Reactivation of multisystemic sarcoidosis after immunosuppression withdrawal in a transplanted patient returning to chronic dialysis

Bone histomorphometry in a long-term hemodialysis patient with hypoparathyroidism and sarcoidosis

A bone biopsy specimen in a long-term hemodialysis patient with sarcoidosis coexisting with severe hypoparathyroidism has demonstrated that a persistent near physiological level of 1,25-dihydroxyvitamin D3 contributes to the preservation of bone remodeling and has the potential to retard the development of vascular calcification and atherosclerosis. Sarcoidosis-related hypercalcemia and hypoparathyroidism, which is characterized by 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) overproduction, is rarely seen in hemodialysis patients. Herein, we describe a 60-year-old Japanese woman on hemodialysis for 35 years who presented with malaise and hypercalcemia. Severe hypoparathyroidism without parathyroidectomy and a preserved 1,25(OH)2D3 level were detected. Computed tomography showed bilateral axillary lymphadenopathy and minimal aortic and soft tissue calcification. The axillary node biopsy led to a definite diagnosis of sarcoidosis. A bone biopsy specimen obtained from the right iliac crest showed remodeling of normal lamellar bone with scalloped cement lines and clear double labeling by tetracycline on fluorescence microscopy. Histomorphometric analysis revealed that the bone formation rate was preserved (30.0 %/year), together with a decrease of osteoid volume (5.75 %) and fibrous volume (0 %), indicating that the patient did not have adynamic bone disease and only showed mild disease. This is the first documented case of sarcoidosis-related hypercalcemia associated with severe hypoparathyroidism in a long-term hemodialysis patient who underwent bone histomorphometry. Our findings suggest that, in hemodialysis patients with sarcoidosis coexisting with severe hypoparathyroidism, a persistent near physiological level of 1,25(OH)2D3 contributes to the preservation of bone remodeling and has the potential to retard the development of vascular calcification and atherosclerosis.

Sarcoidosis presenting with hypercalcaemia following withdrawal of long-term immunosuppression in renal transplantation

Long-term immunosuppression, including corticosteroids, is a hallmark of renal transplantation. We describe a patient who had a failed transplant after 15 years, subsequent graft nephrectomy and withdrawal of his immunosuppression therapy including prednisolone. Within months of complete cessation of prednisolone, he developed hypercalcaemia and subsequent systemic symptoms including ocular, respiratory and dermatological. A skin biopsy demonstrated non-caseating granulomatous lesion and a diagnosis of sarcoidosis was confirmed. Re-commencement with prednisolone resulted in complete resolution of clinical and biochemical features of sarcoidosis. Sarcoidosis is unlikely to present in the immunosuppressed patient. This case highlights that unexplained hypercalcaemia at the time of withdrawal of immunosuppression, including corticosteroids, may be a feature of sarcoidosis.

Sarcoidosis in a chronic dialysis patient diagnosed by sarcoidosis-related hypercalcemia with no common systemic clinical manifestations: a case report and review of the literature

Sarcoidosis is a systemic granulomatous disease of unknown origin. We herein report a case of sarcoidosis in a chronic dialysis patient diagnosed by hypercalcemia without any common clinical manifestations. The onset of sarcoidosis in chronic dialysis patients is rare; to the best of our knowledge, only 23 cases have been reported. Evaluation of the 23 previously published cases revealed that a diagnosis of sarcoidosis was often achieved by the presence of sarcoidosis-related hypercalcemia without any common clinical presentations, as in the present case. This characteristic may arise from a specific immune deficiency and the unique physiology of 1,25-dihydroxyvitamin D3, a main cause of sarcoidosis-related hypercalcemia, in chronic dialysis patients. These clinical features may be useful to understand the pathogenesis of sarcoidosis.

Hypercalcemia after transplant nephrectomy in a hemodialysis patient: a case report

INTRODUCTION

Hypercalcemia is a complication often seen in chronic hemodialysis patients. A rare cause of this condition is sarcoidosis. Its highly variable clinical presentation is challenging. Especially in patients suffering chronic kidney graft failure the nonspecific constitutional symptoms of sarcoidosis like fever, weight loss, arthralgia and fatigue may be easily misleading.

CASE PRESENTATION

A 51 year old male developed hypercalcemia, arthralgia and B-symptoms after explantation of his kidney graft because of suspected acute rejection. The removed kidney showed vasculopathy and tubulointerstitial nephritis, which had not been overt in the biopsy taken half a year earlier. Despite explantation and withdrawal of the immunosuppression the patient's general condition deteriorated progressively. A rapid rise in serum calcium finally provoked us to check for sarcoidosis. CT scans of the lungs, broncho-alveolar-lavage and further lab tests confirmed the diagnosis.

CONCLUSION

This case demonstrates that withdrawal of immunosuppressive drugs sometimes unmasks sarcoidosis. It should be considered as differential diagnosis even in hemodialysis patients, in whom other reasons for hypercalcemia are much more common.