A 16-months-old female patient admitted to our hospital with a 3-days history of fever, fatigue and poor appetite. On examination, she was cachectic and lethargic. Height was 63.5 cm (less than the third percentile), weight was 6.150 g (less than the third percentile), and head circumference was 45 cm (3-10 percentile). A systemic examination revealed bilateral coarse crackles throughout both lung fields and hepatosplenomegaly. Laboratory tests are summarized in Table 1. The total calcium and the ionized calcium levels were elevated (18.3 mg/dL, N: 9-11; 4.57 mmol/L, N:1.12-1.32, respectively). The phosphate level was 4.4 mg/dL (N: 3.4-6) within the normal range. There was neither a reported history of excessive calcium or vitamin D intake nor consumption of thiazides. Alkaline phosphatase was 131 U/L (N: 5-281), 25-hydroxy vitamin D was 133 ng/mL (N: 30-70), and parathyroid hormone level was decreased 1.2 pg/mL (N: 15-65). The 1,25-dihydroxy-vitamin D3 level was also high at 345 pg/mL (N: 21-156). Random urinary calcium/creatinine ratio was high at 1.25 (N:<0.5) and there was nephrocalcinosis in renal ultrasonography. Intravenous hydration with normal saline and furosemide therapy was started on admission, but the serum calcium level remained elevated above the upper normal limit. Consequently, she received an infusion of 0.5 mg/kg pamidronate-disodium for two doses with no side effects observed, and her serum calcium gradually decreased to 11.3 mg/dL. A chest radiograph demonstrated opacities and interstitial infiltrates; hence, computed tomography of the lungs was performed. This revealed widespread pulmonary opacities and consolidation, multiple calcified lymph nodes and parenchymal mass with cavitary lesions (Fig. 1). The patient was again questioned for contact with anyone with tuberculosis. It was learned that anti-tuberculosis therapy was initiated to the mother at the gestation, but she did not complete the treatment. In addition, the patient was not immunised for bacilli Calmette-Guerin. In view of the severe symptomatology and radiological findings, a diagnosis of a hypercalcemic crisis secondary to tuberculosis was defined. The patient was empirically started on treatment for tuberculosis with rifampin, isoniazid (INH), pyrazinamide and ethambutol during the hospital admission. Three weeks after admission, we detected Mycobacterium tuberculosis complex DNA by the polymerase chain reaction in the serum specimen. Within two weeks of the initiation of therapy, the serum calcium level dramatically decreased to 9.1 mg/dL, and the patient showed a markedly improved sense of well-being. Her anti-tuberculosis therapy is continuing without any complaint and a follow-up computed tomography scan showed resolution of her previous lesions in the lung and the hypercalcemia had not recurred again.
Chest radiography and thoracic computed tomography of the patient with pulmonary tuberculosis. (A) The chest radiograph demonstrated opacities and interstitial infiltrates bilaterally.