GRANULOMATOUS DISEASE OF UNUSUAL SITES CAUSING HYPERCALCEMIA: TWO CASE REPORTS.

OBJECTIVE: Hypercalcemia with suppressed parathyroid hormone (PTH) levels is mostly due to granulomatous disease (GD) or neoplastic disease. In GD, autonomous activity of extra-renal 1α-hydroxylase enzyme is usually the underlying cause. We describe a pair of cases where hypercalcemia resulted from GD of unusual sites posing significant diagnostic challenges. METHODS: We describe 2 cases of PTH-independent hypercalcemia due to GD of the prostate gland and the stomach. RESULTS: Both cases presented with marked hypercalcemia and suppressed PTH levels. Case 1 is an elderly male who presented with marked symptomatic hypercalcemia on multiple occasions. Investigations revealed elevated levels of 1,25-dihydroxyvitamin D3 and prostate-specific antigen but normal PTH-related protein. Transrectal biopsy of the prostate gland confirmed the presence of chronic granulomatous prostatitis. The patient responded very well to steroids which entirely normalized his calcium level. Case 2 is a male who presented similarly with significant hypercalcemia but had upper gastrointestinal symptoms and anemia at onset. Endoscopy and biopsy established the presence of granulomatous gastritis likely due to Crohn disease which responded to steroids resulting in normalization of calcium levels within a short span of time. CONCLUSION: While the majority of PTH-independent hypercalcemia cases are due to GDs of lymph nodes or malignancy, our cases indicate that in uncertain cases, granulomatous processes involving unusual sites should be considered in the evaluation of hypercalcemia with suppressed PTH.

Retroperitoneal Fibrosis as a Cause of Chylous Ascites.

Retroperitoneal fibrosis is a rare condition characterized by chronic inflammation and marked fibrosis of the retroperitoneal tissue, often leading to entrapment of abdominal organs. We report a 69-year-old white man who presented with a 5-week history of gradual onset of progressive abdominal distension. He had no history or risk factors for an underlying liver condition. Ascites and a retroperitoneal mass encasing the major abdominal vessels were revealed on imaging. Biopsies of the mass confirmed the presence of retroperitoneal fibrosis, and the ascitic fluid was milky, consistent with chylous ascites. We discuss this rare presentation and the challenges of treatment for chylous ascites caused by RPF, including the role for supportive treatment.