SUN-787 A Case of Hypercalcemia Secondary to Isolated Hepatic Sarcoidosis

Abstract Disclosure: M. Dillon: None. G. Gupta: None. S. Rabieihashemi: None. I. Alpertunga: None. V. Kantorovich: None. Introduction: Hypercalcemia is a common finding with a clinical presentation ranging from mild fatigue and constipation to nephrogenic diabetes insipidus or mental status changes. Each patients’ symptoms depend on the severity and acuity of calcium elevation. This case highlights a rare cause of chronic hypercalcemia. Case: A 65-year-old female with non-alcoholic steatohepatitis cirrhosis presented with 10 days of dizziness. Vitals were unremarkable. Laboratory studies found hypercalcemia of 15.5 mg/dL and an acute kidney injury. She had no history of hypercalcemia or hematologic malignancies, but took daily calcium and vitamin D supplements. She was treated with aggressive hydration, calcitonin and zoledronic acid. Further work up showed normal magnesium, low phosphorus, appropriately suppressed parathyroid hormone (PTH), and normal 25-hydroxy vitamin D. The patient was discharged for outpatient follow up after calcium normalized. Further studies showed a normal PTH related protein (PTHrP), high levels of 1,25-dihydroxy vitamin D at 106 pg/mL, and high angiotensin-converting enzyme at 99 U/L. Despite a chronic alkaline phosphatase elevation, she underwent liver biopsy. Pathology showed non-necrotizing granulomatous hepatitis with multinucleated giant cells. Chest X-ray showed lack of pulmonary involvement. Patient was started on prednisone 40 mg daily for hepatic sarcoidosis. On medication, there was improved fatigue, stabilized calcium levels, and normalization of 1,25 dihydroxy vitamin D. Methotrexate was tried as steroid sparing agent, but was stopped after increase in liver enzymes suggested possible flare. Discussion: The differential of hypercalcemia is broad. The majority of cases are secondary to primary hyperparathyroidism and malignancy. However, suppressed PTH, normal PTHrP and elevated 1,25 dihydroxy vitamin D are indicators of granulomatous disease. Commonly, this is caused by sarcoidosis and tuberculosis. These disorders have activated macrophages or multinucleated giant cells producing increased 1α-hydroxylase. This produces a PTH independent hypercalcemia that results from increased intestinal calcium absorption. While granulomatous disease produces hypercalcemia, it can be difficult to diagnose when the granulomas are isolated in hepatic sarcoidosis as it is less common to have clinically significant disease with no pulmonary involvement. Hepatic sarcoidosis is typically asymptomatic, pruritic, or associated with chronic increased alkaline phosphatase. If there is significant clinical disease, it is important to begin treatment of corticosteroids and ursodeoxycholic acid to prevent progression to portal hypertension. In addition to calcium levels in these patients, liver enzymes can be used as a marker for inflammation and disease activity. Presentation: Sunday, July 13, 2025