Refractory hypercalcemia in a patient with disseminated tuberculosis: A successful case of prolonged treatment with corticosteroid

Abstract

Pulmonary tuberculosis (TB) is a major health problem worldwide. Hypercalcemia has been described in patients with TB. Symptomatic hypercalcemia is treated using aggressive hydration and short courses of systemic corticosteroid to decrease serum calcium levels. The duration and dosage of steroid treatment are not well established. The present report describes a case of a 66-year-old man diagnosed with pulmonary TB, who received anti-TB therapy for 4 months, after which he presented with an episode of hypercalcemia with acute kidney injury. Systemic corticosteroids were prescribed for 8 weeks and gradually tapered. Subsequently, the chest plain film revealed new infiltrates, and his hypercalcemia relapsed. Immune reconstitution inflammatory syndrome (IRIS) was suspected. Calcium levels normalized 1 week after the steroid was increased and the anti-TB drugs were maintained. Prednisolone was gradually withdrawn over a 1-month period and completely stopped during the 7th month of anti-TB therapy. The patient remained under observation for 1 more month, during which his calcium levels remained in the normal range. Therefore, the use of steroids for approximately 4 weeks might be suggested for TB-IRIS in HIV-uninfected patients.

Keywords

• Pulmonary tuberculosis
• hypercalcemia
• acute kidney injury
• immune reconstitution inflammatory syndrome