Sarcoidosis presenting as isolated anasarca & hypercalcemia
The following case has been reported in the American Journal of Medicine.

A 62-year-old woman presented to clinic for a second evaluation. Previously healthy, she initially presented for care several months earlier with anasarca. Initial workup was notable for normal renal function, calcium level, and liver function tests, no proteinuria, and echocardiogram demonstrating mild diastolic dysfunction and concentric left ventricular hypertrophy but preserved systolic function.

One month later the patient developed severe, acute, symptomatic hypercalcemia with a calcium level of 14.7 mg/dL (corrected to 15.3 mg/dL). Parathyroid hormone (PTH) was suppressed, parathyroid hormone-related peptide (PTHrP) was negative, and 25-hydroxyvitamin D was normal.

Further workup demonstrated an elevated 1,25-dihydroxyvitamin D level (123 pg/mL) and angiotensin converting enzyme (ACE) level (152 U/L).

A cardiac MRI demonstrated preserved systolic function with nulling of the myocardium and blood pool on T1 imaging, concerning for protein deposition. There was no ventricular hypertrophy, dysfunction, or bi-atrial enlargement present, however, to support a diagnosis of amyloid.

The patient subsequently underwent a fat pad biopsy which demonstrated a negative Congo Red stain and patchy perivascular and interstitial granulomatous inflammation, consistent with sarcoidosis. The patient's hypercalcemia and anasarca resolved with steroids and hydroxychloroquine.

Key takeaways:-
- This case highlights the importance of checking both the active and inactive form of vitamin D because a normal inactive form can hide an elevated active form.

- Once having confirmed an elevated 1,25-dihydroxyvitamin D, it is clinically pertinent to classify this patient as having calcitriol-mediated hypercalcemia because this narrows the differential diagnosis to a granulomatous process.

- Similarly, an elevated ACE level is suggestive of granulomatous disease, even in the absence of radiographic findings.

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