|Year : 2016 | Volume
| Issue : 2 | Page : 62-64
A Case of Sarcoidosis Associated with Recurrent Many Urinary Tract Calculi Caused by Hypercalcemia
Akihito Tanaka1, Yuichi Ito2, Noriko Tanaka3
1 Department of Nephrology, Nakatsugawa City Hospital, Nakatsugawa City, Japan
2 Department of Emergency Medicine, Nagoya Ekisaikai Hospital, Nagoya, Japan
3 Department of Hospital Pharmacy, Nagoya University Graduate School of Medicine City, Nagoya, Japan
|Date of Web Publication||26-Apr-2016|
Department of Nephrology, Nakatsugawa City Hospital, 1522-1 Komaba, Nakatsugawa, Gifu Prefecture 508-8502
Source of Support: None, Conflict of Interest: None
We report a 76-year-old man who was diagnosed with bilateral hilar lymphadenopathy and elevated level of angiotensin-converting enzyme 3 years ago, and uveitis 2 years ago. He was performed lithotripsy for bilateral urinary tract calculi 1 year ago and referred to our department for chronic kidney disease. After then, urinary tract calculi relapsed and lithotripsy was performed 5 times and the level of adjusted calcium maintained from 10 to 12 mg/dL. In 2014, the level of creatinine (Cr) increased gradually, and abdominal computed tomography showed as many as 19 urinary tract calculi. We diagnosed this case as sarcoidosis clinically. The frequent recurrence of urinary tract calculi seemed to be caused by hypercalcemia derived from sarcoidosis, so we treated hypercalcemia by prednisolone 30 mg/day. Then the level of calcium and Cr improved rapidly. We should take the probability of sarcoidosis into consideration for the frequent recurrence of urinary tract calculi and hypercalcemia.
Keywords: Hypercalcemia, recurrence, sarcoidosis, urinary lithiasis
|How to cite this article:|
Tanaka A, Ito Y, Tanaka N. A Case of Sarcoidosis Associated with Recurrent Many Urinary Tract Calculi Caused by Hypercalcemia. J Integr Nephrol Androl 2016;3:62-4
|How to cite this URL:|
Tanaka A, Ito Y, Tanaka N. A Case of Sarcoidosis Associated with Recurrent Many Urinary Tract Calculi Caused by Hypercalcemia. J Integr Nephrol Androl [serial online] 2016 [cited 2019 Aug 20];3:62-4. Available from: http://www.journal-ina.com/text.asp?2016/3/2/62/181221
| Introduction|| |
Sarcoidosis is a chronic systemic disorder of unknown etiology characterized by noncaseating granulomatous infiltration into multiple organs. Although lung, skin, and eye are the main lesions, kidney is sometimes involved by several mechanisms, such as hypercalcemia, urinary tract calculi, and interstitial nephritis. From the viewpoint of urinary tract calculi, hypercalcemia derived from sarcoidosis is important causatively.
We experienced a case of sarcoidosis with frequent relapses of many urinary tract calculi. This presentation is important although the number of reports is very less in Japan.
| Case report|| |
We report a 76-year-old man who was diagnosed with bilateral hilar lymphadenopathy (BHL) and elevated level of angiotensin-converting enzyme (ACE) 3 years ago in another hospital because he had been suspected with sarcoidosis but not diagnosed. He was diagnosed with uveitis 2 years ago in our hospital. Transurethral ureterolithotripsy was performed for bilateral urinary duct calculi a year ago in our hospital, and the component is calcium oxalate. He was referred to our department for chronic kidney disease with a creatinine (Cr) level of about 1.7 mg/dL. After then, renal pelvis and ureter calculi frequently relapsed and lithotripsy, such as transurethral ureterolithotripsy or extracorporeal shock wave lithotripsy, was performed 5 times and the level of adjusted calcium maintained from 10 to 12 mg/dL. In 2014, the level of Cr increased gradually up to 3.7 mg/dL and abdominal computed tomography (CT) showed as many as 19 urinary tract calculi with the diameters were <1 cm. The patient was admitted to our hospital for treatment in December 2014. He had histories such as hypertension and dyslipidemia.
On admission, his height was 154 cm and weight was 51 kg. His physical examination revealed clear respiratory sounds and no cardiac murmur. His abdomen was soft and flat. Knocking pain in the costovertebral angle was not noted. Body temperature was 36.2°C, blood pressure was 136/77 mmHg, and heart rate was 70 beats/min with sinus rhythm. His urine volume ranged from about 1000 to 1500 mL. Clinical laboratory data of blood and serum were as follows : w0 hite blood cell count, 5.1 × 10 3 /mL; red blood cell count, 303 × 10 4 /mL; hemoglobin, 11.0 g/dL; platelet count, 14.7 × 10 4 /mL; C-reactive protein, 0.39 mg/dL; total protein, 7.0 g/dL; albumin, 3.7 g/dL; glutamic oxaloacetic transaminase, 17 IU/L; glutamic pyruvic transaminase, 14 IU/L; total bilirubin, 0.7 mg/dL; creatine kinase, 82 IU/L; blood urea nitrogen, 49.1 mg/dL; Cr, 3.76 mg/dL; sodium, 141 mEq/L; potassium, 3.7 mEq/L; uric acid, 6.5 mg/dL; corrected calcium, 11.6 mg/dL; phosphorus phosphate, 3.5 mg/dL; IgG, 1900 mg/dL; IgA, 251 mg/dL; IgM, 98 mg/dL; C3, 51 mg/dL; C4, 25 mg/dL; antinuclear antibody, ×160; proteinase 3 antineutrophilic cytoplasmic antibody (ANCA), 1.4 U/mL; myeloperoxidase ANCA, 1.0 U/mL; lysozyme, 45.3 mg/mL; ACE, 24.4 U/L; 1,25-dihydroxyvitamin D3, 149 pg/mL; intact parathyroid hormone (PTH), 3 pg/mL; PTHrP, 1.0pmol/L; and tuberculosis-specific gamma interferon release assays, negative. Abdominal CT showed as many as 19 urinary tract stones and bilateral hydronephrosis [Figure 1].
