The treatment of sarcoidosis remains controversial.[2,5,6] Corticosteroids remain the cornerstone of therapy, but immunosuppressive, cytotoxic, and immunomodulatory agents have emerged as viable therapeutic options for patients who do not respond to or experience adverse effects from corticosteroids. The published data most extensively documents treatment with methotrexate, but favorable responses have been noted with leflunomide, azathioprine, and antimalarial and antimicrobial agents, as well as with tumor necrosis factor–alpha inhibitors. The dosage and the duration of corticosteroid therapy must often be individualized. Treatment is continued until the clinical manifestations of the disease resolve or show significant improvement.[2,5,6]
The patient in this case received prednisone, 1.5 mg/kg per day for 1 month, with gradual tapering of the dose over the following 4-5 months. Hypercalcemia and renal failure reversed completely, as did the pulmonary changes seen on radiography (Figure 4).
No recurrence was observed at 1-year follow-up. Renal nephrocalcinosis persisted, however, despite symptomatic and biochemical improvement. During corticosteroid therapy, measurement of the urinary beta-2-microglobulin concentration by sodium dodecyl sulfate polyacrylamide gel electrophoresis proved a valuable monitoring tool for assessing recovery of the tubular impairment.
Chest radiography obtained after 3 weeks of corticosteroid therapy showed resolution of the findings seen in Figure 2.
This patient represents a rare case of sarcoidosis presenting with acute renal failure and hypercalcemia as the initial manifestations. Sarcoidosis should be considered in the differential diagnosis of hypercalcemia and renal failure, occurring singly or in combination. Corticosteroids are useful for treatment and can lead to the reversal of hypercalcemia and renal failure and the resolution of pulmonary lesions. Renal nephrocalcinosis may persist despite symptomatic and biochemical improvement.
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