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A Rock and a Hard Place
A C A Clinic linical Prob al Problem S lem Solv
- lving C
A Rock and a Hard Place A C A Clinic linical Prob al Problem S - - PDF document
A Rock and a Hard Place A C A Clinic linical Prob al Problem S - - PDF document
10/25/14 A Rock and a Hard Place A C A Clinic linical Prob al Problem S lem Solv olving C ing Cas ase e Gurpreet Dhaliwal, MD Professor of Medicine University of California, San Francisco 1 10/25/14 Ground Rules for
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History
A 52-year-old man with HIV and chronic
hepatitis B presented with a six month history of fatigue, polyuria, nausea, and a 12 pound weight loss
Goop’s Initial Thoughts
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History of Present Illness
The patient’s HIV was diagnosed in 1989
No opportunistic infections except for possible thrush CD4 nadir in the low 200s Numerous ARVs in past (truvada/atazanavir/ritonavir) but
changed to Complera (emtricitabine/rilpivirine/tenofovir) six months ago for ease of dosing
Also has history of hepatitis B but quiescent, nl LFTs
Was well until about 2 months ago when he noticed
subacute onset of fatigue, polyuria, nausea, and a 12 pound weight loss
He self-discontinued his ARVs (as well as his
atorvastatin) 2 months ago and sought medical attention
Labs Two Months Ago
Labs at the time (2 months ago) included:
139 | 105 | 28 / Ca 12.4
- -------------------------- 92
4.1 | 29 | 1.91 \ \ 12.5 / TP 5.9 4.6 ----------- 143 Alb 3.9 / 37.4 \ Alk phos 57 Vitamin D 30 CD4 444 (31%), Viral Load undetectable
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What do you think is going on?
- 1. I think his kidney problem has led to
hypercalcemia
- 2. I think his hypercalcemia has led to his kidney
problem
- 3. I think his kidney problem and his hypercalcemia
represent two different processes
Ockham’s Razor vs. Hickam’s Dictum
“Entities must not be multiplied beyond necessity.”
- - William of Ockham
“Patients can have as many diseases as they damn well
please.”
- - John Hickam
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My Leading Diagnosis Is…
- 1. Side effect of his HIV medications
- 2. A complication of his HIV disease
- 3. Sarcoid
- 4. Tuberculosis
- 5. Ebola
- 6. Hyperparathyroidism
- 7. Multiple myeloma
- 8. Something else
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Two Months Ago
The hypercalcemia and kidney injury were felt to
be complications of his new HIV medication
Patient was told to stay off the medication and
drink more fluids
No medical attention in the subsequent two
months
Symptoms persisted
New UCSF PCP
(1st visit)
Complains of persistent nausea,
polyuria, weight loss
Notes increasing fatigue with climbing
steps, as well as more weakness
Denies fevers, chills, sweats, cough, abdominal
pain, bone pain, muscle aches, dysuria, confusion
On no meds (d/ced 2 months ago)
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Remainder of History
Social History
Born and raised in Eureka, CA, now lives in SF Works as a firefighter Homosexual Never smoked, Denies illicit drug use, Drinks one
glass of wine a week
FH: Father w/ prostate cancer, Mother w/ salivary
gland cancer
ROS otherwise negative
Physical Examination
NAD, appears well nourished Afebrile, 118/78, HR 60, RR normal Eyes: EOMI, PERRL, anicteric Neck: normal without masses CV: RRR, no murmurs, rubs, gallops Lungs: Normal breath sounds Abdomen: Non-tender, no masses or HSM Musculoskeletal: Normal tone, no edema Neuro: 5/5 strength throughout, Alert/oriented x 3 Psych: Normal mood, affect, thought content, memory WITHIN NORMAL LIMITS
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Repeat Labs (now)
137 | 103 | 29 / Ca 13.3
- -------------------------- 94
4.4 | 29 | 2.18 \ \ 9.9 / Phos 2.3 4.6 ---------- 84 Alb 3.3 / 28.1\ UA spec grav1.012 Prot/Cr ratio 0.33
Hospital Course
The patient was admitted and treated with IV
fluids and pamidronate
Additional labs returned:
PTH <3 Vitamin D (25-OH) 22 (low) TSH 2.5 Cortisol 13 CXR normal
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Now I Want…
- 1. An SPEP/UPEP
- 2. Some other Vitamin D thingy
- 3. A chest CT
