STONES, BONES, MOANS AND GROANS, SARCOIDOSIS? AN ATYPICAL PRESENTATION OF SARCOID DISEASE

Introduction: Sarcoidosis is a poorly understood disease wherein extra-pulmonary involvement is common, but isolated extra-pulmonary disease is rare. This case describes hepatic sarcoidosis without pulmonary involvement, presenting as symptomatic hypercalcemia. Case: A 65y.o. female presented to clinic with polydipsia, polyuria, nausea, abdominal pain, and 50 lb weight loss. Her serum calcium was 17mg/dL, prompting admission. CT was significant for three 2mm basilar lung nodules. Labs showed elevated Alk Phos, GGT, normal AST, ALT, PTH, and PTHrp. Light chain analysis was consistent with CKD. Bone and liver biopsies showed non-caseating granulomas. She responded to crystalloids, calcitonin, and bisphosphonates. She was diagnosed with extra-pulmonary sarcoidosis, started on steroids, and discharged home with follow-up. Discussion: The differential of symptomatic hypercalcemia is broad, including PTH mediated causes, malignancy, and medications. While sarcoidosis is a known cause, it typically presents with hilar adenopathy and hypercalciuria, not symptomatic hypercalcemia. This case describes a patient presenting with symptomatic hypercalcemia without hilar adenopathy, ultimately diagnosed with hepatic sarcoidosis. Liver and renal involvement among sarcoidosis patients are common, however studies show only 2% of isolated extrathoracic sarcoidosis. Hilar adenopathy is the typical finding of sarcoidosis. Scholarly Question: In patients with hypercalcemia, what is the probability of sarcoidosis without hilar adenopathy? Conclusion: The differential of hypercalcemia is broad. Sarcoidosis is a common cause of hypercalcemia that affects many organ systems with atypical presentations. During an initial hypercalcemia workup, early investigation of other potentially involved organ systems for sarcoidosis may prevent delayed diagnosis and unnecessary interventions in patients without hilar adenopathy.