|Figure 1: Abdominal computed tomography just before admission. Many stones appeared in kidney and renal pelvis. Arrows show hydronephrosis. Arrowheads show the stones in ureters in enlarged views|
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We confirmed diagnosis sarcoidosis clinically by BHL, uveitis, elevation of ACE and lysozyme, and hypercalcemia. Because the renal function decreased [Figure 2], oral prednisolone (30 mg/day) was administered. Then the level of calcium and Cr improved rapidly [Figure 3] and the number of stones decreased [Table 1].
|Figure 2: Clinical course before admission. A blue line shows the level of creatinine. A red line shows the level of adjusted calcium. Cr; the level of creatinine, aCa; adjusted level of calcium|
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|Figure 3: Clinical course after admission. A blue line shows the level of creatinine. A red line shows the level of adjusted calcium. Cr; the level of creatinine, aCa; adjusted level of calcium, PSL; prednisolone|
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| Discussion|| |
Sarcoidosis is a chronic systemic disorder characterized by noncaseating granulomatous infiltration involving multiple organs such as superficial and mediastinal lymph nodes, lung, eye, skin, nerve system, muscle, heart, kidney, bone, and digestive tract.  Complication of hypercalcemia with sarcoidosis has been known. Although in Europe and in the United States the prevalence of hypercalcemia in sarcoidosis is reported to be from 10% to 20%, in Japan the prevalence of hypercalcemia is relatively small, i.e., it is reported to be from 3.7% to 14.3%. ,, Although there is a report describing that hypercalcemia in sarcoidosis is controllable by reducing the intake of Vitamin D and sunlight exposure,  steroid therapy is a basic treatment for hypercalcemia in sarcoidosis.  In this case, because the degree was not severe, hypercalcemia was observed for some period without treatment. This might result in urinary tract calculi and the regrettable point.
Urinary tract calculi in sarcoidosis are reported to be complicated with from 1.3% to 14%. , However, the number of reports is small in Japan. The most frequent component of stone is calcium oxalate  that is consistent with this case.
Kidney insufficiency in sarcoidosis is caused by hypovolemia derived from hypercalcemia, urinary tract calculi, and interstitial nephritis.  In this case, hypercalcemia and urinary tract calculi were seen. As abdominal CT revealed hydronephrosis and atrophy of kidney, kidney biopsy was not the adaptation. Hence, it is difficult to diagnose interstitial nephritis. This case is characterized by frequent recurrence and lots of stones caused by sustained hypercalcemia and rapid improvement by steroid therapy.
| Conclusion|| |
We experienced a case of sarcoidosis presenting repeated urinary tract stones derived from hypercalcemia with the need for steroid therapy. It is important to place the potential for sarcoidosis in mind when we find repeated urinary tract stones and hypercalcemia.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Thomas PD, Hunninghake GW. Current concepts of the pathogenesis of sarcoidosis. Thomas PD, Hunninghake GW. Current concepts of the pathogenesis of sarcoidosis. Am Rev Respir Dis 1987;135:747-60.
Goldstein RA, Israel HL, Becker KL, Moore CF. The infrequency of hypercalcemia in sarcoidosis. Am J Med 1971;51:21-30.
Holick MF. Vitamin D deficiency. N Engl J Med 2007;357:266-81.
Mikami R, Ryujin Y. Disorder of calcium metabolism in sarcoidosis. Nihon Rinsho 1982;40:2702-7.
Katakami N. Hypercalcemia in sarcoidosis. Nihon Rinsho 2002;60:1778-84.
Rizzato G, Colombo P. Nephrolithiasis as a presenting feature of chronic sarcoidosis: A prospective study. Sarcoidosis Vasc Diffuse Lung Dis 1996;13:167-72.
Rizzato G, Fraioli P, Montemurro L. Nephrolithiasis as a presenting feature of chronic sarcoidosis. Thorax 1995;50:555-9.
Kato Y, Taniguchi N, Okuyama M, Kakizaki H. Three cases of urolithiasis associated with sarcoidosis: A review of Japanese cases. Int J Urol 2007;14:954-6.
Muther RS, McCarron DA, Bennett WM. Renal manifestations of sarcoidosis. Arch Intern Med 1981;141:643-5.
[Figure 1], [Figure 2], [Figure 3]