Hypercalcemia and Acute Renal Failure Indicating Peritoneal Sarcoidosis

      An 82-year-old Chinese man with a history of diabetes mellitus and chronic renal failure of undetermined origin (steady-state serum creatinine level 140 µmol/l) was referred for fatigue and decreased renal function. The clinical examination was unremarkable. Blood cell count was normal, serum creatinine 253 µmol/L (normal <100), and urea 13.7 mmol/L (normal <6.4). Serum protein electrophoresis and dosage of light chains were normal. Serum ionized calcium was increased at 1.47 mmol/L (normal <1.31), phosphate 1.49 mmol/L (normal <1.31), 1,25-(OH)D3 70 pg/mL (normal <67), 25-(OH)D3 40 ng/mL (normal 30-100), parathyroid hormone (PTH) 6.7 ng/L (normal > 8), and urine calcium 3.01 mmol/24 h (normal 2.5-7.5). Thoraco-abdominopelvic computed tomography (CT) scan with no contrast product showed normal kidney size and no urinary tract obstruction, but hilar lymphadenopathy, micronodules in the upper lobe of right lung, peritoneal nodules, and thickening (Figure A). 2-[18F]FDG PET/CT revealed intense uptake of pleural, pericardial, and peritoneal thickening, and of thoracic lymph nodes (Figure B). Direct search for mycobacteria in sputum and urine and QuantiFERON Tb Gold Test (QIAGEN, Hilden, Germany) were negative. Pending explorative laparoscopy for a high suspicion of peritoneal tuberculosis delayed because of the coronavirus disease pandemic, rapid control of serum calcium was obtained under cinacalcet, but fatigue persisted and creatinine level plateaued at 280 µmol/L. The explorative laparoscopy revealed diffuse soft and white nodules, 2-5 mm in diameter, in the peritoneal cavity (Figure C), histologic examination displaying non-caseating granuloma with negative bacterial, mycobacterial, and fungal cultures. Diagnosis of sarcoidosis was established with no other organ involvement, but the patient declined renal biopsy. Treatment with prednisone was given (1 mg/kg/d) tapered over 6 months, associated with isoniazid and rifampicin during 3 months (until the infectious investigations were definitely negative). This allowed cinacalcet withdrawal within 2 weeks and return of serum creatinine level to steady level and complete metabolic response on 2-[18F]FDG PET/CT at 6-months follow-up (Figure D).
      Figure(A) Abdominal computed tomography scan without contrast showing peritoneal thickening (star) and small peritoneal nodules (arrow). (B) 2-[18F]FDG PET/CT showing increased uptake of the tracer at pleural, pericardial, and peritoneal hypermetabolic sites and hilar lymphadenopathy. (C) Diffuse soft and white peritoneal nodules demonstrated on laparoscopy. (D) Complete metabolic response on 2-[18F]FDG PET/CT at 6-month follow-up.
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