Chest
Volume 126, Issue 3, September 2004, Pages 995-998
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Selected Reports
Pregnancy and Sarcoidosis: An Insight Into the Pathogenesis of Hypercalciuria

https://doi.org/10.1378/chest.126.3.995Get rights and content

Hypercalciuria with or without hypercalcemia is a well-known complication of sarcoidosis, the pathogenesis of which is not fully understood. Pregnancy is associated with physiologic alterations in calcium metabolism. These changes can further alter the derangement of calcium metabolism that occurs in sarcoidosis, if the two conditions coexist. We had the opportunity to study prospectively the changes in serum and urine calcium along with all the hormonal changes that occur during pregnancy in a young woman with sarcoidosis, who had hypercalciuria at presentation. We believe that an increased level of calcitriol is central to the calcium abnormalities in our patient. In her case, the increased calcitriol is derived from sarcoid granulomas and renal sources enhanced by the effect of estradiol and prolactin on the conversion of 25(OH)D to 1,25(OH)2 D. She acquired hypoparathyroidism, with normal serum calcium, which probably was due to the direct suppression of parathyroid hormone (PTH) secretion by calcitriol. Finally, hypercalciuria is the result of the combined effect of hyperabsorption of calcium from the gut (the result of increased calcitriol levels leading to increased filtration of calcium) and decreased tubular reabsorption of calcium, as a result of undetectable PTH.

Section snippets

Case Report

This 33-year-old woman received a diagnosis of sarcoidosis 5 months after her first delivery. The diagnosis was based on a skin lesion biopsy and bilateral parenchymal lesions on chest radiograph. Except for the skin lesions, she had no other symptoms. Her mother also had sarcoidosis, which was detected after her second pregnancy, and remitted after a course of corticosteroids without further relapse. The present patient was referred to our service, because of severe hypercalciuria (24-h urine

Materials and Methods

The ADVIA 1650 analyzer (Bayer Diagnostics; Bershire, UK) was used to estimate serum creatinine, calcium, albumin, urine creatinine, and urine calcium levels. The Jaffe reaction and enzymatic reaction of Tanganelli was used to measure urine creatinine and serum creatinine respectively. The Doumas, Watson, and Biggs method using bromcresol green as the binding dye was used to estimate serum albumin. The reaction between calcium and o-cresolphthalein complex one was used to measure serum and

Results

Hypercalciuria that had subsided 1 year after the patient's first delivery returned early in the second pregnancy. In contrast to her first pregnancy, it persisted even after delivery to her latest follow-up in October 2003, but at lower levels than those seen during pregnancy (Table 2). The 1,25-dihydroxy vitamin D (calcitriol) level that was normal before pregnancy increased throughout pregnancy, and became normal soon after delivery only to rise again and remain high thereafter.

Discussion

Sarcoidosis complicating pregnancy was first reported by Nordland et al12 in 1946. Their patient, who had idiopathic thrombocytopenic purpura and sarcoidosis of the spleen, underwent splenectomy and subsequently had a normal delivery. Mayock et al6 studied 16 pregnancies in 10 patients with sarcoidosis and found that lymphadenopathy, parenchymal lung lesions, and hyperglobulinemia improved during pregnancy and returned after delivery, while chronic uveitis did not improve. Djrolo et al7

Conclusion

Pregnancy complicating sarcoidosis is a well-documented entity. Physiologic changes in mineral metabolism during pregnancy can complicate sarcoidosis-related calcium disturbances. An increased level of calcitriol is central to the calcium abnormalities in sarcoidosis, which lead to hypercalciuria and undetectable levels of PTH, throughout pregnancy, in the presence of normal serum calcium. This report also highlights the familial occurrence of sarcoidosis.

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