. N Engl J Med 1981;305:440-443.Crossref 20. Barbour GL, Coburn JW, Slatopolsky E, et al: Hypercalcemia in an anephric patient with sarcoidosis: Evidence for extrarenal generation of 1,25-dihydroxy vitamin D. N Engl J Med 1981;305:440-443.Crossref 21. Maesaka JK, Batuman V, Pablo NC, et al: Elevated 1,25-dihydroxyvitamin D levels: Occurrence with sarcoidosis with end stage renal disease. Arch Intern Med 1982;142:1206-1207.Crossref 22. Breslau NA, McGuire JL, Zerwekh JE, et al: Hypercalcemia associated with increased serum calcitriol levels in three patients with lymphoma. Ann Intern Med 1984;100:1-7.Crossref 23. Gray TK, Lowe W, Lester GE: Vitamin D and pregnancy: The maternal-fetal metabolism of vitamin D. Endocr Rev 1981;2:264-274.Crossref 24. Fraser DK, Kodicek E: Regulation of 25 hydroxycholecalciferol-1-hydroxylase activity in kidney by parathyroid hormone. Nature New Biol 1973;241:163-166.Crossref 25. Hughes MR, Brumbaugh PF, Haussler MR, et al: Regulation of serum 1α,25-dihydroxyvitamin D3 by calcium and phosphate in the rat. Science 1975;190:578-580.Crossref 26. Trechsel U, Eisman JA, Fischer JA, et al: Calcium-dependent, parathyroid hormone-independent regulation of 1,25-dihydroxyvitamin D. Am J Physiol 1980;239:E119-E124. 27. Llach F, Felsenfeld AJ, Haussler MR: The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. N Engl J Med 1981;305:117-123.Crossref 28. Eisman JA, Hamstra AJ, Kream BE, et al: A sensitive, precise and convenient method for the determination of 1,25 dihydroxyvitamin D in human plasma. Arch Biochem Biophys 1976;176:235-237.Crossref 29. Eisman JA, Shepard RM, DeLuca HF: Determination of 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3 in human plasma using high-pressure liquid chromatography. Anal Biochem 1977;80:298-300.Crossref 30. Lyle KW, Clark AG, Drezner MK: Serum 1,25-dihydroxyvitamin D levels in subjects with X-linked hypophosphatemic rickets and osteomalacia. Calcif Tissue Int 1982;34:125-130.Crossref 31. Brickman AS, Coburn JW, Massry SG: 1,25 Dihydroxyvitamin D3 in normal man and patients with renal failure. Ann Intern Med 1974;80: 161-168.Crossref 32. Lund B, Sorenson OH, Lund B, et al: Stimulation of 1,25-dihydroxyvitamin D production by parathyroid hormone and hypocalcemia in man. J Clin Endocrinol Metab 1980;50:480-484.Crossref 33. Blum JW, Trechsel U, Born W, et al: Rapidity of plasma 1,25-dihydroxyvitamin D responses to hypo and hypercalcemia in steers. Endocrinology 1983;113:523-526.Crossref 34. Eisman JA, Prince RL, Worek JD, et al: Modulation of plasma 1,25-dihydroxyvitamin D in man by stimulation and suppression tests. Lancet 1979;2:931-933.Crossref 35. Bilezekian JP, Canfield RE, Jacobs TP, et al: Response of 1,α25-dihydroxyvitamin D3 to hypocalcemia in human subjects. N Engl J Med 1978;299:437-441.Crossref 36. Adams ND, Gary RW, Lemann J Jr: The effects of oral CaCO3 loading and dietary calcium deprivation on plasma 1,25-dihydroxyvitamin concentrations in healthy adults. J Clin Endocrinol Metab 1979;48:1008-1016.Crossref 37. Prince RL, Wark JD, Omond S, et al: A test of 1,25-dihydroxyvitamin D3 secretory capacity in normal subjects for application in metabolic bone diseases. Clin Endocrinol 1983;18:127-133.Crossref 38. Yasuda T, Nakajima H: 1,25-Dihydroxyvitamin D production after stimulation with synthetic human parathyroid hormone (1-34) in hypoparathyroid and renal tubular disorders. Endocrinol Jpn 1984;31:407-415.Crossref 39. Markowitz ME, Rosen JF, Smith C, et al: 1,25-Dihydroxyvitamin D3 treated hypoparathyroidism: Thirty-five patient years in ten children. J Clin Endocrinol Metab 1982;55:727-733.Crossref 40. Mayer GP, Hurst JG: Sigmoidal relationship between parathyroid hormone secretion rate and plasma calcium concentration in calves. Endocrinology 1978;102:1036-1042.Crossref 41. Blum JW, Fischer JA, Schwoerer D, et al: Acute parathyroid hormone response: Sensitivity, relationship to hypocalcemia, and rapidity. Endocrinology 1974;95:753-759.Crossref 42. Voigts A, Felsenfeld AJ, Andress D, et al: Parathyroid hormone and bone histology: Response to hypocalcemia in osteitis fibrosa. Kidney Int 1984;25:445-452.Crossref 43. Andress D, Felsenfeld AJ, Voigts A, et al: Parathyroid hormone response to hypocalcemia in hemodialysis patients with osteomalacia. Kidney Int 1983;24:364-370.Crossref 44. Chertow BS, Baylink DJ, Wergedal JE, et al: Decrease in serum immunoreactive parathyroid hormone in rats and in parathyroid hormone secretion in vitro by 1,25 dihydroxycholecalciferol. J Clin Invest 1975;56: 668-678.Crossref 45. Chan YL, McKay C, Dye E, et al: The effect of 1,25 dihydroxycholecalciferol on parathyroid hormone secretion by monolayer cultures of bovine parathyroid cells. Calcif Tissue Int 1986;38:27-32.Crossref 46. Slatopolsky E, Weerts C, Thielan B, et al: Marked suppression of secondary hyperparathyroidism by intravenous administration of 1,25 dihydroxycholecalciferol in uremic patients. J Clin Invest 1984;74: 2136-2143.Crossref 47. Mayer GP, Habener JF, Potts JT: Parathyroid hormone secretion in vivo: Demonstration of a calcium-independent nonsuppressible component of secretion. J Clin Invest 1976;57:678-683.Crossref 48. Muirhead N, Catto GRD, Edward N, et al: Suppression of secondary hyperparathyroidism in uremic acute and chronic studies. Br Med J 1984;288:177-179.Crossref 49. Bell NH, Shary J, Shaw S, et al: Hypercalcemia associated with increased circulatory 1,25-dihydroxyvitamin D in a patient with pulmonary tuberculosis. Calcif Tissue Int 1985;37:588-591.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Hypercalcemia and Elevated Calcitriol in a Maintenance Dialysis Patient With Tuberculosis

