Recurrent Nephrolithiasis as a Presentation of Sarcoidosis
Disorders of the Mediastinum SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum SESSION TYPE: Student/Resident Case Rep...
Disorders of the Mediastinum SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Recurrent Nephrolithiasis as a Presentation of Sarcoidosis Hani Alkrad MD* Emad Alkhankan MD Muneer Al Zoby MD Hani Alkhankan MD; and Fuad Zeid MD Marshall University, Huntington, WV
DISORDERS OF THE MEDIASTINUM
INTRODUCTION: Sarcoidosis is a multisystemic immune disorder of unknown cause characterized by the formation of epithelioid granulomas in involved organs particularly the lung and the lymphatic system. Extrapulmonary sarcoidosis account for up to 30% of all patients, however renal presentation accounts for only 0.7% such cases CASE PRESENTATION: A 48 -years old white male presented to the hospital with left flank pain associated with nausea and vomiting; He has no hematemesis or melena also denies any urinary urgency, but had mid dysuria with gross hematuria.His past medical history was remarkable for nephrolithiasis s/p lithotripsy. Lab work up was unremarkable, except for mild elevation in 1.25 OH Vit D and microscopic hematuria CT scan of the abdomen shows 4 mm kidney stone located at left proximal uretropelvic junction with new diffuse prominent mesenteric and bilateral inguinal lymph nodes.The patient was initially worked up for lymphoma, PET scan was done and showed abnormal uptake within bilateral hilar and subcarinal LN stations . Excisional lymph node biopsy from inguinal region was consistent with noncaseating epithelioid-cell granulomas concerning for sarcoidosis. He underwent EBUS TBNABX and transbronchial biopsy that also showed noncaseating granuloma . PFTs showed Vital capacity of 2.54L (67% of predicted), FEV1 of 1.91(71%) and FEV1/FVC of 75% Lung volume measurement showed TLC of 4.26L (64% pf predicted) ,DLCO 88 compatible with restrictive disease. Patient was started on Prednisone with clinical and radiology improvement evident on CT scan by decreased lymph nodes size . Due to disease progression, he required MTX and Humira for better disease control. DISCUSSION: Sarcoidosis rarely presented with nephrolithiasis as initial presentation. In our case the recurrent nephrolithiasis was attributed to the renal sarcoidosis which is a functional abnormality due to altered metabolism of calcium By increased synthesis of vitamin 1,25-dihydroxy-vit D3 by macrophages of the granulomatous cells that leads to increase calcium absorption from the gastrointestinal tract causing hypercalciurea and kidney stones formation CONCLUSIONS: Sarcoidosis is a rare yet a significant cause of renal pathology including but not conclusive to nephrolithiasis which can be the initial presentation of the disease. Reference #1: Rizzato G, Fraioli P, Montemurro L. Nephrolithiasis as a presenting feature of chronic sarcoidosis. Thorax. 1995;50(5):555-559. Reference #2: Rao DA, Dellaripa PF. Extrapulmonary Manifestations of Sarcoidosis.Rheumatic diseases clinics of North America. 2013;39(2):277-297. doi:10.1016/j.rdc.2013.02.007. Reference #3: Ponce C, Gujral J.Renal Failure and Hypercalcemia as Initial Manifestations of Extrapulmonary Sarcoidosis. South Med J. 2004;97(6) DISCLOSURE: The following authors have nothing to disclose: Hani Alkrad, Emad Alkhankan, Muneer Al Zoby, Hani Alkhankan, Fuad Zeid No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.636
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.