- 4. A parathyroid scan
- 5. A vacation
- 6. My mother
Goop’s Riff on the Labs
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Additional Labs
SPEP/UPEP negative
IFE negative, normal immunoglobulins Kappa 65, lambda 48: both high, but normal
ratio
Vitamin D 1,25-OH: 128 (normal = 18-72) Chest CT: two 4 mm pulmonary nodules, slightly
increased number of normal-sized LNs in mediastinum/axilla: “non-specific”
CT Abdomen: normal abdomen/pelvis; “nodular
soft tissue density in the subcutaneous fat of both buttocks”
Now My Leading Dx Is…
- 1. Sarcoid
- 2. An occult malignancy producing PTH-related
peptide
- 3. An occult malignancy producing something else
- 4. Isinglass syndrome
- 5. Castleman’s disease
- 6. Tuberculosis
- 7. A non-sarcoid granulomatous disease
- 8. Milk-alkali syndrome
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Inisglass
Fish bladder, used in the process of making beer
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Hospital Course
Within a couple of days of receiving IV fluids and
pamidronate, calcium down to ~10.5
A diagnostic procedure was performed
PET/CT Scan
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Diffuse FDG uptake noted within muscles of the upper extremities and the subcutaneous tissue corresponding to the proximal thighs and buttocks.
Now I’m Worried About…
- 1. Sarcoid
- 2. An occult malignancy
- 3. Trichinosis
- 4. Ebola
- 5. Atorvastatin-induced myositis
- 6. Something else
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Another Diagnostic Procedure Was Performed
I’ll Take Another Shot
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Additional History
After seeing the results of the PET/CT scan,
the physicians asked the patient about whether he had done anything to his deltoids and buttocks
He told them that he received cosmetic
injections in Mexico to his buttocks (5 years ago) and deltoids (about 6 months ago) to treat muscle wasting
Doesn’t anybody take histories anymore?
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Patient Returns to see PCP
A few weeks after discharge, the patient came to
see his PCP
He noted that his thirst and polyuria had
returned
A calcium level was 12.4 He received bisphosphonates and IV fluids via an
- utpatient infusion
Yet Another Diagnostic Procedure Was Performed
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Gurpreet Dhaliwal, what is your… final answer?
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Florid giant cell reaction and histiocytic infiltrate surrounding globules of foreign material. Similar histologic findings to those described for subcutaneous injection of polymethyl methacrylate
Final Diagnosis:
Calcitriol-Mediated Hypercalcemia due to foreign
body reaction to PMMA
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A Few Key Points
Calcitriol-mediated hypercalcemia resulting from
high extrarenal 1,25 hydroxylase activity is associated with granulomatous disease and has been described to accompany foreign body reactions (such as with silicone implants).
Polymethyl methacrylate is a nonbiodegradable
compound often injected w/collagen which over time may become encapsulated contributing to the bulking effect. Granulomatous reactions to PMMA have previously been described.
This phenomenon of hypercalcemia 2/2 foreign
body reaction to PMMA has not previously been described.
A Few More Points
- Hypercalcemia requires a stepwise diagnostic plan
- PTH mediated or not
- Differential Diagnosis of PTH-independent processes:
- Hypercalcemia of malignancy
PTHrP Activation of extrarenal 1 alpha-hydroxylase (increased calcitriol) Osteolytic bone metastases and local cytokines)
- Vitamin D intoxication
- Chronic granulomatous disorders
Activation of extrarenal 1 alpha-hydroxylase (increased calcitriol)
- Meds:
Thiazide, lithium, teiparatide, excess vitamin A, theophylline toxicity
- Misc:
Hyperthyroidism, acromegaly, pheochromocytoma, adrenal
insufficiency, immobilization, parenteral nutrition, milk alkali syndrome
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Probably Best to Avoid This
Polymethylmethacrylate
Sometimes the Best Diagnostic Test is a Good History
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