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References (52)

Publisher
American Medical Association
Copyright
Copyright © 1986 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1986.00360220089018
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Abstract

Abstract • A patient on maintenance hemodialysis had widely disseminated tuberculosis, hypercalcemia, and elevated levels of calcitriol (1,25-dihydroxycholecalciferol). Hypercalcemia was not observed until the eighth month of hemodialysis, when persistent fevers began. At the end of a calcium-free dialysis, the plasma calcium concentration decreased to 6.6 mg/dL (1.65 mmol/L). The baseline calcitriol level was 56 pg/mL (normal, 19 to 50 pg/mL and increased to 147 pg/mL at the end of hemodialysis. Parathyroid hormone levels by three separate assays did not appreciably increase during the hypocalcemia Induced by the calcium-free hemodialysis. The serum phosphate concentration decreased from 7.3 to 4.5 mg/dL (2.36 to 1.45 mmol/L). Extrarenal production of calcitriol may occur in disseminated tuberculosis and may be stimulated by hypocalcemia and reduced serum phosphate. The expected parathyroid hormone response to hypocalcemia may have been inhibited by persistently elevated calcitriol levels or preexisting hypercalcemia. (Arch Intern Med 1986;146:1941-1945) References 1. Stern PH, De Olazabal J, Bell NH: Evidence of abnormal regulation of circulating 1,25-dihydroxy-vitamin D in patients with sarcoidosis and normal calcium metabolism. J Clin Invest 1980;66:852-855.Crossref 2. Sandler LM, Winearls CG, Fraher LJ, et al: Studies of the hypercalcemia of sarcoidosis: Effect of steroids and exogenous vitamin D3 on the circulating concentrations of 1,25-dihydroxy vitamin D3. Q J Med 1984;53: 165-180. 3. Zimmerman J, Holick MF, Silver J: Normocalcemia in a hypoparathyroid patient with sarcoidosis: Evidence for parathyroid hormone independent synthesis of 1,25 dihydroxyvitamin D. Ann Intern Med 1983;98:338.Crossref 4. Lee JC, Catanzaro A, Parthemore JG, et al: Hypercalcemia in disseminated coccidioidomycosis. N Engl J Med 1977;297:431-433.Crossref 5. Parker MS, Dokoh S, Woolfenden JM, et al: Hypercalcemia in coccidioidomycosis. Am J Med 1984;76:341-344.Crossref 6. Walker JV, Baran D, Yakum YN, et al: Histoplasmosis with hypercalcemia, renal failure, and papillary necrosis: Confusion with sarcoidosis. JAMA 1977;237:1350-1352.Crossref 7. Stoeckle JD, Hardy HL, Weber AL: Chronic beryllium disease: Long-term follow-up of 60 cases and selective review of the literature. Am J Med 1969;46:545-561.Crossref 8. Halverson JO, Mohler HK, Bergeim 0: Calcium in the blood in tuberculosis. JAMA 1917;68:1309-1311.Crossref 9. Shai F, Baker RK, Addrizzo JR, et al: Hypercalcemia in mycobacterial infection. J Clin Endocrinol Metab 1972;34:251-256.Crossref 10. Braman SS, Goldman AL, Schwarz MI: Steroid-responsive hypercalcemia in disseminated bone tuberculosis. Arch Intern Med 1973;132:269-271.Crossref 11. Abbasi AA, Chemplavil JK, Farah S, et al: Hypercalcemia in active pulmonary tuberculosis. Ann Intern Med 1979;90:324-328.Crossref 12. Gkonos PJ, London R, Hendler E: Hypercalcemia and elevated 1,25-dihydroxyvitamin D levels in a patient with end-stage renal disease and active tuberculosis. N Engl J Med 1984;311:1683-1685.Crossref 13. Kozeny GA, Barbato AL, Bansal VK, et