New Sarcoidosis Diagnosis Following Unresponsive Event During Hemodialysis

Sarcoidosis is a systemic disease where extrapulmonary presentation of the disease often goes unrecognized as it overlaps with many disease manifestations. End-stage renal disease (ESRD) can be complicated by hypercalcemia and encephalopathy, both potential signs of sarcoidosis. These numerous extrapulmonary presentations may delay timely diagnosis and treatment. In this case report, a 53-year-old male with ESRD was admitted following an unresponsive episode during routine hemodialysis, later found to have sarcoidosis. Initial presentation notable for hypothermia, tachycardia, leukocytosis, and metabolic derangements. Bronchoalveolar lavage cultures subsequently grew methicillin-sensitive staphylococcus aureus, successfully treated with cefazolin. However, the patient remained encephalopathic and hypercalcemic. Further workup showed nonparathyroid hormone-mediated hypercalcemia with a normal 25-OH vitamin D and elevated 1,25-OH vitamin D, concerning for sarcoidosis, malignancy, or tuberculosis. Additional computed tomography imaging and endobronchial ultrasound-guided biopsy illustrated enlarged lymph nodes with splenomegaly and nonnecrotizing granulomas, respectively, confirming the diagnosis of sarcoidosis. He was started on methylprednisolone, pantoprazole, and trimethoprim/sulfamethoxazole for pneumocystis jirovecii pneumonia prophylaxis; serum calcium levels started to drop, and his mentation improved. While his encephalopathy was initially presumed secondary to his ESRD and infection, further workup revealed sarcoidosis. Untreated sarcoidosis has significant health complications including lung fibrosis, pulmonary hypertension, heart arrhythmias, and neurological deficits. This case highlights the importance of maintaining a broad differential in the setting of critically ill patients as clinical presentations can be multifactorial. Furthermore, patients with a complex medical history such as ESRD on hemodialysis can make concluding sarcoidosis as a diagnosis more difficult.