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Hypercalcemia as an Early Finding of Opportunistic Fungal Pneumonia in Renal Transplantation: A Case Series Report
María Cora Giordani1, Susana K Villamil Cortez1, María Diehl2
1Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
Background:
Pneumonia caused by opportunistic fungi is a serious complication in immunocompromised patients. Hypercalcemia has been described in renal transplantation associated with Pneumocystis jirovecii (PJP) or Histoplasma capsulatum (HCP) pneumonia.
Methods:
We describe 5 patients who underwent kidney transplant between 2014 and 2019 and developed hypercalcemia before the diagnosis of pulmonary fungal infection: 4 patients with PJP and 1 with HCP. We assessed calcium metabolism and kidney function by total and ionized calcium, phosphorus, intact parathormone (iPTH), 25-OH vitamin D, 1,25(OH)2 vitamin D, and serum creatinine levels.
Results:
Mean albumin-corrected calcium and ionized calcium were 12.56 mg/dL (range, 10.8-13.8 mg/dL) and 1.57 mmol/L (range, 1.43-1.69 mmol/L). Patients were normocalcemic, at 10.12 mg/dL (range, 9.6-10.5 mg/dL), before diagnosis and resolved hypercalcemia after antifungal treatment, at 8.86 mg/dL (range, 8.0-9.5 mg/dL). All patients had low or normal iPTH values, at 29.1 pg/mL (range, <3-44 pg/mL), with higher PTH levels 3 months before diagnosis and after treatment, at 147.3 pg/mL (range, 28.1-479 pg/mL) and 117.5 pg/mL (range, 18.2-245 pg/mL), respectively. The mean value for 25-OH vitamin D was 30.8 ng/mL (range, 14.6-62.8 ng/mL). This supports a PTH-independent mechanism, and we postulated an extrarenal production of 1,25(OH)2 vitamin D.
Conclusion:
In kidney transplant patients, hypercalcemia independent of PTH and refractory to treatment should alert for the possibility of opportunistic fungal pneumonia.
Insights
Hypercalcemia in kidney transplant patients may signal opportunistic fungal pneumonia. This condition, independent of parathyroid hormone (PTH), often resolves after antifungal treatment, suggesting an alternative calcium regulation pathway.
Area of Science:
- Nephrology
- Infectious Diseases
- Endocrinology
Background:
- Opportunistic fungal pneumonia poses a significant risk to immunocompromised individuals, particularly kidney transplant recipients.
- Hypercalcemia has been an observed complication in renal transplant patients with Pneumocystis jirovecii (PJP) or Histoplasma capsulatum (HCP) pneumonia.
Purpose of the Study:
- To investigate the relationship between hypercalcemia and opportunistic fungal pneumonia in kidney transplant recipients.
- To analyze calcium metabolism and kidney function in patients presenting with hypercalcemia and subsequent pulmonary fungal infections.
Main Methods:
- Retrospective analysis of 5 kidney transplant patients diagnosed with hypercalcemia preceding pulmonary fungal infection (4 PJP, 1 HCP) between 2014-2019.
- Assessment of calcium, phosphorus, intact parathormone (iPTH), vitamin D metabolites (25-OH and 1,25(OH)2), and serum creatinine levels.
Main Results:
- Patients presented with significant hypercalcemia (mean albumin-corrected calcium 12.56 mg/dL) that resolved after antifungal therapy.
- Low or normal iPTH levels were observed, indicating a parathyroid hormone-independent mechanism for hypercalcemia.
- Postulated extrarenal production of 1,25(OH)2 vitamin D as a potential cause of PTH-independent hypercalcemia.
Conclusions:
- Hypercalcemia refractory to treatment and independent of PTH in kidney transplant recipients should raise suspicion for opportunistic fungal pneumonia.
- Early recognition and treatment of fungal infections are crucial for managing hypercalcemia in this patient population.
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