Session: SAT 199-223-Disorders of Bone & Calcium Homeostasis: Case Reports
Poster Board SAT-215
THE CASE: 47 yr Puerto Rican woman was referred to Endocrinology for hypercalcemia with calcium levels varying from 11.0 mg/dl to 14.5 mg/dl for the last 5 yrs associated with recurrent nephrolithiasis requiring lithotripsy, urethral strictures, and stent placement. The stents were replaced frequently due to clogging and recurrent urinary tract infections. Consequently she developed nephrocalcinosis and chronic kidney disease requiring intermittent dialysis. An extensive workup revealed that hypercalcemia was due to granuloma formation from silicone injections 15 yrs earlier into her thighs and buttocks for cosmetic reasons. She was treated with IV hydration, calcitonin and IV pamidronate on her previous hospital admissions. Oral bisphosphonate therapy led to renal insufficiency so she was treated with prednisone up to 240mg/day in tapering doses that resulted in reduction of serum calcium from 15.2mg/dl to 9.9mg/dl in one month. However, long term low dose Prednisone (10mg/day) failed to keep her in remission and subsequent high dose steroids caused psychosis. Treatment with subcutaneous Denosumab 60 mg normalized her serum calcium into the range of 9.5mg/dl -10.5 mg/dl for the next four months. She was re-admitted to the hospital with a calcium level of 13.5mg/dl and the second dose of Denosumab was given with the same response.
DISCUSSION: Denosumab is a human monoclonal antibody directed against RANK-L that blocks osteoclastogenesis. It is indicated for post menopausal osteoporosis, prevention of skeletal related events in solid tumors and fracture prevention in prostate cancer patients on GnRH agonists. Rare case reports indicate that is has been used for malignancy associated hypercalcemia. In our patient with refractory hypercalcemia, renal failure, and steroid intolerance Denosumab treatment lowered serum calcium into the normal range. We believe this is the first evidence of Denosumab use in a patient with granulomatous hypercalcemia.
Nothing to Disclose: UZS, DB, MPR
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