al: Hypercalcemia associated with silicone-induced granulomas. N Engl J Med 1984;311:1103-1105.Crossref 14. Epstein S, Stern PH, Bell NH, et al: Evidence for abnormal regulation of circulating 1α,25-dihydroxyvitamin D in patients with pulmonary tuberculosis and normal calcium metabolism. Calcif Tissue Int 1984;36: 541-544.Crossref 15. Fraser DK, Kodicek E: Unique biosynthesis by kidney of biologically active vitamin D metabolite. Nature 1970;28:764-766.Crossref 16. Gray RW, Boyle I, DeLuca HF: Vitamin D metabolism: The role of kidney tissue. Science 1971;172:1232-1234.Crossref 17. Haussler MR, Baylink DJ, Hughes MR, et al: The assay of 1,25-dihydroxy vitamin D3: Physiologic and pathologic modulation of circulating hormone levels. Clin Endocrinol 1976;5( (suppl) ):151-165.Crossref 18. Lund B, Clausen E, Friedberg M, et al: Serum 1,25-dihydroxycholecalciferol in anephric haemodialyzed, and kidney-transplanted patients. Nephron 1980;25:30-33.Crossref 19. Reinhardt TA, Horst RL, Orf JW, et al: A microassay for 1,25-dihydroxyvitamin D. N Engl J Med 1981;305:440-443.Crossref 20. Barbour GL, Coburn JW, Slatopolsky E, et al: Hypercalcemia in an anephric patient with sarcoidosis: Evidence for extrarenal generation of 1,25-dihydroxy vitamin D. N Engl J Med 1981;305:440-443.Crossref 21. Maesaka JK, Batuman V, Pablo NC, et al: Elevated 1,25-dihydroxyvitamin D levels: Occurrence with sarcoidosis with end stage renal disease. Arch Intern Med 1982;142:1206-1207.Crossref 22. Breslau NA, McGuire JL, Zerwekh JE, et al: Hypercalcemia associated with increased serum calcitriol levels in three patients with lymphoma. Ann Intern Med 1984;100:1-7.Crossref 23. Gray TK, Lowe W, Lester GE: Vitamin D and pregnancy: The maternal-fetal metabolism of vitamin D. Endocr Rev 1981;2:264-274.Crossref 24. Fraser DK, Kodicek E: Regulation of 25 hydroxycholecalciferol-1-hydroxylase activity in kidney by parathyroid hormone. Nature New Biol 1973;241:163-166.Crossref 25. Hughes MR, Brumbaugh PF, Haussler MR, et al: Regulation of serum 1α,25-dihydroxyvitamin D3 by calcium and phosphate in the rat. Science 1975;190:578-580.Crossref 26. Trechsel U, Eisman JA, Fischer JA, et al: Calcium-dependent, parathyroid hormone-independent regulation of 1,25-dihydroxyvitamin D. Am J Physiol 1980;239:E119-E124. 27. Llach F, Felsenfeld AJ, Haussler MR: The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. N Engl J Med 1981;305:117-123.Crossref 28. Eisman JA, Hamstra AJ, Kream BE, et al: A sensitive, precise and convenient method for the determination of 1,25 dihydroxyvitamin D in human plasma. Arch Biochem Biophys 1976;176:235-237.Crossref 29. Eisman JA, Shepard RM, DeLuca HF: Determination of 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3 in human plasma using high-pressure liquid chromatography. Anal Biochem 1977;80:298-300.Crossref 30. Lyle KW, Clark AG, Drezner MK: Serum 1,25-dihydroxyvitamin D levels in subjects with X-linked hypophosphatemic rickets and osteomalacia. Calcif Tissue Int 1982;34:125-130.Crossref 31. Brickman AS, Coburn JW, Massry SG: 1,25 Dihydroxyvitamin D3 in normal man and patients with renal failure. Ann Intern Med 1974;80: 161-168.Crossref 32. Lund B, Sorenson OH, Lund B, et al: Stimulation of 1,25-dihydroxyvitamin D production by parathyroid hormone and hypocalcemia in man. J Clin Endocrinol Metab 1980;50:480-484.Crossref 