Department of Nephrology, Klinikum der Universität Heidelberg, Bergheimer Strasse 56a, D-69115 Heidelberg, Germany Email: daniel_henriquez{at}med.uni-heidelberg.de
An 80-year-old male patient was admitted with a 2-week medical history of progressive weakness, anorexia, pollakisuria and subsequent oliguria.
The patient was slightly disoriented and a detailed history was difficult to obtain. His private physician reported a history of arterial hypertension, dyslipidaemia, atrial fibrillation and thyroidectomy because of suspected (but disproven) thyroid malignancy. On admission the patient was hypotensive (90/60 mmHg). Hypotension promptly responded to intravenous (i.v.) saline. Laboratory investigation revealed acute renal failure, with serum creatinine 3.65 mg/dl, urea 123 mg/dl, uric acid 7.1 mg/dl and metabolic acidosis.
The patient had hypercalcaemia, a serum calcium of 3.11 mmol/l, serum phosphorus of 1.20 mmol/l and serum albumin of 4.6 g/dl. Serum PTH and PTH-related peptide were low (Table 1). Urinalysis was unremakable (no haematuria or proteinuria). Ultrasonography showed normal sized kidneys, no renal calculi and no nephrocalcinosis.
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Questions
What is the diagnosis?
What further possibilities would you explore?
Answer to the quiz on the preceding page
Because of PTH suppression and no evidence of malignancy (including PTH-related peptide concentration) the patient was treated empirically with i.v. saline, and the administration of loop diuretics (furosemide) and corticosteroids (Table 2). The patient responded slowly to treatment and serum calcium returned to the upper normal range within 10 days.
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An interview with the former physician who had taken care of the patient up until a year previous revealed that he had received the vitamin-D analogue dihydrotachysterol (AT-10) (Figure 1). The patient had faithfully continued to take the drug. It is of note that the concentration of dihydrotachysterol is not detected by the 25 OH-vitamin D3 assay [1].
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This case illustrates that for an inclusive history of potentially prescribed drugs, not only the referring physician, but also his predecessors should be consulted.
Notes
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