Rapid progression of myocardial calcification in a patient presenting with hypercalcemia of unidentified etiology: a case report

Abstract

Myocardial calcification is an uncommon but clinically important finding that may result in severe cardiac dysfunction. It is generally classified as metastatic calcification triggered by an elevated serum calcium-phosphate product or dystrophic calcification occurring at sites of prior inflammatory or ischemic injury. There are few reports describing dynamic changes in myocardial calcification among patients with hypercalcemia. In addition, hypercalcemia with an unidentified cause has rarely been reported. We encountered a fatal case that developed both metastatic and dystrophic myocardial calcification. This case may contribute to a better understanding of the potential cardiac complications of severe hypercalcemia.Affiliations: Journal instruction requires a city and country for affiliations; however, these are missing in affiliation [2, 3]. Please verify if the provided city and country are correct and amend if necessary.All authors’ affiliation addresses are Osaka, Japan. A 57-year-old Japanese woman with a history of asthma presented with nausea and fatigue. She had severe hypercalcemia with acute kidney injury and marked eosinophilia. Intact parathyroid hormone was suppressed (11 pg/mL), with normal parathyroid hormone-related protein and vitamin D metabolites. Fractional excretion of calcium was elevated to 12%. Imaging studies, bone marrow examination, and renal biopsy did not identify a definitive etiology. She was diagnosed with severe hypercalcemia of unidentified etiology complicated by acute kidney injury and eosinophilia. Despite intravenous fluids, calcitonin, and denosumab followed by hemodialysis, she developed progressive respiratory failure and circulatory collapse with myocardial injury and coronary microvascular dysfunction, and serial CT showed new myocardial calcification from day 9 with rapid diffuse progression. She died 22 days after admission despite extracorporeal circulatory support, and autopsy revealed extensive multi-organ calcification including the heart and lungs. Severe hypercalcemia of unidentified etiology can be complicated by extensive myocardial calcification. Ectopic calcification initially induced by hypercalcemia may have been influenced by inflammatory conditions such as eosinophilia. In addition, subsequent myocardial injury may accelerate dystrophic calcification. Clinicians should be aware of the risk of early and progressive cardiac involvement in patients with hypercalcemia, particularly in the presence of inflammatory conditions.