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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 5  |  Page : 959-960
Hypercalcemia with renal failure in a patient with immunoblastic variant of non-hodgkins lymphoma of the bone


1 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
2 Department of Radiology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
3 Department of Pathology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India

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Date of Web Publication31-Aug-2010
 

How to cite this article:
Sivakumar V, Krishnakishore C, Sriramnaveen P, Sivaramakrishna G, Devi B V, Lakshmi A Y, Reddy M K. Hypercalcemia with renal failure in a patient with immunoblastic variant of non-hodgkins lymphoma of the bone. Saudi J Kidney Dis Transpl 2010;21:959-60

How to cite this URL:
Sivakumar V, Krishnakishore C, Sriramnaveen P, Sivaramakrishna G, Devi B V, Lakshmi A Y, Reddy M K. Hypercalcemia with renal failure in a patient with immunoblastic variant of non-hodgkins lymphoma of the bone. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Dec 10];21:959-60. Available from: http://www.sjkdt.org/text.asp?2010/21/5/959/68904
To the Editor,

Hypercalcemia with renal failure in a patient with the immunoblastic variant of non-Hodg­kins lymphoma is rare. We herewith report on an elderly male patient who presented to us with recent onset generalized weakness, easy fatigability, diffuse myalgia and bone pains. In the recent past, he was evaluated elsewhere in a nephrology facility for similar symptoms and was found to have mild renal failure, hypercal­cemia and tested normal for serum protein elec­trophoresis with a renal biopsy showing focal and segmental glomerulosclerosis and no cast nephropathy. In our evaluation, he was emacia­ted in appearance, with pedal edema, and dif­fuse bony tenderness, predominantly over lum­bosacral spine and pelvic bones and no signi­ficant lymphadenopathy. Laboratory evaluation revealed anemia [hemoglobin (Hb) 8.1 gm/dL, PCV, 23%)] and raised ESR (102 mm/1 st hour), significant proteinuria (4.5 gm/day), absent uri­nary bence jones protein, 24-hour urinary cal­cium and phosphorous of 50 mg and 414 mg res­pectively and benign urinary sediment. He had renal failure (blood urea: 42 mg/dL, serum crea­tinine: 3.6 mg/dL), hyponatremia (125 mEq/L), hypokalemia (2.8 mEq/L), hypercalcemia (cor­rected, 12.8 mg/dL), hypoalbuminemia (serum albumin 3.1 gm/L) and normal serum phospho­rus (2.4 mg/dL). He tested negative for HBsAg, anti-HCV and anti-retroviral serology by ELISA technique. Ultrasound abdomen showed normal sized kidneys with diffuse increased echogenicity and mild prostatomegaly. Computerized tomo­graphic (CT) scan of the brain showed old la­cunar infarct in the right lentiform nucleus area. CT scan of the abdomen revealed multiple os­teolytic areas in the lower lumbar and sacral regions and in the iliac bones bilaterally [Figure 1]. CT guided fine needle aspiration cytology (FNAC) from the affected iliac bone revealed the presence of binucleated immature cells sug­gesting the possibility of immunoblastic lym­phoma. Bone marrow examination showed mild megaloblastic changes. During his hospital stay, he received adequate hydration and correction of the electrolyte abnormalities. He did not receive bisphosphonates. The patient achieved sig­nificant clinical improvement with this treat­ment. Also, the serum creatinine came down to 2.4 mg/dL. Subsequently, the patient left the fa­cility at request and did not come for follow-up.
Figure 1 :Plain CT scan of the pelvis showing lytic lesion in the right iliac blade with soft tissue component.

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Immunoblastic lymphoma is a malignant dis­order of B-cells. It is a subtype of non-Hodg­kins lymphoma accounting for 30-40% of indi­viduals. It occurs in middle or old age-group. The presentation may be nodal or extra-nodal, the extra-nodal sites being the gastrointestinal tract, bone, testis and central nervous system. Immunocompromized individuals constitute the high-risk group. [1],[2] The most common causes of hypercalcemia in hospitalized patients are ma­lignancies such as non-small cell carcinoma of the lung, squamous cell tumors, renal cell carci­noma, T or B cell lymphomas, hepatoma and melanoma. Other causes include primary hyper­parathyroidism, hyperthyroidism, hypervitami­noses A and D, thiazide diuretics, prolonged im­mobilization, granulomatous diseases, familial hypocalciuric hypercalcemia and Paget's disease. [3] The reported mechanisms underlying hypercal­cemia in pregnancy include PTHrP (PTH-rela­ted protein), calcitriol production and cytokine mediated. [3]

In conclusion, this patient presented with hy­percalcemia related renal failure secondary to immunoblastic variant of non-Hodgkin's lym­phoma in bone, a rare entity.

 
   References Top

1.Gonzalez-Bonet LG, Gatierrez-Herrera JM, Gallego JM, Barcia JA. Primary immunoblastic B cell Lymphoma of the cranial vault. Acta Neurochir 2008;150:507-8.  Back to cited text no. 1      
2.Takasaki H, Kanamori H, Takabayashi M, et al. Non hodgkins lymphoma presenting as multiple bone lesions and hypercalcemia. Am J Hematol 2006;81(6):439-42.  Back to cited text no. 2      
3.Kremer R, Shustik C, Tabak T, Papavasiliou V, Goltzman D. Parathyroid hormone related pep­tide in hematologic malignancies. Am J Med 1996;100(4):406-11.  Back to cited text no. 3      

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Correspondence Address:
V Sivakumar
Department of Nephrology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati
India
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PMID: 20814144

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