RESUMEN
SUMMARY: Hypercalcaemia is a very common endocrine condition, yet severe hypercalcaemia as a result of fungal infection is rarely described. There are have only been two reported cases in the literature of hypercalcaemia associated with Cryptococcus infection. Although the mechanism of hypercalcaemia in these infections is not clear, it has been suggested that it could be driven by the extra-renal production of 1-alpha-hydroxylase by macrophages in granulomas. We describe the case of a 55-year-old woman with a 1,25-OH D-mediated refractory hypercalcaemia in the context of a Cryptococcus neoformans infection. She required treatment with antifungals, pamidronate, calcitonin, denosumab and high-dose glucocorticoids. A disseminated fungal infection should be suspected in immunosuppressed individuals presenting with hypercalcaemia. LEARNING POINT: In immunocompromised patients with unexplained hypercalcaemia, fungal infections should be considered as the differential diagnoses; Glucocorticoids may be considered to treat 1,25-OH D-driven hypercalcaemia; however, the benefits of lowering the calcium need to be balanced against the risk of exacerbating an underlying infection; Fluconazole might be an effective therapy for both treatment of the hypercalcaemia by lowering 1,25-OH D levels as well as of the fungal infection.
RESUMEN
Research shows that people with dual disorders (i.e., a co-occurring mental illness and substance use disorder) are successful in supported employment programs and that employment can be a crucial step in their recovery. Based on experience observing supported employment services for 15 years, we propose practice guidelines for people with dual disorders. Successful programs share several approaches: 1) encourage employment, 2) understand substance abuse as part of the vocational profile, 3) find a job that supports recovery, 4) help with money management, and 5) use a team approach to integrate mental health, substance abuse, and vocational services.