A 32-year-old African American man is admitted to the hospital due to dizziness. For the past 2 weeks he has had decreased appetite, nausea, dry cough, constipation, and excessive urination. He has had no fever or night sweats and was in good health prior to these symptoms. The patient has no other medical problems and takes no medications. He has 10-pack-year history of smoking. He admits to drinking a few beers on weekends but does not use illicit drugs.
His blood pressure is 110/70 mm Hg and pulse is 110/min. Lung examination shows normal breath sounds. The remainder of the examination is normal.
Laboratory results are as follows:

Chest x-ray is shown below.

In addition to intravenous fluids, which of the following medications is most appropriate for this patient?

Question

A 32-year-old African American man is admitted to the hospital due to dizziness.  For the past 2 weeks he has had decreased appetite, nausea, dry cough, constipation, and excessive urination.  He has had no fever or night sweats and was in good health prior to these symptoms.  The patient has no other medical problems and takes no medications.  He has 10-pack-year history of smoking.  He admits to drinking a few beers on weekends but does not use illicit drugs.
His blood pressure is 110/70 mm Hg and pulse is 110/min.  Lung examination shows normal breath sounds.  The remainder of the examination is normal.
Laboratory results are as follows:

Chest x-ray is shown below.

In addition to intravenous fluids, which of the following medications is most appropriate for this patient?

Quizplus · Accepted Answer

This patient presents with symptoms of hypercalcemia (anorexia, nausea, polyuria, and constipation) and has a chest x-ray showing bilateral hilar adenopathy. He most likely has sarcoidosis. Patients with sarcoidosis and other granulomatous diseases may have hypercalcemia due to extra-renal production of 1-hydroxylase. This results in excessive conversion of 25-hydroxyvitamin D to 1, 25-dihydroxyvitamin D (calcitriol). Calcitriol in turn leads to increased intestinal calcium absorption as well as bone resorption. Elevated calcium levels are independent of serum parathyroid hormone levels, which in most cases are low. Many patients with sarcoidosis also have hypercalciuria that leads to nephrolithiasis. granulomatous diseases Elevated calcium levels Treatment of hypercalcemia and/or hypercalciuria in granulomatous disorders includes decreasing calcium and oxalate intake and avoidance of sun exposure, which aggravates hypercalcemia in some patients. In patients with sarcoidosis, low-dose glucocorticoid therapy is helpful in lowering serum calcium levels by decreasing calcitriol production. The effect usually takes about 2-5 days. Thus, in this patient with chronic hypercalcemia due to sarcoidosis, volume expansion and glucocorticoids are the treatment of choice. (Choice A) Calcitonin causes a rapid (within 4-6 hours) reduction in serum calcium levels by decreasing bone resorption, but this effect is short-lived. Calcitonin is a good choice for cancer patients with severe hypercalcemia (calcium > 14 mg/dL) along with bisphosphonates. However, patients with granulomatous diseases have elevated calcitriol levels and increased intestinal calcium absorption. Therefore, calcitonin would not be helpful in this patient. (Choice B) Cinacalcet (Sensipar®) is a calcium mimetic drug that acts on calcium-sensing receptors on parathyroid cells to decrease secretion of parathyroid hormone. It is effective only in hypercalcemia due to hyperparathyroidism (primary or tertiary). (Choice C) Aggressive fluid hydration followed by furosemide (to induce renal excretion of calcium) is not a preferred treatment choice due to the risk of renal failure and electrolyte abnormalities caused by loop diuretics. Most patients with malignancy-induced hypercalcemia are treated with intravenous fluids, followed by bisphosphonates or calcitonin. (Choice E) Zoledronate is effective in decreasing calcium levels due to excessive bone resorption. However, in this patient with granulomatous disease, glucocorticoids will lead to sustained decrease in calcium levels by decreasing calcitriol production. Moreover, zoledronate is contraindicated in patients with renal failure. Educational objective: Hypercalcemia in patients with granulomatous diseases is caused by extra-renal production of 1-hydroxylase, which results in excessive conversion of 25-hydroxyvitamin D to 1, 25-dihydroxyvitamin D (calcitriol). Glucocorticoids are the treatment of choice in these patients (eg, those with sarcoidosis and lymphoma). __________ References: Vitamin D, calcium and sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/8620732)

A 32-Year-Old African American Man Is Admitted to the Hospital