33. Blum JW, Trechsel U, Born W, et al: Rapidity of plasma 1,25-dihydroxyvitamin D responses to hypo and hypercalcemia in steers. Endocrinology 1983;113:523-526.Crossref 34. Eisman JA, Prince RL, Worek JD, et al: Modulation of plasma 1,25-dihydroxyvitamin D in man by stimulation and suppression tests. Lancet 1979;2:931-933.Crossref 35. Bilezekian JP, Canfield RE, Jacobs TP, et al: Response of 1,α25-dihydroxyvitamin D3 to hypocalcemia in human subjects. N Engl J Med 1978;299:437-441.Crossref 36. Adams ND, Gary RW, Lemann J Jr: The effects of oral CaCO3 loading and dietary calcium deprivation on plasma 1,25-dihydroxyvitamin concentrations in healthy adults. J Clin Endocrinol Metab 1979;48:1008-1016.Crossref 37. Prince RL, Wark JD, Omond S, et al: A test of 1,25-dihydroxyvitamin D3 secretory capacity in normal subjects for application in metabolic bone diseases. Clin Endocrinol 1983;18:127-133.Crossref 38. Yasuda T, Nakajima H: 1,25-Dihydroxyvitamin D production after stimulation with synthetic human parathyroid hormone (1-34) in hypoparathyroid and renal tubular disorders. Endocrinol Jpn 1984;31:407-415.Crossref 39. Markowitz ME, Rosen JF, Smith C, et al: 1,25-Dihydroxyvitamin D3 treated hypoparathyroidism: Thirty-five patient years in ten children. J Clin Endocrinol Metab 1982;55:727-733.Crossref 40. Mayer GP, Hurst JG: Sigmoidal relationship between parathyroid hormone secretion rate and plasma calcium concentration in calves. Endocrinology 1978;102:1036-1042.Crossref 41. Blum JW, Fischer JA, Schwoerer D, et al: Acute parathyroid hormone response: Sensitivity, relationship to hypocalcemia, and rapidity. Endocrinology 1974;95:753-759.Crossref 42. Voigts A, Felsenfeld AJ, Andress D, et al: Parathyroid hormone and bone histology: Response to hypocalcemia in osteitis fibrosa. Kidney Int 1984;25:445-452.Crossref 43. Andress D, Felsenfeld AJ, Voigts A, et al: Parathyroid hormone response to hypocalcemia in hemodialysis patients with osteomalacia. Kidney Int 1983;24:364-370.Crossref 44. Chertow BS, Baylink DJ, Wergedal JE, et al: Decrease in serum immunoreactive parathyroid hormone in rats and in parathyroid hormone secretion in vitro by 1,25 dihydroxycholecalciferol. J Clin Invest 1975;56: 668-678.Crossref 45. Chan YL, McKay C, Dye E, et al: The effect of 1,25 dihydroxycholecalciferol on parathyroid hormone secretion by monolayer cultures of bovine parathyroid cells. Calcif Tissue Int 1986;38:27-32.Crossref 46. Slatopolsky E, Weerts C, Thielan B, et al: Marked suppression of secondary hyperparathyroidism by intravenous administration of 1,25 dihydroxycholecalciferol in uremic patients. J Clin Invest 1984;74: 2136-2143.Crossref 47. Mayer GP, Habener JF, Potts JT: Parathyroid hormone secretion in vivo: Demonstration of a calcium-independent nonsuppressible component of secretion. J Clin Invest 1976;57:678-683.Crossref 48. Muirhead N, Catto GRD, Edward N, et al: Suppression of secondary hyperparathyroidism in uremic acute and chronic studies. Br Med J 1984;288:177-179.Crossref 49. Bell NH, Shary J, Shaw S, et al: Hypercalcemia associated with increased circulatory 1,25-dihydroxyvitamin D in a patient with pulmonary tuberculosis. Calcif Tissue Int 1985;37:588-591.Crossref

Journal

Archives of Internal Medicine – American Medical Association

Published: Oct 1, 1986

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