A 36-year-old female with history of diabetes and hypertension presented with complaints of pain in the abdomen and fatigue for a duration of one month. She denied history of vomiting, diarrhoea, fever, chills, rashes, haematuria, cough, weight loss, chest pain, and shortness of breath. On examination, vitals were stable. General and systemic examination was also normal.
Laboratory investigations revealed the total serum calcium of 13.2 mg/dl, with corrected calcium of 14.4 mg/dl and a low intact parathyroid hormone level (IPTH) of 6.8 pg/dl, and serum creatinine of 2.4 mg/dl. She denied to a history of calcium supplements intake. The serum vitamin D3 (125OH) levels are 37.6 ng/ml and vitamin D (25OH) levels are 9.9 ng/ml. The PTHrP levels could not be tested due to unavailability of the test. Work up for multiple myeloma, thyrotoxicosis, and tumor markers were negative.  Table 1 shows the relevant laboratory investigations performed. Ultrasound of the abdomen showed increased echotexture of liver, normal kidney, and no other abnormalities. The patient was treated conservatively for hypercalcemia, hyperuricemia, and renal failure.
Since hypercalcemia and renal failure persisted even after treatment with intravenous fluids, diuretics, and calcitonin, a whole body flourine-18-fluorodeoxyglucose positron emission tomography computed tomography (18F-FDG PET/CT) was done which showed lesions with increased metabolic activity in the liver, spleen, and left internal iliac, left external iliac, right internal iliac lymph nodes as shown in Figure 1. Hence, CT:guided percutaneous biopsy of the liver lesions was done which showed necrotizing granulomatous inflammation with no features suggestive of vasculitis as shown in Figure 2. 
Biopsy stain for fungi, AFB, TB PCR and blood TB QuantiFERON gold test was negative, but angiotensin converting enzyme (ACE) levels were elevated (119 mcl, Normal range: 8-53 mcl).
The patient was diagnosed with sarcoidosis of liver with necrotizing granulomatous lesions which is a rare variant of sarcoidosis. The patient was started on 1 mg/kg/day prednisolone. After one month follow up the patient was symptomatically better with normal calcium levels (8.6 mg/dl), reduced ACE levels (<50 mcl) and with serum creatinine of 0.9 mg/dl (eGFR- 82 ml/min/1.73m2). Steroids were tapered after one month and presently she is on a regular follow up with minimal dose of steroids.